Non –Trauma Emergency CT Imaging: How Relevant is it to Patient Care? Lavanya Kalla, M. D., Jessica S. Conn, M. D., Teresita L. Angtuaco, M. D., Ernest J. Ferris, M. D.

Background Research project performed by two first year residents (Drs. Kalla and Conn) as part of ACGME residency competency requirement for practice-based learning Choice of topic was prompted by concern for “overutilization” of Radiology imaging resources Question: are radiology residents asked to perform “electronic physical examinations on call”

Purpose The purpose of our study was to investigate whether CT examinations requested for non trauma related emergencies on-call made an impact in patient care.

Subjects 274 total patients 132 (48 %) Neuroradiology 142 (52%) Body CT charts of 274 patients undergoing emergency CT scans for non trauma related reasons (January-February 2003) 132 scans were neuroradiology CT scans (head, spine and neck) 142 were body CT scans (chest, abdomen and pelvis) Follow-up was available on 271, 3 patients left AMA

Methods Post imaging diagnoses were compared to the pre-imaging referral diagnoses The impact of initial imaging on further patient management was determined after retrospectively reviewing the discharge summaries Outcome was determined based upon whether our diagnoses led to patients’ admission or discharge.

Methods CT scans were classified according to the type of diagnosis provided at the time they were ordered Specific diagnosis (i.e. stroke, SAH, diverticulitis, appendicitis, renal stones) Non specific diagnosis (i.e. generalized abdominal pain, mental status change) Yield of positive findings was determined based on the type of diagnosis and how the findings impacted patient management

(142) = 52% Body CT (83)=59%Specific (58)=41% Non-specific (132)=48% Neuroradiology (39)= 30% Specific (91) =70% Non-specific Results

91 scans = 70% Non specific 11% were positive 89% were negative 39 scans = 30% specific 43% were positive 57% were negative Results for Neuroradiology CT scans

H: New onset right sided weakness, r/o stroke F: Infarct in the left motor cortex H: worst headache of my life, rule out SAH F: Hemorrhagic infarct in the left parietal lobe Specific Diagnosis – Positive Findings

H: Dysphagia with fever, r/o abscess F: Right tonsillar abscess H: New onset seizures, rule out stroke F: Hemorrhagic stroke in the brainstem with decompression into the fourth ventricle. Incidental old infarct in the right temporal lobe.

H: Mental status changes, F: embolic stroke in the right motor cortex Same patient with thrombus in the right carotid artery Non-specific Diagnosis – Positive Findings

58 = 41% Non specific 43% were significant 57% were negative 83 = 59% specific 57% were positive 43% were negative Results for Body CT scans

High grade SBO H: Bowel obstruction F: SBO with transition zone in the distal ileum H: LLQ pain and fever r/o diverticulitis F: Left hydrosalpinx H: RLQ pain, r/o appendicitis F: Appendicitis H: Bowel obstruction F: High grade SBO with ischemia Specific Diagnosis – Positive Findings

H: Fever and pain in the LUQ with rebound tenderness, r/o abscess F: Abscess in LUQ H: APPENDICITIS F: Abscess in rlq H: Excruciating mid abdominal pain, r/o pancreatitis F: Duodenal perforation with free air

H: Diffuse abdominal pain, N/V Findings – sigmoid diverticulitis History: RUQ pain Findings – Non specific colitis H: Diffuse abd pain F: acute pancreatitis H: Diffuse abd pain F: LLQ abscess Non-specific History – Positive Findings

Fournier’s gangrene Necrotic mesenteric nodes and ascites Acute appendicitis with abscess Immunosuppressed pts with diffuse abdominal pain

H:Patient was admitted based on clinical symptoms. F: acute left basal ganglia stroke diagnosed after admission on MRI Clinically positive findings – Initially negative CT

H: Old thalamic infarcts, presenting with new onset mental status changes, r/o acute hemorrhage F: no hemorrhage H: Neck swelling, r/o abscess F: large goiter Neuro CT which helped in decision to discharge patient

H: Abdominal distension and pain, r/o SBO F: Wide neck ventral hernia w/o obstruction H: Post partum, presenting with rlq pain, r/o appendicitis F: Right hydroureter (postpartum) H: Non specific, non localizing abdominal pain F: Ovarian cysts CT helped in decision to discharge patients

Acute exacerbation of Crohn’s disease Patient admitted Patient with known ulcerative colitis, no acute findings; patient discharged Known hernia with acute abdominal pain F: Pneumonia, no bowel obstruction – patient discharged CT role in patient management

CONCLUSIONS CT imaging plays a pivotal role with respect to patient admission and discharge in the acute setting. For neurological studies the yield of positive findings was higher when a specific diagnosis was sought (43 % vs. 11 %). For body imaging, there was no significant difference in the results of the scans whether they were performed based on specific or non specific diagnosis (57% vs. 43%)

CONCLUSIONS NEURORADIOLOGY – For neurological studies the yield of positive findings was higher when a specific diagnosis was sought (43 % vs. 11 %). However even when a specific dx was not sought, we helped triage the patients and it was imperative to rule out life threatening conditions.

CONCLUSIONS BODY CT - For body imaging, there was no significant difference in the results of the scans whether they were performed based on specific or non specific diagnosis (57% vs. 43%) In both categories we found findings which were significant and helped in further patient management.

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