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. 

 Aftermath: The Night Shift Season 1 Finale Review

Aftermath: The Night Shift Season 1 Finale Review

At Loose Ends

It’s strange calling this a season finale, because it’s only been an 8-episode summer run, and nearly every episode has…

Doximity’s Next Trick: Connectivity at the Point of Care

Doximity’s Next Trick: Connectivity at the Point of Care

You’ve raised $81 million in investments and your physician membership now exceeds that of the AMA. What’s next?

If you're Doximity, it's time to dream big. 

Subcutaneous Insulin in DKA: Safe — But Not Better

Subcutaneous Insulin in DKA: Safe — But Not Better

Newer Isn't Always Better

Studies show that the benefits of subcutaneous insulin over old fashioned IV insulin are marginal at best.

A Return to (Lousy) Form: Episode 7 of The Night Shift

A Return to (Lousy) Form: Episode 7 of The Night Shift

Forks! Strippers! Guns!

Once again, our characters are responding to the (frankly unbelievable) events unfolding around them, rather than driving the action.

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. 

Oh Henry: A Sucker is Born Every Minute

Oh Henry: A Sucker is Born Every Minute

Pharmaceutical Ads, Government, and the Physician-Patient Relationship

Though it pains me to say it, this is one time where caveat emptor doesn’t apply. 


A Ray of Hope

A Ray of Hope

The Night Shift, episode 6

This was the first episode where it felt like the characters were driving the plot.

The Downside of the Upswing

The Downside of the Upswing

You should have cashed in big-time. 
But did you?

The last several years of returns have been among the best ever.

5 Things Your Patients Might Think After Watching ‘Code Black’

5 Things Your Patients Might Think After Watching ‘Code Black’

An inside view of the ED

Code Black provides a harrowing and enlightening window into the front lines of healthcare. 

Talking Points

Talking Points

Link your vision to action

As an ED leader, you must not only have a vision and plan, but you must communicate that vision effectively…

Toxic Liquid Nicotine

Toxic Liquid Nicotine

New FDA regulations proposed for E-cigs

Highly unregulated, the sale of toxic nicotine concoctions for e-cigarette refills pose a serious threat to children.

All Choked Up

All Choked Up

Best Practices for Battery Ingestion

A two-year-old presents at a clinic with persistent cough and neck discomfort and winds up in the ED.

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.

Lock the Gates!

Lock the Gates!

Board certification is vital in EM

Last month, Rick Bukata suggested that ACEP open its gates to non-boarded EPs. 
This would be an insult to EM…

AMA Meeting Highlights

AMA Meeting Highlights

Association Gives Nod to First EP President-elect

This June’s AMA Annual Meeting proved as eventful as ever, with one exciting twist that has the potential to impact…

The Storm Episode!

The Storm Episode!

Episode 5 of NBC's "The Night Shift"

It’s time for the passion that’s been building up between the two lead ED doctors for … the past few…

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 Counter: Go Ahead with Non-Contrast CTs
Safely Saves Time and Money

by Kevin Klauer, DO


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. 


 

Popular Authors

  • Greg Henry
  • Rick Bukata
  • Mark Plaster
  • Kevin Klauer
  • Jesse Pines
  • David Newman
  • Rich Levitan
  • Ghazala Sharieff
  • Nicholas Genes
  • Jeannette Wolfe
  • William Sullivan
  • Michael Silverman

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