When is an MRI warranted in the ED?

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DeadCactus

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Looking for both a general conceptual answer and specific diagnosis being seriously considered. What are your thoughts?
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Not to derail my own thread but I Googled this out of curiosity to see if a similar conversion was out there.

http://www.injuryclaimcoach.com/er-doctor-didnt-give-me-an-mri.html#

"I'm very upset that the ER doctor didn't order my an MRI. I think since I had walked into the ER on my own and the nurse told the doctor, they thought I was stretching the pain factor and brushed me off. They didn't perform the proper medical tests to diagnose my injury. Can I sue them for medical malpractice?"
 
1. Acute spinal cord compression (not routine herniated disk/sciatica) - motor findings only (epidural abscess, cauda equina, epidural hematoma)
2. Delineate CVA in a critical situation, VERY rarely done, or cerebral venous sinus thrombosis
3. R/o appendicitis in pregnancy
4. R/o ligamentous injury / cord contusion / central cord in a trauma patient with a concerning exam and focal neurologic findings

I do not need any approval from anyone to order these tests at my level 1 trauma center, and I would say I order less than 10 MRI's a year. Probably 2-3 spine/cord, 2-3 appy, ~1 odd CVA situation, and 5 or so trauma ones. The obvious cord injuries / abnormal CT ones trauma handles those.

I do not and have not ever ordered an MSK MRI. However, in a patient who I suspect torn knee ligaments, I tell them, hey, you may have a bunch of torn ligaments, here's crutches, brace, orthopedic follow up, you need another exam and an MRI as an outpatient when the swelling goes down, and we don't do that MRI here. I think that is where the doc made a misstep in the case you posted, but no, that is not going to result in a successful malpractice suit.
 
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DeadCactus said:
Not to derail my own thread but I Googled this out of curiosity to see if a similar conversion was out there.

http://www.injuryclaimcoach.com/er-doctor-didnt-give-me-an-mri.html#

"I'm very upset that the ER doctor didn't order my an MRI. I think since I had walked into the ER on my own and the nurse told the doctor, they thought I was stretching the pain factor and brushed me off. They didn't perform the proper medical tests to diagnose my injury. Can I sue them for medical malpractice?"
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I think this might be the first time in history that the comments to an online post are actually useful.
 
goodoldalky said:
1. Acute spinal cord compression (not routine herniated disk/sciatica) - motor findings only (epidural abscess, cauda equina, epidural hematoma)
2. Delineate CVA in a critical situation, VERY rarely done, or cerebral venous sinus thrombosis
3. R/o appendicitis in pregnancy
4. R/o ligamentous injury / cord contusion / central cord in a trauma patient with a concerning exam and focal neurologic findings
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This pretty much sums it up. I guess the one exception to this would be request by a specialist. Very rarely, ortho or another specialty will request on a patient for surgical planning. We do need radiology approval for all MRIs.
 
Dr.McNinja said:
I think this might be the first time in history that the comments to an online post are actually useful.
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Of course, there is the scumbag lawyer comment, who, several times, repeats "misdiagnosis". Umm, even if the doc called it a "knee sprain", that is a correct diagnosis. Hell, "knee contusion" or "knee pain" are correct, if nonspecific, diagnoses.

"99% of lawyers make all the rest of them look bad."
 
It really does depend on which kind of ED you are working- community, level 1, academic etc. At my ED, no MRIs are done after 430PM weekdays. If someone truly has a cord compression, they would need to be transferred to another facility or talk to the radiologist to see if they can send in the staff (not likely to happen). Luckily, I haven't had a caudal equina pt.

Stroke like patients? They get a CT scan without contrast and if within the TPA window (and all the other stroke checklist etc, they get admitted for an MRI the next day). The MRI staff apparently goes home early and would have to be called in for the evening MRIs (and they don't like that)

I would venture to say that a pregnant person with an appendix gone bad can be admitted for an MRI the next day (if not obviously toxic) or just admitted to OB and let them handle it from there

There are times when I want to get an MRI on a pt who could go home if the MRI is neg (re- rule out posterior circulation problem for example, older pt who has dizziness, doesn't sound quite peripheral but not quite a stroke yet,) but that patient also gets admitted where I am and gets their MRI, the next day. This does suck admittedly.

We transfer peds cases so after the CT if more work up is needed, they would be sent elsewhere too.

Working at the current place has changed my thinking about when an emergent MRI is needed- i.e very few cases actually need an emergent MRI
 
TooMuchResearch said:
That site linked above gets into some weird examples. ER doctors using cocaine and leaving surgical instruments in people or severing the femoral artery resulting in death?
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Pretty sure that was an episode of code black
 
I order MRIs to rule out SEA not infrequently. And with my patient population's love of illicit IV pharmaceuticals, we find them
 
Some high end EDs are also using MRAs for PEs in certain populations.
 
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This is pretty simple, but an MRI is needed if it will change acute management for an emergent diagnosis.

There are many other conditions where an MRI may be needed as part of an inpatient eval.

If the patient is getting admitted no matter the results, the MRI can be ordered and followed up by the admitting team.
 
There are very few cases where an MRI is emergent. Sure, there are some tricks you may want to do with an MRI but it also depends on the resources and if you can safely delay the MRI (or do alternative test)
 
It's hard to believe what you guys are saying. I routinely read anywhere from a couple to 10 MRIs a night on night float as a radiology resident that are ordered from the ED. Most of them for stroke, some for trauma, occasional appendicitis in pregnancy, every now and again internal derangement in a knee (wtf?), handful of MRs of the abdomen or pelvis for a mass or something weird. Perhaps I am not understanding the question, as some of these exams are ordered by the stroke or trauma services, for example, and not the ED itself. Are you guys just discussing situations where an MR will determine ultimate disposition or something?
 
meister said:
It's hard to believe what you guys are saying. I routinely read anywhere from a couple to 10 MRIs a night on night float as a radiology resident that are ordered from the ED. Most of them for stroke, some for trauma, occasional appendicitis in pregnancy, every now and again internal derangement in a knee (wtf?), handful of MRs of the abdomen or pelvis for a mass or something weird. Perhaps I am not understanding the question, as some of these exams are ordered by the stroke or trauma services, for example, and not the ED itself. Are you guys just discussing situations where an MR will determine ultimate disposition or something?
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You're at an academic center. Crap gets abused there. Mris got ordered all the time in the ed at my old residency cause it was so hard to get anyone dispod. Neuro wouldn't take neuro symptoms Without an MRI or if the MRI was normal. Ortho or Nsgy wouldn't admit back pain with neuro symptoms without an mr. Trauma wouldn't admit neck pain sp mvc with normal ct until mr was normal. Basically a bunch of crap. Since it was so easy to get mrs, our attendings would occasionally start taking advantage of it ordering knees and stuff for people they felt sorry for.
 
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winkleweizen said:
You're at an academic center. Crap gets abused there. Mris got ordered all the time in the ed at my old residency cause it was so hard to get anyone dispod. Neuro wouldn't take neuro symptoms Without an MRI or if the MRI was normal. Ortho or Nsgy wouldn't admit back pain with neuro symptoms without an mr. Trauma wouldn't admit neck pain sp mvc with normal ct until mr was normal. Basically a bunch of crap. Since it was so easy to get mrs, our attending a would occasionally start taking advantage of it ordering knees and stuff for people they felt sorry for.
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Agree. But why in the world are you admitting neck pain after trauma with a negative CT???
 
meister said:
It's hard to believe what you guys are saying. I routinely read anywhere from a couple to 10 MRIs a night on night float as a radiology resident that are ordered from the ED. Most of them for stroke, some for trauma, occasional appendicitis in pregnancy, every now and again internal derangement in a knee (wtf?), handful of MRs of the abdomen or pelvis for a mass or something weird. Perhaps I am not understanding the question, as some of these exams are ordered by the stroke or trauma services, for example, and not the ED itself. Are you guys just discussing situations where an MR will determine ultimate disposition or something?
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Go to a community hospital. That number will approach 0. The only time it's really appropriate in the ED is to R/o epidural abscess. Most other times, the patient can be admitted or discharged with followup.
 
meister said:
It's hard to believe what you guys are saying. I routinely read anywhere from a couple to 10 MRIs a night on night float as a radiology resident that are ordered from the ED. Most of them for stroke, some for trauma, occasional appendicitis in pregnancy, every now and again internal derangement in a knee (wtf?), handful of MRs of the abdomen or pelvis for a mass or something weird. Perhaps I am not understanding the question, as some of these exams are ordered by the stroke or trauma services, for example, and not the ED itself. Are you guys just discussing situations where an MR will determine ultimate disposition or something?
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Rad resident too. I probably read a similar amount overnight. I think part of the problem on our side is that at least at our institution, if the order is placed in the ER or before the pt is admitted, the MRI comes across as an ED study with a stat turnaround time expectation even though the patient is getting admitted and is more a routine inpt priority exam. Probably suboptimal for MSK as there is less subspecialty coverage at off hours.
 
turkeyjerky said:
And not evidenced based (afaik, mra has not been shown to be effective for r/o PE)
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It's an option -- just that it's a crappy option relative to CTA. Expensive, not as efficient, time-consuming.

MRA has about an 80% sensitivity for acute emboli. Obviously, it's higher for big, proximal goombas, and much lower for more distal, smaller clots.
 
I try to not call neurology. They always want MR something or other.

I used to order MRI brain for elderly vertigo, now they often get CT and admission. The non-treatable stroke gets identified a few hours later.

Trauma and neurosurgery often want MR ordered on patients who are getting admitted and not getting urgent surgery. These can get ordered after the bed is assigned, and Epic allows you to order it and assign it to whichever inpatient doc requested it. Stat MRI for neurosurgery coming in from home to fix a spine with neuro deficit, of course I'll arrange to get it done immediately. Rule out ligamentous injury in the intubated CT negative patient? That can happen upstairs.
 
winkleweizen said:
" rule out ligamentous injury". Our spine ppl want mrs if they won't range their neck after a neg ct
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You admit for that?? We DC in collar with spine f/u. My understanding is that 99% of them feel better in 2-3 days, self-DC collar and never show up.
 
here's another -- MRI a hip for occult fracture if xrays are neg in elderly who cannot walk due to hip pain/trauma.
 
Zebra Hunter said:
Why would you not just CT them?
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you can. But if it's neg and they still can't walk then get an MRI because it is more sensitive. There's an argument to jump straight to MRI because if the CT is neg, the patient will need an MRI anyway. I suppose this could be an "admit for MRI" scenario. I do it in the ED and have caught numerous CT neg occult fractures.
 
DeadCactus said:
Not to derail my own thread but I Googled this out of curiosity to see if a similar conversion was out there.

http://www.injuryclaimcoach.com/er-doctor-didnt-give-me-an-mri.html#

"I'm very upset that the ER doctor didn't order my an MRI. I think since I had walked into the ER on my own and the nurse told the doctor, they thought I was stretching the pain factor and brushed me off. They didn't perform the proper medical tests to diagnose my injury. Can I sue them for medical malpractice?"
Click to expand...


Interesting... do you think the patient would want to sue the ED doc if he didn't think the doc thought he was "stretching the pain factor"? Is this evidence for, "be nice and you won't get sued"?
 
BAM! said:
you can. But if it's neg and they still can't walk then get an MRI because it is more sensitive. There's an argument to jump straight to MRI because if the CT is neg, the patient will need an MRI anyway. I suppose this could be an "admit for MRI" scenario. I do it in the ED and have caught numerous CT neg occult fractures.
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I usually just admit these people--because they can't walk.
 
BAM! said:
here's another -- MRI a hip for occult fracture if xrays are neg in elderly who cannot walk due to hip pain/trauma.
Click to expand...

turkeyjerky said:
I usually just admit these people--because they can't walk.
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We use CT, not MRI for these folks. So many logistic advantages to CT.

The fracture missed by CT – well, that basically gets managed the same way as a fracture diagnosed on MRI at my place: placement for pain control and rehabilitation. We do it directly from the ED.
 
xaelia said:
We use CT, not MRI for these folks. So many logistic advantages to CT.

The fracture missed by CT – well, that basically gets managed the same way as a fracture diagnosed on MRI at my place: placement for pain control and rehabilitation. We do it directly from the ED.
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more than one way to skin a cat. Not saying either is better. However, depending on your availability/access, this may be another indication for MRI in the ED.
 
Extremehippo11 said:
I had a guy who I thought had cauda equina syndrome (like almost the only time we order them) the other day. Turned into having to page spine and get their permission, then talk to the MRI coordinator, then my attending who has been there like 30 years had to retroactively sacrifice her firstborn. Basically turned into an hour arguing with the coordinator before we could get it.


Sent from my iPhone using SDN mobile app
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And whatd the scan show
 
In my peds ED, we often get MRIs - especially qBrain MRIs, in order to spare kids the radiation. But we have in house pediatric radiologists and neuroradiologists 24/7, which is not possible at most places.
 
Just had a cauda equina syndrome today 2/2 an epidural abscess. Felt nice when the family was impressed that I had essentially made the diagnosis prior to the MRI even though the patient did not have a fever.
 
Zebra Hunter said:
Just had a cauda equina syndrome today 2/2 an epidural abscess. Felt nice when the family was impressed that I had essentially made the diagnosis prior to the MRI even though the patient did not have a fever.
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Name/post synergy
 
xaelia said:
We use CT, not MRI for these folks. So many logistic advantages to CT.

The fracture missed by CT – well, that basically gets managed the same way as a fracture diagnosed on MRI at my place: placement for pain control and rehabilitation. We do it directly from the ED.
Click to expand...

If one were to construct an MMPI to evaluate the practice environment of a hospital this would be one of the questions.

Radiologists will tell you that CT has essentially no role in these types of cases since this scenario rarely happens in healthy 20 year old men, but rather in 80 yo females with significant osteopenia. This means that the bone essentially behaves more like a soft tissue and requires MRI, not like typical bone that is best imaged with CT. Thus radiology and IM (who have to know what is happening) will tell you that CT has no role in the evaluation.

EM and ortho will of course tell you that it doesn't really matter. If CT doesn't see the fracture, it is still going to be treated almost exactly the same way in the near term at least. And as mentioned CT has advantages in logistics and who cares about radiation dose in a 90 yo?

So it often turns into a subtle tug-of-war between those who insist on "imaging correctly" and "you really have to have a good diagnosis" versus "it doesn't make any difference so who cares?"

For those of us old enough to remember, one of the early MASH episodes featured a psychiatrist sent in under-cover to evaluate how the unit was holding up. If such a scenario played out today, this is probably one of those things that would give him an idea of how the organization thinks.
 
I order maybe 1 mri a month emergently if that.

R/o epidural? I usually admit for that unless its a non ivdu. But i dont typically think about it unless its a ivdu. Ivdu fevers require more workup hence the admission.
Cant walk? CT then admit. You are talking a few percentage points of sensitivity you are missing
Cva? Never
Appy in preg? Admit for serial exams.
PE? Never
Spine compromise. Yes.
Post stroke? Yes, rarely.
Dsvt is the one i prob i over order on. Pregnant headaches scare me. Still a rare occurrence.

In residency our specialists ordered MRIs all the time out of the ER. Knees and such.
 
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