CT Radiation Dosing Calculations

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There have been a couple articles  suggesting the benefit of CT
scanning--including ~20-30 frequency of "occult injuries" requiring a
change in management and the even improved survival(ie the Lancet
study).  As with EVERYTHING  we do, it is all about risk vs benefit.

Pat 


Patrick J. Offner MD MPH
Chief, Surgical Critical Care
St Anthony Central Hospital

-----Original Message-----
From: trauma-list-bounces at trauma.org
[mailto:trauma-list-bounces at trauma.org] On Behalf Of Dr Timothy
Hardcastle
Sent: Thursday, October 15, 2009 1:14 PM
To: Trauma-List [TRAUMA.ORG]
Subject: Re: CT Radiation Dosing Calculations

Ken et al

I have been silent for a while now, but I feel it is time to comment.
Firstly let me remind everyone that I am all for good clinical medicine
and come from a place where we are often forced to use clinical
judgement and hope for the best.

However, I think that the experience I have recently gained from dealing
with many more blunt trauma cases where plain films were often done
prior to referral to our unit, where we will liberally use full body
trauma scan, with a 128 slice scanner. The number of clinically relevant
additional injuries in our subgroup of severely injured patients (our
admission average ISS is 24 and NISS is 36) are sufficient to justify
such scans. These patients are almost all sedated, intubated and
ventilated, which complicates clinical assessment. These patients have a
significant risk for missed injury - which by liberal scanning we have
reduced to under 2%. The more modern scanners use less radiation for the
same quality of scan - mostly even better than the older generation of
scanners. It is all about risk-benefit and these patients - ISS >16 and
BLUNT trauma or transmediastinal penetrating trauma are best served by
early comprehensive imaging - as a one-stop shop, rather than numerous
segmental scans.

Secondly, the patient must SURVIVE the trauma and the hospital stay to
get to the point where they can get their ALL or lymphoma. If we look at
the missed injury with blunt trauma (particularly missed bowel injury) -
with associated poor outcomes, the increased survival is enough to
justify the risk.

Finally though - quality control of the technical issues and of the
appropriate use of the scan - i.e. not for the fully conscious,
evaluable patient, is essential. Most penetrating trauma should NOT be
undergoing scan - exceptions transmediastinal and maybe RUQ GSW. Not for
stabs, or other GSW's

On the issue of CT as an angio device - fine for blunt arch / vessel
screen. For anything else use a catheter directed angio! The miss rate
for other injury is just too high.

My 2c
Dr T C Hardcastle
M.B., Ch.B. (Stell); M. Med. (Chir) (Stell); FCS (SA) Principal
Specialist Trauma Surgeon / Honorary Lecturer University of
KwaZulu-Natal Dept Surgery Deputy Director - IALCH Trauma Service Durban
- South Africa

> I am very aware that Ionizing radiation dosing from radiotherapy, CT 
> scanning, arteriography, C-Arm imaging in the OR, cardiac 
> catheterization, and trauma injury screening and diagnosis has 
> historically been administered most
> of  the time in a professional and standard manner.   I am also aware
that
> each of these modalities has had its miscalculations and subsequent
injury
> to  patients as well as to health care workers at all  levels.
The
> recent experience reported by  many sources of a hospital in Los 
> Angeles was
> one such mis  calculation.      However, I am aware that such
"accidents"
> often lead to regulatory agencies using such an incident to now
inspect
> hospitals who have never had a known similar miscalculation.    While
> making a
> visit, they very often raise questions of relivance, indication,  and 
> use of
> imaging, or whatever has brought them to the  facility.    Following
the
> announcement earlier this week of the  miscalculation, I did a quick 
> check among patients in this hospital and sought  information from 
> many of my colleagues at other hospitals. That led to my  earlier post

> regarding guidelines for ordering imaging, how images are often mis  
> used and lead to inappropriate
> decisions, and other issues.    It  was to raise the awareness of all
of
> us
> regarding the use of a modality that we  all have over used.
>
> k
> --
> trauma-list : TRAUMA.ORG
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>


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