Joshua Broder

CT utilization: the emergency department perspective

CT scan utilization in the pediatric emergency department (ED) has dramatically increased in recent years. This likely reflects the improved diagnostic capability of CT, as well as its wider availability. However, the utility of CT is tempered by the high radiation exposure to patients as well as cost. In this review we will consider the magnitude of changes in CT use in the pediatric ED, and we will examine some of the driving forces behind these increases. In addition, we will consider strategies to limit growth in CT scan utilization or even result in reductions in CT use in the future. These strategies include better physician and patient education, application of existing clinical decision rules to reduce CT utilization and development of new rules, technical alterations in CT protocols to reduce per-exam exposures, use of alternative imaging modalities such as US and MRI that do not expose patients to ionizing radiation, and expanded use of clinical observation in place of immediate diagnostic imaging. Reform of liability laws might alleviate another driving force behind high CT utilization rates. Protocols must be designed to maximize patient safety by limiting radiation exposures while preserving rapid and accurate diagnosis of time-sensitive conditions.

Content and Style of Radiation Risk Communication for Pediatric Patients

The diagnostic benefits of medical imaging, including CT, must be weighed against the risks of ionizing radiation and communicated effectively to patients. Health care providers requesting and performing these examinations have a shared responsibility for this risk-benefit discussion. Effective and balanced communication of these risks requires style as well as content mastery. Fundamentals of communication are similar for all patients, but special attention is needed in the pediatric setting.

ACR Appropriateness Criteria Head Trauma

Neuroimaging plays an important role in the management of head trauma. Several guidelines have been published for identifying which patients can avoid neuroimaging. Noncontrast head CT is the most appropriate initial examination in patients with minor or mild acute closed head injury who require neuroimaging as well as patients with moderate to severe acute closed head injury. In short-term follow-up neuroimaging of acute traumatic brain injury, CT and MRI may have complementary roles. In subacute to chronic traumatic brain injury, MRI is the most appropriate initial examination, though CT may have a complementary role in select circumstances. Advanced neuroimaging techniques are areas of active research but are not considered routine clinical practice at this time. In suspected intracranial vascular injury, CT angiography or venography or MR angiography or venography is the most appropriate imaging study. In suspected posttraumatic cerebrospinal fluid leak, high-resolution noncontrast skull base CT is the most appropriate initial imaging study to identify the source, with cisternography reserved for problem solving. The ACR Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed every three years by a multidisciplinary expert panel. The guideline development and review include an extensive analysis of current medical literature from peer-reviewed journals and the application of a well-established consensus methodology (modified Delphi) to rate the appropriateness of imaging and treatment procedures by the panel. In those instances in which evidence is lacking or not definitive, expert opinion may be used to recommend imaging or treatment.

Cost-effective, Reusable, Leak-resistant Ultrasound-guided Vascular Access Trainer.

BACKGROUND Ultrasound guidance for insertion of a peripheral venous catheter is becoming common practice in many emergency departments in the difficult-to-access patient, and simulation has become an important tool for health care practitioners to learn this technique. Commercial trainers are expensive, and low-cost alternatives described to date provide a sub-optimal training experience. We introduce ballistics gel as a new material for the creation of simulating phantoms. MATERIALS AND METHODS Directions describe construction of a simulating phantom composed of 10% ballistic gelatin and commonly available latex tubing. The models success as used by one residency training program and medical school is described. RESULTS Cost per phantom was

Malaria: a rising incidence in the United States.

22.83, with less than an hour preparation time per phantom. We found these phantoms to offer a comparable user experience to commercially available products and better than other homemade products. DISCUSSION Ballistics gel is a novel material for production of simulation phantoms that provides a low-cost, realistic simulation experience. The clear gel material works well for novice learners, and opacifying agents can be added to increase difficulty for more advanced learners. The material offers flexibility in design to make models for a broad range of skill instruction. CONCLUSION A relatively quick and easy process using ballistics gel allowed us to create a simulation experience similar to commercially available trainers at a fraction of the cost.

Prospective Double-Blinded Study of Abdominal-Pelvic Computed Tomography Guided by the Region of Tenderness: Estimation of Detection of Acute Pathology and Radiation Exposure Reduction

Malaria is frequently a deadly disease, particularly in tropical countries of the world where this protozoan infection is endemic. While physicians in tropical countries are familiar with the presentation, those who do not practice in endemic regions of the world may neglect to add tropical diseases to their differential diagnosis of fever. Epidemiologic data from the CDC show the number of cases of malaria being diagnosed in the United States in the last decade has risen sharply. With international travel continuing to rise, there is strong reason to consider malaria as a source of fever.

Head Computed Tomography Interpretation in Trauma: A Primer

STUDY OBJECTIVE Computed tomography (CT) is increasingly used for emergency department (ED) patients with abdominal tenderness. CT-related radiation contributes to 2% of US cancers. We hypothesized that in the ED patient with nontraumatic abdominal tenderness, the tender region accurately delineates acute pathology. z axis-restricted CT guided by this region could detect pathology while reducing radiation dose. METHODS This was a prospective double-blinded observational trial with informed consent and was institutional review board-approved and registered with ClinicalTrials.gov. A convenience sample of ED patients undergoing abdominal CT was recruited, excluding pregnant women, patients with altered mental status or abdominal sensation, preverbal children, and patients with abdominal trauma or surgery in the previous month. Before standard CT, physicians demarcated the tender region with labels invisible to radiologists on abdominal windows. Radiologists blinded to the tender region recorded cephalad-caudad limits of pathology on CT. Personnel blinded to pathology location recorded label positions on lung windows. Two hypothetical CT strategies were then explored: CT restricted to the tender region and CT from the cephalad skin marker to the lower caudad limit of the usual CT. The percentage of the pathologic region contained within the extent of the 2 hypothetical z axis restricted CTs was calculated. z axis reduction, which is linearly related to radiation reduction, from the restricted CTs was determined. RESULTS One hundred two subjects were enrolled, 93 with complete data for analysis. Fifty-one subjects had acute pathology on CT. CT limited to the tender region would reduce z axis (radiation exposure) by 69% (95% confidence interval [CI] 60% to 78%). All acute pathology was included within these boundaries in 17 of the 51 abnormal cases (33%; 95% CI 22% to 47%). CT from the cephalad marker through the caudad abdomen and pelvis would reduce z axis (radiation exposure) by 38% (95% CI 29% to 48%). All acute pathology was included within these boundaries in 36 of 51 abnormal cases (71%; 95% CI 57% to 81%). With both strategies 1 and 2, the pathologic region was at least partially included within the CT region in the majority of cases (84% and 92%, respectively). CONCLUSION CT with z axis restriction based on abdominal tenderness could reduce radiation exposure but with a potentially unacceptably high rate of misdiagnosis, using our current methods. Further prospective study may be warranted to determine the diagnostic utility of partially visualized pathology.

Versatile, Reusable, and Inexpensive Ultrasound Phantom Procedural Trainers.

Noncontrast computed tomography (CT) provides important diagnostic information for patients with traumatic brain injury. A systematic approach to image interpretation optimizes detection of pathologic air, fractures, hemorrhagic lesions, brain parenchymal injury, and abnormal cerebrospinal fluid spaces. Bone and brain windows should be reviewed to enhance injury detection. Findings of midline shift and mass effect should be noted as well as findings of increased intracranial pressure such as hydrocephalus and cerebral edema, because these may immediately influence management. Compared with CT, magnetic resonance imaging may provide more sensitive detection of diffuse axonal injury but has no proven improvement in clinical outcomes. This article discusses key CT interpretation skills and reviews important traumatic brain injuries that can be discerned on head CT. It focuses on imaging findings that may deserve immediate surgical intervention. In addition, the article reviews the limits of noncontrast CT and discusses some advanced imaging modalities that may reveal subtle injury patterns not seen with CT scan.

Acute aortic emergencies--part 2: aortic dissections.

We have constructed simple and inexpensive models for ultrasound‐guided procedural training using synthetic ballistic gelatin. These models are durable, leak resistant, and able to be shaped to fit a variety of simulation scenarios to teach procedures. They provide realistic tactile and sonographic training for our learners in a safe, idealized setting.

Acute aortic emergencies--part 1: aortic aneurysms.

Patients with aortic disease are some of the highest acuity patients that emergency clinicians encounter. Dissection is the most common aortic catastrophe and involves separation of the aortic layers in a longitudinal fashion leading to diminished perfusion and systemic ischemia. Characteristics of pain, branch vessel involvement, and incidence lead to an understanding of patient presentation, morbidity, and mortality. Diagnosis, selection of diagnostic studies, the degree of preoperative ischemia, and risk of operative mortality can be accomplished using validated clinical decision tools. Emergency interventions are guided by the type of dissection according to the Stanford classification system. Medical management includes pain control and anti-impulse, antihypertensive therapy through vasodilatation and blockage of the sympathetic β-response. The patient may then be evaluated for open surgical intervention, aortic fenestration, endovascularly placed stent grafts, or a combination possibly in a staged approach. Morbidity includes rupture, stroke, paraplegia, acute renal failure, bowel ischemia, and peripheral ischemia.