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Too much or not enough? When to order a CT scan for neck and head trauma

OCTOBER 24, 2017
Clinical Congress Daily Highlights, Tuesday Second Edition

The question of whether we do too many head and cervical computed tomography (CT) scans of trauma patients — or not enough — has nagged surgeons for years.

Due to the significant morbidity and mortality from a missed intracranial bleed from head trauma, many surgeons may feel undue pressure to order CT scans of the head. Yet concerns about radiation risk and the cost of too much imaging has led many to question this liberal approach.

Several studies presented on Tuesday conclude that surgeons can scan selectively and appropriately without harming the patient, thus saving money and lowering radiation risk.

“Mindless Scanning: Does Every Trauma Patient Need a Head CT?” led by Ryan Lindborg, MD, New York Presbyterian Brooklyn Methodist Hospital, Brooklyn, NY, found that an educational intervention with a real-time electronic decision support tool can reduce unindicated CT scans of the head and lead to more cost-effective patient care. The intervention led to a 72 percent reduction in unindicated scans from the preintervention group of patients to the postintervention group.

“What really made a difference is that the decision tool was made part of the electronic health record, reminding them (the person ordering a scan) of the specific criteria for head trauma patients,” Dr. Lindborg said.

Some physicians argue that because elderly patients are more susceptible to injury from falls and other trauma, they don’t get scanned enough.

But another study showed that elderly can be safely and selectively scanned according to well-established criteria, such as those established by the National Emergency X-radiography Utilization Study (NEXUS). “Over the Hill and Falling Down: Can the NEXUS Criteria Be Applied to the Elderly?” led by Amani Jambhekar, MD, New York Presbyterian, Brooklyn Methodist Hospital, New York, NY, reported that the use of NEXUS criteria may lead to decreased radiation exposure and health care costs, allowing for better allocation of resources to patients who do warrant imaging of the cervical spine.

Although NEXUS has been criticized as unreliable in detecting injury to the spines of elderly patients, in this study none of the 596 patients who were deemed negative for imaging under NEXUS, including the elderly, had cervical injuries.

Finally, there is concern that radiation from cervical and head CT scanning may pose a risk of cancer, especially to younger patients. “Selective Computed Tomography (CT) Imaging is Superior to Liberal CT Imaging in the Hemodynamically Normal Pediatric Blunt Trauma Patient” concluded that surgeons may safely take a more selective approach in CT scanning, especially among children, without hurting patient outcomes. The study, led by Emily Pott, Keck Medicine of the University of Southern California, Los Angeles, found that a selective imaging strategy is the optimal approach for stable blunt pediatric trauma, and leads to superior outcomes and significantly less radiation exposure.

Additional Information:
The Scientific Forum, Critical Care Surgery/Trauma I, was held October 24, at the 2017 Clinical Congress of the American College of Surgeons in San Diego, CA. Program, webcast and audio information is available online at FACS.org/clincon2017.

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