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Home > List Archives

Opiates & the Acute Abdomen

ecthompson trauma-list@trauma.org
Fri, 11 Apr 2003 01:11:23 -0500


I think even Dr. Polk would admit that AJS isn't the best surgical
journal.  

Now, your arguing that a study that is based on a telephone survey of 60
ER's is worth getting all fired up over?

I think if you look at most hospitals and look at the literature CT
scans are being used as I described.  Maybe my hospital is the only one
but I doubt it.  I'm in the ER working up a trauma patient when I hear
the ER doc talking with the general surgeon on call.  They ask for some
type of test the majority of the type.  

Data?

Carrico CW,  Fenton LZ,  Taylor GA,  DiFiore JW,  Soprano JV  
Impact of sonography on the diagnosis and treatment of acute lower
  abdominal pain in children and young adults.

In: AJR Am J Roentgenol (1999 Feb) 172(2):513-6

ISSN: 0361-803X

OBJECTIVE: Our purpose was to evaluate the impact of sonographic data
  on clinical physicians' diagnostic confidence and their treatment of
  children and young adults with acute lower abdominal pain. SUBJECTS
  AND METHODS: Senior surgical and emergency department staff completed
  questionnaires before and after abdominal sonography was performed on
  94 of 101 consecutive children and young adults with acute lower
  abdominal pain, pelvic pain, or both. Physicians who were unaware of
  sonographic data stated the most likely diagnosis and their level of
  confidence in their diagnosis and then formulated clinical plans.
  After they were given sonographic data, physicians again stated the
  most likely diagnosis, estimated their level of confidence, and
  formulated revised treatment plans. RESULTS: Sonographic data
  resulted in revised clinical diagnoses in 52% of the patients.
  Overall, the gain in diagnostic confidence for the entire study
  population was 33% (95% confidence interval [CI], 27-38%; p < .0001).
  The impact on the physicians' confidence was greater in those
  children and young adults whose diagnoses changed after sonography
  (mean increase in physicians' confidence, 48.3%; 95% CI, 47-75%). In
  patients whose diagnoses were not changed after sonography, the mean
  increase in physicians' confidence was 17.6% (95% CI, 11-24%; p <
  .0001 [analysis of variance]). Physicians used sonographic data to
  change initial treatment plans in 43 patients (46%). Of these 43
  patients, a lower intensity of care was given to 30 patients (70%)
  and a higher intensity to 13 patients (30%). CONCLUSION: Sonographic
  data frequently changed initial clinical diagnoses, thus increasing
  diagnostic confidence and changing clinical treatment decisions in
  the setting of acute lower abdominal pain in children and young
  adults.

Institutional address: 
     Department of Radiology
     Children's Hospital and Harvard Medical School
     Boston
     MA 02115
     USA.

Peck J,  Peck A,  Peck C,  Peck J  
The clinical role of noncontrast helical computed tomography in the
  diagnosis of acute appendicitis.

In: Am J Surg (please note!!)(2000 Aug) 180(2):133-6

ISSN: 0002-9610

BACKGROUND: The accuracy of noncontrast helical computed tomography
  (CT) for appendicitis has recently been demonstrated. What is its
  clinical utility? METHODS: This was a retrospective review of 443
  consecutive community hospital patients evaluated for acute
  appendicitis over an 18-month period using limited pelvic CT scan or
  clinical acumen alone. RESULTS: Appendicitis was pathologically
  proven in 158 patients. The negative appendectomy rate was 5.4%. The
  best radiological indicators for a positive CT for appendicitis were
  pericecal inflammation (88%) and appendicolith(57%). Appendiceal CT
  was found to have a 92% sensitivity, 99.6% specificity, and a 97.5%
  accuracy. There were 260 patients who had a negative CT; 243 of these
  were sent home. Alternative diagnoses were identified in 22% of
  patients. CONCLUSIONS: The liberal use of noncontrast helical CT
  results in a low negative appendectomy rate and a high degree of
  confidence that a negative CT will allow patients to be sent home
  safely.

Stroman DL,  Bayouth CV,  Kuhn JA,  Westmoreland M,  Jones RC,  
  Fisher TL,  McCarty TM  
The role of computed tomography in the diagnosis of acute
  appendicitis.

In: Am J Surg (kinda intentional) (1999 Dec) 178(6):485-9

ISSN: 0002-9610

BACKGROUND: Routine contrast-enhanced computed tomography (CECT) has
  been described as an accurate diagnostic imaging modality in patients
  with acute appendicitis. However, most patients with acute
  appendicitis can be diagnosed by clinical findings and physical exam
  alone. The role of CECT in patients suspected of having appendicitis
  but with equivocal clinical exams remains ill defined. METHODS: One
  hundred and seven consecutive patients who were thought to have
  appendicitis but with equivocal clinical findings and/or physical
  exams were imaged by CECT over a 12-month period. Oral and
  intravenous contrast-enhanced, spiral abdominal and pelvic images
  were obtained using 7-mm cuts. CECT images were interpreted by a
  board-certified radiologist. Main outcome measures included CECT
  sensitivity, specificity, positive predictive value (PPV), negative
  predictive value (NPV), and accuracy in the diagnosis of acute
  appendicitis, comparing CECT with ultrasound, and determining the
  impact of CECT on the clinical management of this patient population.
  RESULTS: A group of 107 patients consisting of 44 males (41%) and 63
  females (59%) with a median age of 33 years (range 13 to 89 years)
  were imaged with CECT to evaluate suspected appendicitis. Of the 107
  CECTs performed, 11 false-positive and 3 false-negative readings were
  identified, resulting in a sensitivity of 92%, specificity of 85%,
  PPV of 75%, NPV of 95%, and an overall accuracy of 90%. Forty-three
  patients were imaged with ultrasound and CECT, and CECT had
  significantly better sensitivity and accuracy (30% versus 92% and 69%
  versus 88%, P<0.01). With regard to clinical management, 100% (36/36)
  of patients with appendicitis, and 4.2% (3/71) of patients without
  appendicitis underwent appendectomy. Therefore, the overall negative
  appendectomy rate was 7.6% (3/39). CONCLUSIONS: CECT is a useful
  diagnostic imaging modality for patients suspected of having acute
  appendicitis but with equivocal clinical findings and/or physical
  exams. CECT is more sensitive and accurate than ultrasound and is
  particularly useful in excluding the diagnosis of appendicitis in
  those without disease.

Wade DS,  Marrow SE,  Balsara ZN,  Burkhard TK,  Goff WB  
Accuracy of ultrasound in the diagnosis of acute appendicitis
  compared with the surgeon's clinical impression.

In: Arch Surg (1993 Sep) 128(9):1039-44; discussion 1044-6

ISSN: 0004-0010

OBJECTIVE: To compare the accuracy of the surgeon's clinical
  diagnosis of acute appendicitis with that of an ultrasonographic
  examination of the abdomen. DESIGN: Prospective trial. SETTING: US
  Navel Hospital, San Diego, Calif. PATIENTS: One hundred ten patients
  admitted to the hospital with suspected appendicitis from May 1990 to
  June 1992. INTERVENTION: Symptoms and signs for each patient were
  recorded, along with the surgeon's clinical impression of immediate
  surgery or observation. The patient then underwent an ultrasound
  examination performed by a staff radiologist. On the basis of the
  ultrasound findings the patient was placed into one of three
  categories: appendicitis, normal examination results, or other
  conditions. Patients with an ultrasound-based diagnosis of
  appendicitis proceeded to the operation, regardless of the surgeon's
  clinical impression. Those with other conditions diagnosed with
  ultrasonography were treated as was appropriate for the condition.
  RESULTS: The ultrasound-derived diagnosis of appendicitis had a
  sensitivity of 85.5%, a specificity of 84.4%, a positive predictive
  value of 88.3%, a negative predictive value of 80.1%, and an overall
  accuracy of 85.0%. The surgeon's clinical impression at the time of
  admission had a sensitivity of 62.9%, a specificity of 82.2%, a
  positive predictive value of 82.9%, a negative predictive value of
  61.7%, and an overall accuracy of 71.2%. CONCLUSION: The overall
  accuracy of ultrasonography in the diagnosis of appendicitis was
  statistically superior to that of the surgeon's clinical impression
  (P < .0001). However, 24% of the patients with normal ultrasound
  findings were ultimately found to have appendicitis at operation,
  emphasizing the point that ultrasonography cannot be relied on to the
  exclusion of the surgeon's careful and repeated evaluation.

Garcia Pena BM,  Mandl KD,  Kraus SJ,  Fischer AC,  Fleisher GR,  
  Lund DP,  Taylor GA  
Ultrasonography and limited computed tomography in the diagnosis and
  management of appendicitis in children.

In: JAMA (1999 Sep 15) 282(11):1041-6

ISSN: 0098-7484

CONTEXT: Limited computed tomography with rectal contrast (CTRC) has
  been shown to be 98% accurate in the diagnosis of appendicitis in the
  adult population, but data are lacking regarding the accuracy and
  effectiveness of this technique in diagnosing pediatric appendicitis.
  OBJECTIVE: To determine the diagnostic value of a protocol involving
  ultrasonography and CTRC in the diagnosis and management of
  appendicitis in children and adolescents. DESIGN, SETTING, AND
  PARTICIPANTS: Prospective cohort study of 139 children and
  adolescents aged 3 to 21 years (2 patients were older than 18 years)
  who had equivocal clinical findings for acute appendicitis and who
  presented to the emergency department of a large, urban, pediatric
  teaching hospital between July and December 1998. Interventions
  Children were first evaluated with pelvic ultrasonography. If the
  result was definitive for appendicitis, laparotomy was performed; if
  ultrasonography was negative or inconclusive, CTRC was obtained.
  Patients who did not undergo laparotomy had telephone follow-up at 2
  weeks and medical records of all patients were reviewed 4 to 6 months
  after study completion. MAIN OUTCOME MEASURES: Specificity,
  sensitivity, positive predictive value, negative predictive value,
  and accuracy of tests based on final diagnoses; surgeons' estimated
  likelihood of appendicitis on a scale of 1 to 10 for each case and
  their case management plans before imaging, after ultrasonography,
  and after CTRC. RESULTS: A total of 108 patients underwent both
  ultrasonography and CTRC examinations. The protocol had a sensitivity
  of 94%, specificity of 94%, positive predictive value of 90%,
  negative predictive value of 97%, and accuracy of 94%. A normal
  appendix was identified by ultrasonography in 2 (2.4%) of 83 patients
  without appendicitis and by CTRC in 62 (84%) of 74 patients. A
  negative ultrasonography result did not change the surgeons' clinical
  confidence level in excluding appendicitis (P= .06), while a negative
  CTRC result did have a significant effect (P<.001). Positive results
  obtained for either ultrasonography or CTRC significantly affected
  surgeons' estimated likelihood of appendicitis (P=.001 and P<.001,
  respectively). Ultrasonography resulted in a beneficial change in
  patient management in 26 (18.7%) of 139 children while CTRC correctly
  changed management in 79 (73.1%) of 108. CONCLUSIONS: These data show
  that CTRC following a negative or indeterminate ultrasonography
  result is highly accurate in the diagnosis of appendicitis in
  children.

There are 60 more studies that I have found which either support the use
of CT or US or they document the increased usage of this technology.  

As far as pain meds in the ER, you may be right, I don't think that
you're but you may be.  As you know, it is common practice to intubate
head injury patients in the field if they have a low GCS.  Well, this
month's Journal of Trauma argues against this seemingly good and once
thought safe practice.  

I look forward to your multi-center trial.  

E

Errington C. Thompson, MD
Trauma Surgeon
Trinity Mother Frances
Tyler, Tx
ecthompson@tyler.net

Don't think you are
Know you are
                            - Morpheus (The Matrix)


-----Original Message-----
From: trauma-list-admin@trauma.org [mailto:trauma-list-admin@trauma.org]
On Behalf Of caesar ursic
Sent: Thursday, April 10, 2003 9:08 PM
To: trauma-list@trauma.org
Subject: RE: Opiates & the Acute Abdomen

--- ecthompson <ecthompson@msn.com> wrote:

> American Journal of Surgery isn't the best journal
> that we have.  So,
> you're already standing on shaky ground.

Hmmmm....did you even read the article?  Seems like
you're committing a variant of the Ad Hominem fallacy
here.  The paper should stand or fall on its own
merits, not your perception of what a good journal is.
 And, pray tell, what makes the American Journal of
Surgery not so good (in your opinion, of course)?

> It may not be based on great science but it seems to
> be the right thing.
> Patients writhing in pain while ER resident, a
> surgery intern, a surgery
> 3rd year and a surgical chief exam them can't be in
> the patient's best
> interest. 

Of course not.  I hope that in your institution, as is
the case in ours, such scenarios are rare.  But that's
not really the point of the article (again, did you
read it?)  The point is that there is no good data
that proves that premedicationg these patients does
not affect the surgeons ability to render an accurate
diagnosis.  And since the overwhelming trend these
days is to premedicate (and literature is quoted to
support this practice) we might want to re-examine the
validity of the conclusions drawn from this
literature.

>With our increased reliance on radiologic
> imaging, I'm not
> sure what the problem is.  Have you missed a
> diagnosis or delayed
> treatment because of a couple of milligrams of
> Morphine?  I can say with
> my retrospectoscope that I have not delayed or
> missed a diagnosis
> because of morphine, to the best of my knowledge. 
> Do you really believe
> that your patients are being harmed?

Sounds like you are saying that physical exam isn't
that important in this day and age of CT scans.  Do
you trust your CT scan to diagnose intestinal
ischemia?  How about perforated viscus?  If so, can
you back up that contention with good data?

> Outside of the ivory tower, I can tell you that 95%
> of patients with an
> acute appendix will get a CT scan or ultrasound or
> both.  Average time
> from when the ER doc calls for a surgical consult to
> when the surgeon
> arrives is 30 minutes to 3 hours.  

Again, I think you've commited the fallacy of Appeal
to Common Practice.  Just because 95% of the RLQ pains
in YOUR hospital get scanned doesn't invalidate the
role of a good abdominal exam to diagnose those
patients with clear signs that do not need CT scan.


> Finally, if this is really bugging you, you could
> without too much
> trouble study this topic in a prospective manner in
> your institution.  

I think, as do the authors of the study, that such a
project would need to be multi-institutional so as to
recruit enough patients to make it valid.

C.M. Ursic, M.D.
Dept. of Surgery
UCSF-East Bay
Oakland, California


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