For this week’s Wednesday Wrap-up, I want to discuss the issue of the pan-scan in blunt abdominal trauma. Dr. Morley gave a great review of the evidence in the literature. This topic is very controversial and you will hear many differing opinions not just between EM and trauma surgery but also within our specialty on this topic. I think it is important to remember that we have great decision rules to help guide us when it comes to whether or not to scan the head or cervical spine and we should use them. The tough choice comes when deciding to scan the chest/abdomen/pelvis. I really enjoyed the review of the use of chest ultrasound in blunt trauma and think it should definitely be the standard. Admittedly, I don’t use it as often as I should.
But, I wanted to discuss further under what circumstances you think an abdominal CT should be performed after blunt abdominal trauma. If a patient is alert, not intoxicated with a reliable exam that is benign and FAST negative, should they still receive a belly CT. Is the deciding factor mechanism? or a constellation of signs and symptoms and what are they? Is there a place for serial abdominal exams, serial FASTs, and observation? I would love to hear what others’ opinions are regarding this issue and what your practice is. I know when trauma surgery gets involved the patient is pretty much guaranteed a pan-scan. Please leave your thoughts below.
Thanks,
JK
Jay Khadpe MD
Latest posts by Jay Khadpe MD (see all)
- Morning Report: 7/30/2015 - July 30, 2015
- Morning Report: 7/28/2015 - July 28, 2015
- IN THE STRETCHER INSTEAD OF BESIDE IT - July 22, 2015
- Morning Report: 7/14/2015 - July 14, 2015
- Morning Report: 7/10/2015 - July 10, 2015
i agree that once trauma gets involved, it’s pretty much a done deal. i suppose my practice is that since i am not managing the patient definitively, i leave it to their discretion. the way surgeons are taught now is to use the CT to “map” the surgery, and I suppose, to set their level of concern for the patient; ie “if they have a negative CT and can go to the floor, i don’t have to worry too much about them” vs if there is any finding on the CT, it increases the patient’s presence on the surgeon’s radar. i think all this talk of what to do regarding trauma patients is great – it stimulates thought, but in terms of changing practice, i think it will only change when the attending surgeons change their practice. if we don’t order the scans they want, they will either not admit the patient or they will order the scan immediately after admission. i hope that as our working relationships improve, the trauma literature moves to support less imaging, when indicated or we develop good clinical decision rules, and lawyers stop suing surgeons and ER docs, maybe then, the practice will change.
rant over.
I order abdominal CT in trauma mostly based on the mechanism (i.e. pedestrian struck, high-speed MVC) and presence of pain. I think the literature suggests (not surprisingly) that physical exam is unreliable in these patients (specific but not sensitive). However, if you are going to observe the patient yourself in the ED, and the patient is low-risk, there may be a place for serial exam/FAST in some cases.
I do think we perform too many CTs, and besides using established guidelines, in the interest of avoiding radiation, one should consider using plain radiography (yes, regular x-rays) to study the cervical spine, especially in younger, cooperative patients.
Lastly, I do not think anyone should order tests they do not believe are indicated just because the consulting service (often a PGY2) requests them. If the consulting service feels strongly about performing a test which you do not believe in, make them order it (or you can order it) under the supervision of THEIR attending. Why should you take the responsibility of any consequences of such a test?