Received: 6 January 2004 / Accepted: 14 January 2004 / Published online: 3 April 2004. © ASER 2004. Abstract The ... radiology technician should be present from 6.30 p.m. to .... clinical course was used as the gold standard [11, 12, 13,.
Emergency Radiology (2004) 10: 296–298 DOI 10.1007/s10140-004-0338-3
POINT–COUNTERPOINT
Mariano Scaglione
The use of sonography versus computed tomography in the triage of blunt abdominal trauma: the European perspective
Received: 6 January 2004 / Accepted: 14 January 2004 / Published online: 3 April 2004 Ó ASER 2004
Abstract The management of the trauma-emergency patient has become an important political and economic issue and one of the major challenges of the industrialized countries. In Europe ultrasonography is always part of the basic work-up, following physical examination, whereas computed tomography (CT) remains a secondline investigation. Injury prevalence, radiation dose exposure, practicability, and costs are relevant considerations in our emergency departments, where we have a growing number of patients seeking medical attention. The radiologist’s task is to decide which imaging modality is most appropriate after the clinical context has been taken into consideration. The clinical value of CT is unquestioned; what is questionable is only its systematic use. With the growing demand for trauma care, screening ultrasonography can lower the number of inappropriate CT examinations. Keywords Sonography Æ Computed tomography Æ Trauma Æ Management
Background: radiology in European EDs National health services in Europe are now facing management problems as a result of the limited resources available for health care, and in contrast to the increased expectations of the population. Traffic accidents are on the increase, as is violence, and there are a growing number of elderly and uninsured, indigent patients seeking medical attention. As a result, acutely ill patients are showing up at emergency departments (EDs) in greater numbers than ever before. In France M. Scaglione (&) Emergency and Trauma CT Section, Department of Radiology, Cardarelli Hospital, Napoli I, Italy M. Scaglione Via G. Merliani 31, 80127 Napoli I, Italy
the number of people making use of the ED is consistently increasing at an estimated rate of 5% per year. Thus, EDs are having considerable socioeconomic impact, with the management of acutely ill patients becoming a major challenge in many European countries. In many European EDs, the mainstay of emergency diagnostic strategy revolves around the clinical evaluation. Beyond partial support from national regulations, the culture and tradition of emergency medicine is that emergency physicians are the only ones responsible for patient management and for deciding on the necessary diagnostic tests: therefore, emergency physicians must see and examine the patients and make specific (written) questions before ordering diagnostic tests. On the other hand, radiologists have the obligation and legal responsibility to choose which imaging test is most appropriate based upon the clinical questions and risks (which include radiation dose exposure) and benefits to the patients, in order to avoid unnecessary radiological examinations. As a result, we now work with two important considerations in mind: (1) emergency radiologists are not mere executors of an order or exclusively confined to performing the examinations requested, but should be considered specialists having a pivotal role in patient management, imaging algorithms, and diagnosis, and (2) emergency radiologists need to be in the emergency room (ER), working and collaborating with emergency physicians 24 h a day, 7 days a week. These two points are the result of a hard-fought battle and represent the success of the European medical community in general and the radiological societies in particular. Surprisingly, until a few years ago, only radiology technicians, rather than a radiologist, were present on a permanent standby basis in many European EDs in Italy, France, and many other European countries. Art. D712–65 of the relevant French regulations state: ‘‘a radiology technician should be present from 6.30 p.m. to 8.00 a.m., and on holidays, to perform diagnostic examinations; the radiographs are to be handed to the department’s physicians and a radiologist must check and record
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them within 12 hours’’. This encouraged the proliferation of false expertise, with many surgeons believing (and still believing today) that they were able to perform ultrasound (US) examinations without the aid of a radiologist, while we, on the contrary, believe that the emergency radiologist is the only specialist who has a complete understanding of all the imaging techniques (including US) as we use them on a regular basis. The presence of a trained radiologist and his or her contributions to patient management affect the ‘‘traditional’’ European way of working in the ED. For example, while no one really questions the merits of CT, debate continues between the USA and Europe regarding its rational use in the management algorithm of multiple trauma patients; similarly, even though the use and advantages of US are well-established, there is still no general agreement on who (radiologists, technicians, surgeons, emergency medicine physicians) and how US should be performed in the emergency room, as well as its real value as a diagnostic procedure. By having a senior radiologist constantly present in the emergency room, all of the imaging procedures—ultrasonography (US), computed tomography (CT), magnetic resonance (MR), angiography, and conventional radiography (rationally allocated in the emergency room) can be performed by a radiology professional when indicated. This integrative approach requires the presence of a trauma team along with the appropriate back-up staff. The team must be ready and awaiting the arrival of the trauma patient. To be successful, close cooperation amongst the representatives of the key specialized disciplines must be automatic.
US in the ED In Europe, ultrasonography (US) has been extensively and successfully used as a screening technique since the late 1980s [1, 2, 3]; today, US has essentially replaced diagnostic peritoneal lavage in the primary evaluation of patients with blunt abdominal trauma [4, 5, 6], and at present it is the primary exam used in most trauma centers in Europe and Asia, as well as in selected centers in the United States [7, 8]. In fact, many studies, both from Europe and the United States, report high sensitivities (80–90%), with specificities greater than 90% [7, 8, 9, 10]; yet recently, some publications have focused on a number of potential pitfalls in using US on patients who have suffered blunt trauma [11, 12, 13, 14, 15].
The ‘‘European’’ sonographic technique The most suitable method for carrying out routine US examinations of blunt abdominal trauma uses sector or curvilinear array transducers of 3- to 5-MHz transducers. The US study is usually performed by an experienced senior radiologist in the ER within minutes of the patient’s arrival and in conjunction with the initial
resuscitation maneuvers [1, 9, 16, 17]. In fact, the standard abdominal sonogram should involve both a full abdominal exploration, with particular attention to the peritoneal pouches for any indication of hemoperitoneum, and a systematic solid organ analysis to detect any solid organ injuries. In addition, the US examination may also detect other findings such as pleural and pericardial effusions, and, on occasion, diaphragmatic, gallbladder, pancreatic and adrenal gland injuries, and non-trauma-related pathology.
The use of US in the triage of blunt abdominal trauma In several European and Asian (and some American) trauma centers US has been accepted as a cost-effective screening modality for that assessment of blunt trauma patients because it can be performed rapidly in the ER and is noninvasive, repeatable, nonirradiating, and inexpensive. US examination is highly sensitive in the depiction of intraperitoneal free fluid and may help differentiate those patients who require immediate abdominal surgery from those who do not, once the clinical picture is taken into consideration. Furthermore (and this is cited not only by European authors), in large series, US is a good adjunct to a negative physical examination (PE) to exclude the presence of significant solid organ lesions requiring surgery [7, 8, 9, 10, 15, 16, 17, 18, 19]. From a practical viewpoint, this is significant, considering the growing demand for trauma centers, the high prevalence of negative findings, and the cost restraints on our hospitals. As a result, this method of triage—US, PE, and laboratory investigations—is considered cost-effective on the whole because it has led to a substantial reduction in the number of negative CT exams performed and more selective use of the CT technology in many institutions. At the Cardarelli Hospital in Naples (Italy)—the only regional institution devoted to emergency and trauma care and one of the main trauma centers in the whole of Italy—of nearly 13,000 abdominal CTs we performed (on three multidetectors working 24 h/day, giving a total of 40,000 emergency patients/year) only 20% were truenegatives [20]. However, while US examination may be useful in a large number of patients, pitfalls do exist, and these are evidenced in those studies where CT rather than the clinical course was used as the gold standard [11, 12, 13, 14, 15]. Even with the limitations of US in mind, the clinical context, the PE, and the radiologist’s expertise all play a significant role in triaging patients with abdominal trauma: if the clinical context and the PE and US findings are negative, then in our practice the patient need not to be examined further. If, however, the patient is unresponsive, has a worsening abdominal pain/clinical condition, or has abnormal laboratory findings (decreasing level of hematocrit, persistent hematuria), then contrast-enhanced CT (or even repeat US) is recommended. A trained emergency radiologist, capable of
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performing US and CT complementarily, must be present in the ER along with all the requisite imaging procedures available and correctly allocated. So, CT, to all intents and purposes, is performed only if emergency US findings are positive or equivocal (i.e., only free fluid), or there is a high clinical suspicion of injury despite negative US findings. Finally, the use of screening US is recommended only in those institutions where an ample observation period is routine for those patients considered at risk.
Conclusions A uniform or cookbook approach in the work-up of trauma patients is neither possible nor desirable; the most important factors seem to depend very much upon local working conditions, the equipment available, the level of expertise of the trauma team, and the prevalence of injury. Anyway, in the trauma setting, surgeons and the emergency radiologists play a vital role for patient management. Being different imaging modalities, US and CT can not be comparable. In our hospitals, they have entirely different roles in the diagnostic work-up of trauma patients. The clinical value of CT is unquestioned! CT is wonderful, perfect in many cases, and all acknowledge its precision. However, CT should certainly not be used routinely in all trauma victims [21, 22]. In our practice, the best results in terms of benefits to the patient are achieved when a team of specialists make an intellectual effort to understand the problem(s) of the patient—to find the appropriate solution(s)—without placing too great a reliance on technology, however breathtaking it is. The current ‘‘liberal criteria’’ governing the use of CT in the emergency setting have de-emphasized the absolute necessity of deductive reasoning and replaced it with the dangerous ‘‘get the CT and then we’ll see what’s going on’’ mentality. Choosing which imaging test is the most appropriate still remains the radiologist’s task. With an experienced radiologist in the ER, he or she has the professional and moral right to decide, case by case, what is best to do. Apart from ethical, political, legal, or socioeconomic considerations, we should point out the inconsistencies of the ‘‘oversimplified’’ way of working, and strive to change this state of affairs—for the benefit of our patients and of our professional identity. Acknowledgements I would like to thank Dr. Paul J. Bode, Roberto Grassi, Fabio Pinto and Diego B. Nunez for their help.
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