Transfusion Confusion

Transfusion Confusion

Knowing the Real Risks of Blood Transfusion

This routine procedure bears real risks and should be handled accordingly.

The ABCs (and T) of Rural EM

The ABCs (and T) of Rural EM

Situational Awareness is Key

When you’re practicing in the middle of nowhere, planning out a timely patient transfer can be as critical as securing…

DNR Means Do Not Treat . . . and Other End-of-Life Care Myths

DNR Means Do Not Treat . . . and Other End-of-Life Care Myths

Debunking 5 Fallacies

Improve your EOL care and communicate more effectively.

Through the Looking Glass

Through the Looking Glass

Three Novel Use Cases for Google Glass in the ED

How might augmented reality change your practice?

Augmented ED

Augmented ED

The future of emergency medicine?

EPs in Rhode island overcome hurdles to trial Glass for telemedicine and consider other applications.

All About Metoclopramide (Reglan)

All About Metoclopramide (Reglan)

Know the risks

Reglan should be used with caution if patients have Parkinson’s disease or are on antipsychotics.

Physicians Won't Be Silenced

Physicians Won't Be Silenced

ACEP's Gag Order Rejected

EPM readers speak out against ACEP’s new ruling prohibiting incoming leaders from answering questions from non-ACEP publications.

Changemaker

Changemaker

How One EP Transformed Mental Health Admissions in Virginia

Debra Perina combined her experience as a coroner with her time leading an ED to challenge the establishment.

Get the Gear Off

Get the Gear Off

Removing the Helmet and Pads is Crucial to Treating Spinal Injuries from Football

Up to 25% of c-spine injuries from football collisions may be exacerbated by the poor removal of helmet and pads.

The War on Death

The War on Death

by Greg Henry, MD

The guns and butter debate is really over, I guess.

The Ebola Plan

The Ebola Plan

CDC Quarantine Map Shows that a U.S. Ebola Outbreak is Unlikely

Amid the worst outbreak of the Ebola virus in recorded history, there have been concerns that the disease could spread…

How Do I Know if I'm Being Paid Fairly?

How Do I Know if I'm Being Paid Fairly?

Trust is key

I get paid based on my productivity, but I don't trust that my company is paying me accurately.

The Stethoscope of the Future

The Stethoscope of the Future

Bedside Ultrasound

The applications of bedside ultrasound have gone well beyond scanning the gallbladder . . . to the lungs?

ICEM 2014

ICEM 2014

Tintinalli Headlines & Holliman Assumes Presidency

On June 11, EPM Editor-in- Chief and renowned educator Judith Tintinalli took to the stage in Hong Kong to address…

The Medical Malpractice Rundown: A State-by-State Report Card

The Medical Malpractice Rundown: A State-by-State Report Card

When it comes to medical liability laws and culture, where you live matters.

Find out how your state stacks up against the other 49.

CT – Lowering Cost and Radiation

CT – Lowering Cost and Radiation

Medicare pays only about 20% of typical charges and radiation can be reduced by 90%.

The cost of a CT is actually quite nominal – the charge, however, is an entirely different matter. 

Oxygen is a Drug— Act Accordingly

Oxygen is a Drug— Act Accordingly

Understanding the dangers of indiscriminate oxygenation in the ED setting

As with many things in medicine, dogma seems to overpower the evidence in this arena. 

Gag Order

Gag Order

New ruling prohibits would-be ACEP leaders from answering questions from non-ACEP publications.

Greg Henry seldom fails to deliver on a promise. But this time, it looks like it’s out of his control.

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Contrast protocols, including intravenous, oral and/or rectal contrast, are just not necessary for abdominal CTs. From my perspective, the only emergent CTs that warrant IV contrast administration are CT pulmonary angiograms to identify pulmonary emboli, chest or abdominal CTs to investigate suspicion for aortic dissection and perhaps for blunt abdominal trauma.  
Several studies have shown the accuracy of unenhanced or non-contrast studies. Their accuracy has been proven for almost any intra-abdominal process you could consider.

Keyzer reported in 2009 that in 131 patients, comparing oral and IV protocols to IV only, visualization of the appendix was dependant upon the reader not the protocol (AJR Am J Roentgenol. 2009 Nov;193(5):1272-81.). Beyond the concept of inter-reader variability is the fact that unenhanced studies are very accurate and are becoming more so as technology continues to improve. In 1999, Lane reported unenhanced CTs to be 96% sensitive and 99% specific for appendicitis in 300 consecutive ED patients suspected of having appendicitis (Radiology 213:341, 1999.).  In 2002, the British Journal of Radiology reported the same findings in 108 patients with surgically proven appendicitis. The sensitivity of unenhanced CTs with 5mm sections was 96% sensitive and 98% specific for appendicitis (Br J Radiol. 2002 Sep;75(897):721-5.).   Some have reported that with less intra-abdominal fat, visualization of the appendix is more difficult in pediatrics, necessitating contrast to discern the appendix from other structures. Hoecker, at the Children’s Hospital of San Diego, reported no difference in the accuracy of unenhanced CT, compared to findings for enhanced CTs reported by previous studies. They reported the positive and negative predictive value to be 91.3% and 90.8%, respectively.  

Hill, from Michigan State University, confirmed that for all non-traumatic intra-abdominal processes, there was no statistical difference between enhanced and unenhanced studies for making the correct diagnosis (World J Surg. 2010 Apr;34(4):699-703.), and Tack reported similar findings for the diagnosis of diverticulitis (Radiology. 2005 Oct;237(1):189-96.).

Although suggesting a place for IV contrast, the use of oral contrast provides no benefit for detecting bowel or mesenteric injuries (J Trauma. 2004 Feb;56(2):314-22.). No evidence refutes the value of IV contrast for splenic and hepatic vascular injuries, reserving a place for its use in trauma.

The situation changes if the concern is for an intra-abdominal vascular catastrophe. Some clinicians mistakenly interchange the terms aortic dissection, a separation of the intima from the media, and aneurysm. Although dissections can sometimes be associated with aneurysms, these two diagnoses are very different. You can have a leaking or ruptured AAA without a dissection, and you can have a dissecting aorta without any aneurysmal dilatation. Thus, if you are looking for a dissection, you need intravenous contrast to show the false lumen (separation) between the intima and the media. Not so for aneurysms, as a dilated aorta can be easily seen without contrast. Blood from a leaking or ruptured AAA is evident without any contrast. The blood is contrast enough.  

The real controversy in the use of oral and/or rectal contrast exists with abdominal/pelvic studies. Radiologists report the increased sensitivity of 64 and 128-slice MDCT scanners and warn us constantly of hypersensitivity reactions, albeit less likely with non-ionic contrast, and contrast-induced nephrotoxicity. And yet, they still want us to use contrast to “improve imaging quality.” If they want to limit the risk of acute hypersensitivity reactions and nephrotoxicity, they need to quit demanding contrast when the evidence just doesn’t support its use.  

In addition to posing additional unnecessary risk to the patient, using contrast also causes substantial operational issues in every emergency department, resulting in increased throughput times, diagnostic delays and less patients being seen. For example, if an oral contrast protocol takes 90 minutes to complete (delivery, ingestion of the contrast and waiting for it to traverse the GI tract) and 10 ED patients undergo this protocol daily, a cascading effect of delays will result.  Those ten protocols will cost your department 15 hours of bed time. This equates to 5,475 hours annually. If the average length of stay (all comers) is two hours, 2,737 less patients can be seen in your department annually, resulting in $273,700 less physician reimbursement (assuming an average $100 collected per patient) and $1,095,000 less revenue for the hospital in ED charges alone (assuming an average of $400 per visit for the facility/hospital side).

So if the contrast is not clinically necessary, per the research, and it’s obstructing the ED, why are we still doing it? The radiologists claim they get better results. However, their own literature suggests that they don’t. To quote Rick Bukata: If we put their own literature in a Mercedes catalog, maybe they’ll read it. The fact is that whatever marginal benefit in image quality is perceived by some Radiologists is most likely personal preference and is so minor that it doesn’t aid them in getting the right answer.

There are limitations to CT with any abdominal process. However, the use of contrast doesn’t remedy those concerns. It has been proposed that we should just order “renal stone protocol CTs” and avoid the argument altogether. I don’t advocate this approach for two reasons.  First, without disclosing what pathology we are truly looking for, we are handicapping the Radiologist, impairing their ability to appropriately interpret the study. If you’re worried about appendicitis, they need to know that. The second reason is that we shouldn’t hide from this discussion. If we stop calling this practice into question, I fear it will be accepted as standard practice, resulting in delays, ED inefficiency and potential patient complications.
 

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