In many trauma centers, the Emergency Department role is essentially: place an IV for which contrast may be delivered for CT. Oh, yes, there’s some airway management, perhaps a FAST exam, some rolling and cutting of clothing, and the remainder of our expertise should not be diminished, but modern management has been distilled to: trauma = pan-scan.
Except in San Diego.
This fascinating paper describes 11 years of experience at a Level 1 trauma center in which the vast minority of their patients underwent automatic CT. Between the hours of 8AM and 11PM, a resident and staff ultrasonographer were available for ultrasound examination of trauma patients. At the discretion of the attending surgeon, the ultrasonographers performed an examination consisting of seven abdominal windows, bilateral visceral organ windows, and cardiac windows.
And, of the 19,126 trauma patients included in this study, essentially all patients presenting between 8AM and 11PM underwent this ultrasound. Minus the 13 patients who went directly to the OR, this constitutes 12,565 patients initially screened with ultrasound. Of these, 12,070 were judged to be negative examinations. By the authors definition of false negative, a positive exploratory laparotomy finding, only 35 ultimately required such – a false negative rate of 0.29%. Comparatively, CT was performed off-hours in 6,548 patients, and had a 0.1% false negative rate.
There were, of course, a mix of patients with positive ultrasound results who ultimately had negative CTs, and 1,119 negative ultrasounds who underwent CT with a 86 positive results. So, there’s a lot of details and hidden corners to evaluate and analyze beyond their narrow definition. But, still, impressively, their trauma protocol at a Level 1 center managed to spare half the patients the ubiquitous pan-scan.
Fascinating!
“Complete ultrasonography of trauma in screening blunt abdominal trauma patients is equivalent to computed tomographic scanning while reducing radiation exposure and cost”
http://www.ncbi.nlm.nih.gov/pubmed/26218686
"Since we all agree that this patient has no injuries, can we do ultrasound instead of CT?"
Yes – sensitivity and specificity limitations (+LR/-LR) can be rendered moot by pretest likelihood, to put it mildly ….