Requesting routine chest radiographs for patients presenting with altered mental status is "based in tradition rather than evidence-based medicine," US radiologists have suggested [1].
This practice is commonplace in many emergency departments owing to the many causes of altered mental status that may be identified.
The group retrospectively reviewed 100 consecutive patients who presented to an emergency department with altered mental status, all of whom underwent head CT and chest X-ray.
Of the 17 patients for whom chest X-ray altered care, all had features that would have prompted the imaging, either on history and examination, or a leucocytosis.
The researchers concluded that "the positive predictive value [of chest X-ray] may be improved if certain symptoms are present."
They added: "Chest radiographs can be expected to provide limited clinically relevant information when performed as a routine screening examination in patients with altered mental status who have no history, signs or symptoms of chest pathology.
"Our results suggest that the yield will be improved for those patients with clinical findings indicating chest symptoms, signs, abnormal lab values, or history that make evaluation of the chest necessary."
Dr Michael Nipper, a diagnostic radiologist at Texas A&M College of Medicine and one of the study authors, commented: ?In my opinion, the chest radiograph is one of the most overutilized imaging exams in medicine. The cost is significant when you look at this as a national issue. Medical radiation is thought to account for up to two per cent of solid malignancies or lymphoma in the United States.?
Dr Rita Joarder, a consultant radiologist at Conquest hospital in Hastings, UK, emphasized: ?Chest X-ray should only ever be performed if there is a clinical indication.?
However Dr Thomas Goodfellow, consultant radiologist at the University Hospitals Coventry & Warwickshire NHS Trust in the UK, disagreed that routine chest X-ray for altered mental state was based on tradition. ?An elderly person with an acute confusional state is highly likely to have an underlying chest infection with few obvious clinical signs.
"A chest X-ray is a quick, effective, cheap examination with low radiation dose? The more relevant question is, does everyone with an acute mental disturbance need a head CT as a routine?"
[1] Is the chest X-ray an appropriate screening exam for ER patients with AMS?
Emerg Radiol Online First
