Unstable Patients Going to Radiology

[Venko]

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Hi all,

I have been pondering something for the past few months and would like people's reactions.

I believe unstable patients that require imaging for definitive diagnosis can and should go to radiology when the radiology department is nearby and it is possible to send resuscitative specialists and equipment with them.

My rationale is that the previous dogma that unstable patients should never be sent to radiology is founded in a time when radiology departments were usually in the basements of hospitals and testing took long periods of time. Many hospitals currently have radiology departments adjacent to emergency departments and CT, Xray etc can often be done in a matter of 5 to 10 minutes if planned properly.

In my current institution, there are many different ICUs and they are scattered over a very large campus and we have a tendency to believe it is better to send unstable hypotensive patients who are getting fluids, colloids, pressors etc to the ICU which may be seven floors up and another long hike across the hospital rather than into the adjacent hallway where there is diagnostic equipment. To me this seems ridiculous that an elevator ride with one nurse would be safer than next hallway with nurse having ready access to the entirety of the ED in the time it takes to press the code button.

To be clear, this would only apply when the testing needed is very close by, the testing is critical to saving the life of the patient, and resuscitative efforts are working maximally with what little information is already available (i.e. don't send someone who needs blood to be infusing to CT before starting the blood).

What do other people think?

Curious,
TL

 

[deleted109597]

You can't go with them on the boards.

Depends on why they're unstable. Trauma? Per Mallon, it does need imaging. With the surgeon's retina. In the OR.
Infectious? Sure, got to figure out where that thing is.
GI Bleeds? No imaging is helpful
AAA? Bedside US.

 

[WilcoWorld]

I agree with Thymeless with respect to dogmatic assertions like "CT is where patients go to die." That's no longer the case. Of course McNinja is correct that the answer depends on the specifics of the case, that's exactly the point. The old teaching that unstable patients can't go to radiology - as a blanket principle - is outdated.

If bedside US can answer your question, then yes, skip the CT. But what about a sick patient with sudden severe chest pain - is it a dissection or a PE? Sure, if they have a swollen leg and a dilated right ventricle I know which direction to take, but what if I can't get a good view on echo and the patient says the chest pain was "tearing"? You think you're going to gat a surgeon to operate without a CT because the root looks dilated to you? Good luck...

 

[Tiger26]

Having very familiar knowledge of the institution Thymeless is talking about, I agree with him--there are 4 CT scanners on the other side of the wall, so it always made more sense to me to run them through. Granted, I always still had a very low threshold to intubate and put in lines prior to moving transporting, even for such a short distance.

As mentioned above, in sick trauma patients, you should be managing those patients in the OR, which is what tends to happen if they're just too unstable for imaging.

Still, I had a ruptured AAA based on exam and bedside u/s who we ended up doing a non-contrast CT for pre-op planning. At first, I was somewhat contentious about this when talking to vascular, but it was a situation where the fellow was in the ED and the attending had to drive in from home. Because of the location, they needed to know whether they could do an endovascular repair vs an open approach, which made way more sense to determine the extent of the rupture based on imaging. In the end, the guy walked out of the hospital neurovascularly intact.

 

[Venko]

I would also add...how unstable / hypotensive does a trauma patient have to be where direct to OR beats outcomes rather than five mins in CT then OR. I would think better understanding of the problem prior to OR results in some smaller surgeries and fewer complications. Certainly is an assumption though. Maybe the answer is that this is center dependent as the closer and faster the trip to CT the more unstable a patient can be and still benefit from the imaging...just my thoughts

TL

 

[deleted109597]

I would tend to disagree about trauma. Granted, it might let them focus on one quadrant a little better, but they're getting an ex lap. Not any studies that I'm aware of that promote laparoscopic trauma surgery. Certainly, scanning the stable patient has allowed us to stop operating on the liver/spleen lacs and have improved outcomes. I just don't see that happening in the unstable patient.

 

[Tiger26]

I'd defer to the surgeons because they're taking them to the OR (or not) but I think the decision to CT unstable trauma patients depends on the organ system involved and the pre-test probability for the location of disease. The two scenarios I see it being helpful are where the suspicion is for an intracranial or pelvic injury.

Isolated head:
--- Negative CXR and neg FAST: CT to eval whether instability is predominantly intracranial or not.
--- Positive FAST or CXR: OR for ex lap

Pelvis: CT if possible to r/o abdominal bleeding needing an ex lap before going to the angio suite

 

[RPedigo]

(all of this is my personal opinion and open for debate, of course)

If there is an unstable patient who is getting an ex lap anyway, they should immediately go to the OR and they'll see everything in the abdomen that they need to see. An ultrasound bedside can show if there is a significant hemothorax, pneumothorax, or pericardial effusion that needs to be acted on immediately in case the etiology of the hypotension is not solely limited to the abdomen. If the etiology of the patient's hypotension/instability is in the abdomen, they should go to the OR because there are not many situations in when CT would alter management. In the case where the patient is unstable and has an abdominal etiology of hypotension, the FAST is pretty sensitive because there will be a significant amount of intraperitoneal fluid. Same goes with penetrating neck trauma with hard signs; over an 80% pretest probability of having an operative lesion, and delay in a CTA of the neck is unnecessary.

In a medical patient, I think ultrasound is again the way to go. The RUSH exam can be performed quickly, reliably, and it takes me 2 minutes to evaluate the patient's contractility, preload, presence or absence of a pneumothorax, presence or absence of free intraperitoneal/pelvic fluid, and presence or absence of an aortic aneurysm. Once they are appropriately resuscitated they can get a CT.

I think some people also tend to underestimate the time it takes to get a CT scan. It takes 5 minutes to get the patient on the scanner table, maybe 3-or-so minutes for the tech to punch in all the settings for the scan and to do the scan, another 2-3 minutes to push the images over to the PACS for viewing, and then another maybe 3-5 minutes to actually read the scan and get data that can be synthesized into changing the operative plan. Even in the best of scenarios, you're delaying operative repair by more than 10 minutes if a surgical suite is already ready.

 

[Janders]

"It depends"

As a resident, I would send anything not literally peri-arrest to CT. Why? Because CT was in the ED, just around a corner, and I could easily send a nurse and a resident and an RT with the patient. Along with meds, a code cart, and whatever else we needed. If it was a trauma case that was "grey zone", then the trauma attending and resident(s) could all go with the patient.

As an attending at a non-teaching institution, I am certainly more aware that "CT is where people go to die." It is rare for me to be able to go and sit with the patient in CT for the 15 minutes it really takes... I HAVE done it a couple times (I'm 2 out of 3 for predicting aortic dissections... and 2/2 for pedi-head bleeds...). That said, CT IS just down the hall. It is closer than the ICU. IF the patient is intubated, on a vent, has good access, and is meta-stable... it is pretty reasonable to get that CT if you need it. Just make sure you talk the game plan over with whomever is going to CT (usually RN +/- RT at my shop).

 

[Rendar5]

It depends. my residency's ED, of course they go to CT.
Here? CT is 5 minutes away, and only the ED responds to in-house codes at night. So peri-code does not go to CT. It stays right here.

 

[pinipig523]

Ah... I was a little cavalier about this before. Send them... it's only 5 minutes and they'll survive.

But, one night shift.... single coverage, sent a syncope guy there.... guy got on the ct table, passed out, stopped breathing. We had to do CPR on the table, then somehow we got him to the gurney, then back to the ER where I had to tube him but it was a crazy process trying to get a line in an ESRD patient.

 

[Venko]

Would this be better happening in an elevator or hallway heading to ICU? CT didn't cause the code it was destined to happen...

 

[deleted109597]

Would this be better happening in an elevator or hallway heading to ICU? CT didn't cause the code it was destined to happen...

At most shops like that, you keep them downstairs until they're no longer peri-code, or transport is there to take them to a staffed ICU. Most rurals I worked at the "ICU" was for people on tele, and everyone else just kind of sat around hoping not to die and be noticed at shift change.
I don't send people upstairs to be "resuscitated." That's my job, unless they need IR or OR.