From: Andrew Bowman
Date: 22.12.2001 05:51 GMT

Need some input please.

21 year old male, just released from local jail a few hours before. Had enough time to get a blood alcohol of 0.122 and stole a car which he crashed at ~70mph into a concrete wall. No seatbelt but air bag deployed. EMS found pinned in by dash/steering wheel, moaning. Extricated, high flow O2 and IV x2 with rapid transport to my ED.

On arrival, awake, moaning, GCS 8. Large laceration above right eye with palpable, non-depressed skull fracture, chest abrasions, firm abdomen, multiple open, lower extremity fractures/dislocations (femur/ankle on right, tibia/fibula on left).

Pulse 120, strong peripheral, BP 110-140/60-80, RR 28 with coarse rhonchi bilaterally.

Rapid sequence intubation without difficulty, breath sounds still = with rhonchi no change vitals.

Off to CT.

Brain CT = "small" shear. No hematomas or contusions.

Abdomen = Grade 3 liver injury with free blood in abdomen

Pelvis = OK

Stable vitals in CT as above. Neuro, general surgery and ortho has been called already and are enroute.

Radiologist sees liver injury and says "Turn the IV's wide open" in a loud voice (not yelling or screaming, just loud).

I say, his BP is okay and his peripheral perfusion is good wait for blood to get ready (has had almost 4 liters crystalloid by now, sorry Dr Mattox).

He again yells to turn the IV's wide open. We promptly get him off CT table and go back to ER, hang 2 units blood via Level 1 warmer and off to surgery.

My thoughts were (no offense to the radiologists on the list) you are looking at the pictures, not the patient. Patient was pink, warm, strong peripheral pulses, BP 130/80, pulse 110-120. I know he is tachycardic but he also has lots of fractures and pain (getting morphine IV). Easy on the non-O2 carrying fluids and do not flood him out with ringers and saline, makes things so much worse.

Any thought from all of you?????

Thanks,

Andrew J. Bowman, RN, CEN, CCRN, NREMT-P
Lafayette, Indiana USA

From: Mathias Kalkum
Date: 22.12.2001 10:00 GMT

Andrew,

Seems to me you are quite right.

Once you have activated your trauma team: who is responsible for the
management of the victim? (Read: who has to decide what's first, where to
go, and what to do / not to do?) He's the one to talk to.

Mathias

From: Eric Frykberg
Date: 22.12.2001 14:10 GMT

You of course are correct--but I do not understand how there could be a problem here--certainly your personnel do not take patient care orders from a radiologist?

If so you have a difficult system problem, mainly consisting of confusion as to who is in charge of the patient--that must be straightened out --patient care cannot be done by committee, and if this case does not demonstrate why, nothing will

ERF

From: Pat Offner
Date: 22.12.2001 17:30 GMT

"Death begins in radiology"

Patrick J. Offner, MD MPH
Chief, Surgical Critical Care
Denver Health Medical Center
Associate Professor of Surgery
University of Colorado Health Sciences Center

From: Bertil Leidner
Date: 22.12.2001 17:46GMT

Some thoughts from a radiologist -

1. of course the call for iv fluids is not to be made by a radiologist but by the trauma leader/surgeon.

2. the mere presence of a significant injury alone does not tell you about the need for more fluids or not.

3. BUT int the presence of a significant injury, there is also good information in the CT images about the patient's volume status
a hypovolemic patient will/may show hypovolemic signs such as a constriction of the aorta (if not too arteriosclerotic) a low volume inferior vena cava, intensive renal (sometimes also bowel and mesenteric ) enhancement ; increased contrast concentration in the aorta, and in the thorax a decreased diameter of aorta with it's branches, superior v cava and cardiac chambers + increased enhancement of pulmonary contusions.

4. These sign are of course to be evaluated together with the bleeding sources of the patient, the age etc, but quite often we find these signs in patients with a slight tachycardia and normal blood pressure - and if not observed and volume loss is not corrected, we see the patient becoming "unstable" shortly afterwards.

Again, this information is to be given to the trauma leader for consideration, not for the radiologist to start taking part of the treatment.

Yours
Bertil Leidner

From: Andrew Bowman
Date: 22.12.2001 18:05 GMT

Thanks for your input. The problem(s) with our system include:

Surgeon(s) not called often until after ED assessment (by the surgical committee decision)

EDP or surgeon often do not accompany the patient to CT

Pt care is left to the trauma nurse with the patient who has to call the ED to talk with EDP/surgeon.

I knew I was right in regards to the fluid management, I acted like I was messing with the IV's to appease the rad doc.

Andrew B

From: Eric Frykberg
Date: 22.12.2001 19:05 GMT

3. BUT int the presence of a significant injury, there is also good information in the CT images about the patient's volume status
a hypovolemic patient will/may show hypovolemic signs such as a constriction of the aorta (if not too arteriosclerotic) a low volume inferior vena cava, intensive renal (sometimes also bowel and mesenteric ) enhancement ; increased contrast concentration in the aorta, and in the thorax a decreased diameter of aorta with it's branches, superior v cava and cardiac chambers + increased enhancement of pulmonary contusions.
4. These sign are of course to be evaluated together with the bleeding sources of the patient, the age etc, but quite often we find these signs in patients with a slight tachycardia and normal blood pressure - and if not observed and volume loss is not corrected, we see the patient becoming "unstable" shortly afterwards.

Interesting how your opinion differs from your own textbooks, and from the teaching of a welll known pediatric radiologist I studied under in medical school, who clearly taught his residents --when they tried to make this very diagnosis from a shadow on a piece of celluloid--that hypotension and hypovolemia is NOT a radiologic diagnosis.

The signs you mentioned are nonspecific, and may apply to many other things as well, whcih you failed to bring out(how about Addison's disease?). It is a classic--and dangerous--pitfall to ever think that these shadows can substitute for actually seeing a patient, and understanding what the patient tells us. You seem to agree with this, but I sensed a little "but..." in there that did not belong, in my opinion

ERF

From: Bertil Leidner
Date: 05.01.2002 22:22 GMT

Dr Frykberg,
you will find CT signs of hypovolemia described in the references below. As any other information these signs must be interpreted (like lab results etc) together with the patients clinical status. Yes, I agree that the signs are not specific but they are to find in the images and are to be interpreted, NOT to be overlooked. Try it, you might like it :-))

Making use of this information demands though that the attending surgeon gets the information as soon as possible, i.e. interpreted by the radiologist directly off the CT monitor and not by any reading off the film later, since the CT scan tells about the patient only at the time when he was scanned.

You also wrote "It is a classic--and
dangerous--pitfall to ever think that these shadows can substitute for
actually seeing a patient, and understanding what the patient tells us. "
Well I did not argue that point, BUT yes, there is a BUT, there is significant information about the patients status, also volume status, that should be observed.

Bertil Leidner

Taylor, G A. Fallat, M E. Eichelberger, M R.
Hypovolemic shock in children: abdominal CT manifestations.
1987 (164(2)) pp 479-481
Radiology

Jeffrey Jr, R B. Federle, M P.
The collapsed inferior vena cava: CT evidence of hypovolemia.
1988 (150(2)) pp 431-432
AJR Am J Roentgenol

Shin, M S. Berland, L L. Ho, K J.
Small aorta: CT detection and clinical significance.
1990 (14(1)) pp 102-103
J Comput Assist Tomogr

Sivit, C J. Taylor, G A. Bulas, D I. Kushner, D C. Potter, B M. Eichelberger, M R.
Posttraumatic shock in children: CT findings associated with hemodynamic instability.
1992 (182(3)) pp 723-726
Radiology

Hara, H. Babyn, P S. Bourgeois, D.
Significance of bowel wall enhancement on CT following blunt abdominal trauma in childhood.
1992 (16(1)) pp 94-98
J Comput Assist Tomogr

Rotondo, A. Catalano, O. Grassi, R. Scialpi, M. Angelelli, G.
Thoracic CT findings at hypovolemic shock.
1998 (39) pp 400-404
Acta Radiol [0284-1851]

Bertil Leidner, M.D.
Specialist of Diagnostic Radiology and Neuroradiology
Department of Radiology
Huddinge University Hospital
SE-141 86 Stockholm, Sweden

From: Eric Frykberg
Date: 06.01.2002 01:05 GMT

[...] excuse me for my skepticism, but such nonspecific "shadow signs" are just not clinically useful--take it for how it is meant from one who deals in the clinical every day. My caution was to radiologists who tend to lose sight of the value of the patient and consequently overblow the value of their shadows, in many cases--as in the original example cited of the radioologist giving simply outlandish orders completely divorced from reality--with potential harm to the patient. Perspective--and a respect for the final clinical--read CLINICAL--judgement--of the clinician in charge, is my plea. What brings about this plea is the simple fact we see so often of radiologists who lose sight of this.

Do NOT misconstrue the above as in any way demeaning the value of radiographic images in the evaluation of trauma, or of the importance of the radiologist as part of the team. A warped perspective, and the misuse and misinterpretation--usually overinterpretation-- of x-rays, is what I caution against, just as much as I would the misinterpretation of the clinical picture by surgeons.

ERF

From: Ken Mattox
Date: 06.01.2002 03:41 GMT

Next someone will write an article about the ability of CT to determine
hematocrit, blood alcohol levels, and bilirubin levels.

k

From: Sal Sclafani
Date: 06.01.2002 05:00 GMT

The CT signs of hypovolemia should not be discarded so abruptly. Just like any other sign, clinical or otherwise, there is value in the observation. When the aorta and vena caval diameters are shrunken to less than a centimeter, woe to those who would dismiss this. they will regret it like dismissing other signs of hypovolemia. Because they are virtual signs does not mean that they are not valid. Auscultation, just like CT, is merely a representation, a reflection of reality, not reality itself dependent upon hearing, vibrations and ambient noise.

The bias against radiological signs reflects a view from the past when xrays were merely shadows. CT is a pretty sophisticated tool and while it may be misinterpreted like, as rick says, other signs, it is far more accurate than many other findings that we rely upon.

sal

From: Avi Roy Shapira
Date: 12.01.2002 11:55 GMT

> Next someone will write an article about the ability of CT to determine
> hematocrit, blood alcohol levels, and bilirubin levels.

In truth, it may be possible. Few people, even cardiologists, know that
there are ECG changes typical to coma. There are. Skilled ECG
interpreters can tell that a patient is in coma, without seeing the
patient.

The pitch and pattern of a murmur is very telling. Some past generation
cardiologists could listen to the heart, and tell you the pressure
gradient across the pulomonic or mitral valve.

Both skills are awesome. But are they of any use? Do you need an ECG to
diagnose coma, or would anyone operate on the pulmonic valve without a
cath?

It is quite possible that a skilled radiologist can read hypovolemia on
the CT scan images. However, it is just as useless as reading coma on an
ECG.

Avi

==========================================================================
Aviel Roy-Shapira, M.D.
Soroka University Hospital &
Ben-Gurion University Medical School
Beer Sheva, Israel

From: Sal Sclafani
Date: 12.01.2002 16:21 GMT

AVI

IS THERE ANY DATA THAT SHOWS THAT THE CLINICAL MANIFESTATIONS PRECEED THE COMPUTED TOMOGRAPHIC SIGNS OF HYPOVOLEMIA?

SAL SCLAFANI

From: Avi Roy Shapira
Date: 13.01.2002 20:05 GMT

Dear Sal,

First, there is no need to shout :-). (in netiquette, using all caps
means shouting)

Second, to quote Eric, it is those who use CT for hypovolemia that need to
show that CT signs occur earlier than clinical ones. The person who
introduces a new test carries the burden of proof that it is better than
the older methods, not the other way around.

But, in most other situations, radiological signs lag behind the
clinical. This is true for plain films, and it is also true for CT
scans. Since signs of hypovolemia on CT must be quite subtle (this is
evidenced by the fact that most radiologists can't recognize them) you
probably need a significant hypovolemia before this signs show up.

When the radiologist can call hypovolemia on the CT, I read it as
a sign that he or she is an astute radiologist. Good to know, and
impressive. The same can be said for the cardiologist who can read coma in
the ECG. It allows you to assess the skill of the cardiologist, but you
don't need it to diagnose coma.

Avi

From: Dave Nappiollelo
Date: 13.01.2002 13:15 GMT

Call me naive, but does anyone have a specific clinical situation in which
relying on CT to prove hypovolemia or an ECG to identify a coma might somehow
supercede standard parameters such as urine output, blood pressure, pulse
rate and dare I say swan?????? The best I can come up with in my head is if a
bus load of EBOLA virus patients were in an accident in front of a CT Scanner
factory.
Dave Nap.

From: Eric Frykberg
Date: 13.01.2002 23:15 GMT

Of course you are right--this is the whole point of the original debate. Only in the minds of those with no clinical experience could this look at all rational, as it sounds on paper like it would be of value. It is always hard for non-clinicians to understand the distinction betwen what a picture shows and how clinically necessary it is. Many examples abound, i.e. CT gives a very accurate and reliable picture of appendicitis--no argument. A number of papers show this (big surprise!), but then make the mistaken jump to the conclusion that CT therefore is of value in the diagnosis because of this--which of course is wrong--accuracy is not the issue--whether it is necessary is the issue, and this disconnect is the biggest fault I find with the radiology literature. Same with the value of arteriography--or noninvasives--to detect peripheral arterial injuries--very accurate, but simply unnecessary in the great majority of scenarios. Routine surgical exploration of all injured extremities for vascular injury is also highly accurate, but again, unnecessary, as the same result can be obtained by doing much less.

again--this is not at all to minimize the value of these tests--just to put their appropriate use in the proper perspective, and it is those who make and must be responsible for the consequences of these clinical decisions every day who are the best to make this judgement--just like the best person to describe a CT or other radiographic image is one who is trained in imaging and does it every day. Problems happen when either such specialist tries to invade the other's expertise --and it is such a problem that was illustrated by the ppost beginning this debate. Any such debate must not lose sight of the distinction betwen how accurate and pretty a picture is, and how much it adds to clinical management.
I am often astounded--as one who consults radiologists often to help describe what an x-ray shows because I know my limitations in this--how often radiologists do NOT recognize their analogous limitations and are perfectly content to expound a clinical decision which is completely off the wall, despite never in their carreers ever having been held primarily accountable for a surgical decision. Not knowing is not the problem--it is not realizing when one does not know that makes them dangerous. And--clinicians may be as guilty of this as nonclinicians
For Sal's benefit, and any radiologists who mistakenly take this as offensive to their profession--this does not refer to him or those many like him with quite a bit of clinical sense, but Sal--you would not pull the kind of idiocy like the radiologist in the opening example of this discussion, who gave a clinical order without having any appreciation whatever for the patient sitting right in front of him.
ERF

From: Sal Sclafani
Date: 14.01.2002 03:30 GMT

Sorry for shouting, i am a little hard of hearing.

I was really asking a question rather than asserting a position. But i have certainly seen cases of blood loss on CT that were unsuspected on clinical grounds but pretty obvious on CT.

Sal.

From: Eric Frykberg
Date: 14.01.2002 03:40 GMT

For Sal's benefit, and any radiologists who mistakenly take this as offensive to their profession--this does not refer to him or those many like him with quite a bit of clinical sense, but Sal--you would not pull the kind of idiocy like the radiologist in the opening example of this discussion, who gave a clinical order without having any appreciation whatever for the patient sitting right in front of him.
ERF

Thanks Rick
I appreciate that.
As a clinician who treats trauma patients, I use as much information as I can to get a global sense of the patient. As a radiologist I rely more than most on imaging information to get the best sense of the patient as i can, just as others use physical appearance to get a sense of status, mechanism etc. Do I use any bit of information in a vacuum, no. Its just that images allow me to see more of the inside. We are taught to remove the patients clothing, I prefer to remove the skin too.

sal

From: Eric Frykberg
Date: 14.01.2002 13:57 GMT

Sorry for shouting, i am a little hard of hearing.
I was really asking a question rather than asserting a position. But i have certainly seen cases of blood loss on CT that were unsuspected on clinical grounds but pretty obvious on CT.

But Sal--here is the point. If unsuspected on clinical grounds, that obviously means the patient is stable, and thus no active bleeding is going on. The patient, not the CT, is the determining factor in the clinical decision-making. Also, we were not talking about seeing blood (actually, let's be accurate here and say "fluid"), which does have some diagnostic value--you were talking about signs on CT of hypovolemia--fluid in the abdomen is not
ERF

From: Sal Sclafani
Date: 14.01.2002 23:50 GMT

Rick
here is the point:

the child died
should never have come to a ct scanner

[...]

Lets be clear...no one, certainly not I, is advocating CT to diagnose hypovolemia. It just happens to be a finding during CT for other reasons. This whole conversation is getting boring. Should I not mention signs of hypovolemia because YOU might be able to diagnose it some other way? Of course not. Is this sign seen in patients where hypovolemia is clinically unrecognized? I would hope so, otherwise there are many surgeons, radiologists and emergency physicians showing in the literature CT scans of patients that they know clinically to be hypovolemic.

This being said, I wasnt party to this discussion's beginning as I was out of town.Perhaps I missed something. I got involved when I picked up a computer virus opening one of these emails.

I am not saying that you should have a CT performed to determine hypovolemia. I am saying that I use that information when I see it, as part of the formulation of my CLINICAL decisions that I am not supposed to make because I am a radiologist. You might find it useful as an adjunct too.

Sal Sclafani

From: Bertil Leidner
Date: 20.01.2002 23:10 GMT

Let me try to clarify once more - of course you do not scan a patient in order to evaluate for hypovolemia, BUT if the traumatized patient is hypovolemic there are signs to observe, not to ignore. I also gave several references in the literature.

We have had several cases of quite badly injured persons (splenic lac; pelvic fx etc) where the surgeon has not appreciated the clinical signs of hypovolemia, and when the anesthesiologist evaluates the patient he/she is in hypovolemic shock. In a world where no one is perfect, it might be of value to make use of more of the information there actually is to find in the CT exam.

Bertil Leidner, Stockholm, Sweden

From: Eric Frykberg
Date: 20.01.2002 23:51 GMT

In all of these cases, as you make clear, the clinical signs ARE there in the patient, just not appreciated by the surgeon--a poor surgeon does not mean you rely on a radiologic sign that the patient already makes clear. The danger of even considering your recommendation is it fosters this clinical incompetence, in not looking at a patient, but just at shadows.

These signs will never be absent in the patient by the time they are present on the CT. The way to solve this problem is to learn how to look at a patient, not to come up with some poor substitute. Of course, those who foster looking at the x-rays are precisely those who typically do NOT look at patients primarily--what a surprise!
ERF