Who should decide on the pan-scan?

Quick answer – it’s a team effort, we have to do the whole difficult “talking to people” thing.

Longer answer?

Gupta M, Schriger DL, Hiatt JR, Cryer HG, Tillou A, Hoffman JR, Baraff LJ. Selective use of computed tomography compared with routine whole body imaging in patients with blunt trauma. Ann Emerg Med 2011 Nov.;58(5):407–416.e15. PMID 21890237

Methods

• prospective data on 701 trauma activations at UCLA

How did they decide who to scan? Quote:

Physicians managed trauma patients in their usual fashion, with the trauma team making the final determination about which scans were performed.

• EPs and surgeons were then surveyed (before the CT was done) on whether on not they thought the scans were necessary
• worth noting that the authors (half EPs, half surgeons) struggled to get consensus on definitions of clinical significance

Results

• 701 patients; 2800 scans; median ISS of 5 which I don’t think is that high. I searched the paper but found no overall mortality figure…
• EPs thought 35% of individual scans were unneeded
• Surgeons thought 7% of individual scans were unneeded
• by consensus they said that only 3 of 102 abnormal undesired scans (out of 900 total undesired scans) had an injury needing a critical intervention. These were:
• T8 burst fracture with SCI not seen on CXR, went to the OR
• SAH, GCS 15, no intervention
• 10 rib fractures and contusion, got a chest tube the next day

It’s worth mentioning more about these three injuries:

• the Spinal Cord injury was already noted and the T8 fracture would have been looked for once the CT neck was noted to be negative
• the SAH was given platelets as they were on aspirin. I’m not sure this is a critical intervention
• 9 of the 10 rib fractures were already seen on the CXR

There were lots of other injuries that were picked up on the CTs that the EPs didn’t want, though most of them weren’t in any way life-threatening.

Discussion

This is the truly fascinating part of the paper. Normally I barely read discussions as they have little relation to what the study actually found. But this one is worth a read.

Both sides get their say. The surgeons on why they think they need to keep on scanning, and the EPs on why they feel OK not scanning.

One more quote:

With physician judgment as the test, the negative likelihood ratio for an undesired scan having abnormal results and producing a critical action was 0.05

My thoughts:

The easier it is to get the CT, the more we’ll do. There is definitely a problem with that. I’m not sure I’m as calm and relaxed about not scanning as Hoffman and Schriger might be but I do lean toward doing less.

I remember working in ICU for a year and often picking up a new injury a day for the first week. I remember taking a big chunk of glass out of a guy’s scalp, 10 days after his RTA! The thing is it wasn’t really a problem.

I want to know what injuries my trauma patient has. I’m just not sure I need to know every single one right now. And pan-scanning is all about right now