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Special focus session on thoracic emergencies at ECR 2011 will no doubt be much better informed about the issues of every request for an emergency CT scan is screened for its appropriateness?, Should you refuse to perform CT scans without a proper indication etc..

Should you insist that every request for an emergency CT scan is screened for its appropriateness? Should you refuse to perform CT scans without a proper indication, risking the anger of your referring colleagues? And how can you manage appropriateness effectively?

There are no easy answers to these three urgent questions facing radiologists, but those who attend the special focus session on thoracic emergencies at ECR 2011 will no doubt be much better informed about the issues.

In many countries, imaging in the emergency department is not solely based on appropriateness but also on defensive medicine, finances, and politics, according to session moderator Dr. Digna R. Kool, from the department of diagnostic imaging, University Medical Centre Nijmegen, The Netherlands, who will moderate the session. Because of fear of missing a significant diagnosis, some clinicians request an imaging examination even when it is in conflict with accepted clinical decision rules and evidence in the literature.

Furthermore, if CT is reimbursed fully under an insurance-based healthcare system, it will be in the interests of the hospital – and of private practice radiologists – to perform CT .

“In many countries, politics rule, and it could be a great PR message for administrators to stress the fact that they offer the best method to exclude potentially life-threatening diseases, although we do not have enough evidence in this field yet,” she said.

Kool thinks all radiologists should brush up on their knowledge of acute chest pain because the number of requests for imaging in these patients is rising fast and it is often encountered during on-call work. Part of the increase in requests for multidetector CT (MDCT) in acute chest pain is appropriate because technical advances have led to significant increases in diagnostic opportunities, resulting in faster and more accurate diagnoses and more effective clinical decision-making .

Clinicians use MDCT to decide if patients need treatment and whether they should be admitted to hospital or can be discharged from the emergency department. Early discharge can decrease hospital costs significantly, she stressed. However, MDCT has important drawbacks, including costs and radiation, and with the increasing use of MDCT, the yield in positive results is decreasing.

Any discussion of how to manage appropriateness in the emergency department should consider patient selection protocols, such as clinical decision rules and research that has been, or should be, done, Kool pointed out. Alternative diagnostic strategies, like ventilation/perfusion lung (V/Q) scans for pulmonary embolism in young women, should also be investigated.

MDCT is already the diagnostic reference standard for chest trauma, and allows the correct definition of life-threatening lesions, the triage of patients, and the decision about whether to adopt a ‘watch and wait’ approach or perform percutaneous or surgical interventions, explained Dr. Filippo Cademartiri, a radiologist from the University of Parma in Italy. The main drawback, however, is related to the skill of the operator in both defining the correct technical strategy and in the interpretation of the findings.

“Patients with chest trauma are usually difficult to image because they are fairly uncooperative, they suffer from chest pain, and their breath-hold can be hard to control,” he commented. “Also, their heart rate, which is very important for a good MDCT examination, is more difficult to manage in chest trauma. The latest technologies are more robust, and they can cope with high heart rate, especially dual source CT equipment because of its higher temporal resolution.”

To minimise radiation exposure to both patients and staff, it is necessary to consider several factors, including the body mass index of the patient, the patient’s ability to manage breathhold and heart rate, and the presence and amount of coronary calcifications. Radiation dose can be reduced the most when all conditions are favourable, stated Cademartiri. Looking to the future, he anticipates a trend towards the progressive widening of the chest CT examination performed for any indication in which the heart and coronary arteries can be assessed.

“This translates into an inevitable screening for coronary artery disease. Radiologists are not ready yet for this, but they should prepare,” he warned.

Finally, because newer CT technologies allow a comprehensive approach to acute chest pain, in the near future radiologists who work in emergency departments will have to confront the possibility of clinical requests to rule out all major causes of acute chest pain.

Source: ESR

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