RESUMEN
BACKGROUND: Small-caliber chest tubes are used to treat pneumothorax and pleural fluid collections. Although commonly considered a less invasive alternative to large-caliber thoracostomy tubes, small-caliber tubes have a high complication rate. Emergency physicians must be familiar with common and dangerous procedure complications associated with these devices and have a systematic and rapid approach to identify and solve malfunctions. Structured root cause analysis can facilitate identification of problems. METHODS: We reviewed the medical literature for complications of small-caliber chest tubes and searched the U.S. Food and Drug Administration (FDA) database for complications of a specific pigtail catheter kit. Using a structured root cause analysis (RCA), we examined two cases of retained pigtail catheter obturators resulting in catheter malfunction and unresolved pneumothorax. RESULTS: We identified common complications of pigtail catheters from the medical literature, as well as 28 reports to FDA of complications with the kit used in the analyzed cases; ours were the only reports of the obturator error. RCA identified multiple contributing factors, including unrecognized and novel radiographic clues, human errors, communication breakdown, device design, and opportunities for improved systematic procedural approach. DISCUSSION: We discuss factors identified in RCA and regulatory considerations relevant to emergency physicians, including FDA reporting mechanisms. CONCLUSIONS: A structured review of complications of pigtail catheter insertion revealed opportunities for improved patient safety. We highlight a preventable error in insertion of a percutaneous catheter and describe radiographic features to enhance error detection. Improved design, systematic processes for device insertion and troubleshooting, and enhanced provider education could reduce the risk of medical device errors. An end-of-procedure time-out including instrument counts and systematic assessment of device function is a generalizable patient safety measure for bedside procedures.
Asunto(s)
Catéteres/efectos adversos , Tubos Torácicos/efectos adversos , Neumotórax , Análisis de Causa Raíz , Drenaje , Humanos , Errores Médicos , Seguridad del Paciente , Neumotórax/etiología , Resultado del TratamientoRESUMEN
BACKGROUND: Duplicated renal collecting system is a urological anomaly often found in pediatric patients. It is less commonly diagnosed in adulthood, particularly in a pregnant patient. Many point-of-care ultrasonography users may not be aware of this diagnosis, particularly in patients in the emergency department. It is important to recognize the duplicated system because in general, patients will often have hydronephrosis in only one renal pole rather than the entire kidney, which corresponds to an unequal renal function as documented on renal nuclear medicine functional scans. As a consequence, if the sonographer only identifies one ureter and incompletely visualizes the kidney, obstruction of one of the duplicated structures may be missed. CASE REPORT: We report 2 cases of duplicated ureter in patients in the emergency department who present with flank pain and urinary symptoms. Both patients were adult females, one pregnant, with duplicated ureter and severe right upper pole hydroureteronephrosis. The first patient was admitted for intravenous antibiotic therapy for pyelonephritis in pregnancy. The second was discharged with oral antibiotics and urgent urologic follow-up. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Duplicated ureter should be considered in patients with recurrent urinary tract infections or enuresis. Point-of-care ultrasonography users should note the differential hydronephrosis between upper and lower renal poles and may visualize duplicate or ectopic ureteronephrosis or ureterocele. Patients should be prescribed prophylactic antibiotics and have urgent urologic follow-up because the untreated condition can lead to irreversible renal damage.
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Hidronefrosis/diagnóstico , Complicaciones Infecciosas del Embarazo/diagnóstico por imagen , Pielonefritis/diagnóstico por imagen , Uréter/anomalías , Ureterocele/diagnóstico por imagen , Adulto , Antibacterianos/uso terapéutico , Diagnóstico Diferencial , Servicio de Urgencia en Hospital , Femenino , Humanos , Embarazo , Complicaciones Infecciosas del Embarazo/tratamiento farmacológico , Pielonefritis/tratamiento farmacológico , Pielonefritis/microbiología , Cateterismo UrinarioRESUMEN
Conventional two-dimensional (2D) ultrasound imaging is a powerful diagnostic tool in the hands of an experienced user, yet 2D ultrasound remains clinically underutilized and inherently incomplete, with output being very operator dependent. Volumetric ultrasound systems can more fully capture a three-dimensional (3D) region of interest, but current 3D systems require specialized transducers, are prohibitively expensive for many clinical departments, and do not register image orientation with respect to the patient; these systems are designed to provide improved workflow rather than operator independence. This work investigates whether it is possible to add volumetric 3D imaging capability to existing 2D ultrasound systems at minimal cost, providing a practical means of reducing operator dependence in ultrasound. In this paper, we present a low-cost method to make 2D ultrasound systems capable of quality volumetric image acquisition: we present the general system design and image acquisition method, including the use of a probe-mounted orientation sensor, a simple probe fixture prototype, and an offline volume reconstruction technique. We demonstrate initial results of the method, implemented using a Verasonics Vantage research scanner.
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Imagenología Tridimensional/instrumentación , Imagenología Tridimensional/métodos , Ultrasonografía/instrumentación , Ultrasonografía/métodos , Humanos , Imagenología Tridimensional/economía , Transductores/economía , Ultrasonografía/economíaRESUMEN
PURPOSE: The purposes of this study were to evaluate the frequency with which emergency physicians involved in residency leadership disclose potential malignancy risks from computed tomography (CT), assess comfort with these discussions, and evaluate factors influencing risk disclosure. METHODS: We surveyed emergency medicine residency program directors and associate/assistant directors. Primary outcome was the proportion who "almost always" or "most of the time" discussed potential risks. RESULTS: Two hundred and seventy-four (50.6%) of 542 eligible physicians responded. There were 82.1% (95% CI 76.8%, 86.6%) who reported almost always or most of the time discussing potential risks for patients ≤18 years; proportions for adults 19-40, 41-65, and >65 years were 50.6% (95% CI 44.4, 56.7%), 20.7% (95% CI 16.0, 26.0%), and 5.2% (95% CI 2.9, 8.5%), respectively (test for trend, p < 0.001). The proportion reporting being "extremely" or "very" comfortable discussing risks was 57.1% (95% CI 51.1, 63.2%). Patient/family CT request that the physician felt was not indicated was of "very high" or "high" importance for driving risk discussions in 86.4% of respondents. For 75.5%, patient/family query about radiation risks was of "high" or "very high" importance. Among 57.4% of respondents, the patient being elderly and/or having a reduced life expectancy was of "high" or "very high" importance in the decision not to discuss risk. CONCLUSIONS: Emergency physicians involved in residency leadership report frequently disclosing potential malignancy risks from CT at frequencies inversely proportional to patient age. About half are comfortable with discussions, and many discussions are driven by patient requests. Opportunities exist to optimize and standardize emergency department CT radiation risk disclosure practices.
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Revelación , Medicina de Emergencia/educación , Relaciones Médico-Paciente , Exposición a la Radiación/efectos adversos , Tomografía Computarizada por Rayos X/efectos adversos , Factores de Edad , Canadá , Educación de Postgrado en Medicina , Servicio de Urgencia en Hospital , Humanos , Internado y Residencia , Liderazgo , Medición de Riesgo , Encuestas y Cuestionarios , Estados UnidosRESUMEN
We have constructed simple and inexpensive models for ultrasound-guided procedural training using synthetic ballistic gelatin. These models are durable, leak resistant, and able to be shaped to fit a variety of simulation scenarios to teach procedures. They provide realistic tactile and sonographic training for our learners in a safe, idealized setting.
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Materiales Biomiméticos/síntesis química , Gelatina/síntesis química , Fantasmas de Imagen/economía , Punciones/instrumentación , Radiología/educación , Ultrasonografía Intervencional/instrumentación , Materiales Biomiméticos/economía , Diseño de Equipo , Análisis de Falla de Equipo , Equipo Reutilizado , Gelatina/economía , Punciones/economía , Punciones/métodos , Radiología/economía , Reproducibilidad de los Resultados , Sensibilidad y Especificidad , Ultrasonografía Intervencional/economía , Estados UnidosRESUMEN
Medical errors are commonly multifactorial, with adverse clinical consequences often requiring the simultaneous failure of a series of protective layers, termed the Swiss Cheese model. Remedying and preventing future medical errors requires a series of steps, including detection, mitigation of patient harm, disclosure, reporting, root cause analysis, system modification, regulatory action, and engineering and manufacturing reforms. We describe this process applied to two cases of improper orientation of a Heimlich valve in a thoracostomy tube system, resulting in enlargement of an existing pneumothorax and the development of radiographic features of tension pneumothorax. We analyse elements contributing to the occurrence of the error and depict the implementation of reforms within our healthcare system and with regulatory authorities and the manufacturer. We identify features of the Heimlich valve promoting this error and suggest educational, design, and regulatory reforms for enhanced patient safety.
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Tubos Torácicos/efectos adversos , Errores Médicos/prevención & control , Neumotórax/terapia , Garantía de la Calidad de Atención de Salud/métodos , Toracostomía/instrumentación , Adulto , Drenaje/métodos , Diseño de Equipo , Humanos , Masculino , Neumotórax/etiología , Toracostomía/educaciónAsunto(s)
Aorta Torácica/patología , Neoplasias del Mediastino/patología , Teratoma/patología , Hidrocele Testicular/patología , Vena Cava Inferior/patología , Protocolos de Quimioterapia Combinada Antineoplásica , Aorta Torácica/diagnóstico por imagen , Humanos , Lactante , Masculino , Neoplasias del Mediastino/diagnóstico por imagen , Neoplasias del Mediastino/tratamiento farmacológico , Teratoma/diagnóstico por imagen , Teratoma/tratamiento farmacológico , Tomografía Computarizada por Rayos X , Vena Cava Inferior/diagnóstico por imagenRESUMEN
BACKGROUND: Controversy exists regarding the need for contrast agents for emergency abdominal computed tomography (CT). OBJECTIVES: We surveyed United States (US) academic Emergency Departments (EDs) to document national practice. We hypothesized variable contrast use for abdominal/pelvic CT, including variance from the American College of Radiology's (ACR) Appropriateness Criteria(®), an evidence-based guideline. METHODS: A survey was sent to physician leaders of US academic EDs, defined as primary site of an Emergency Medicine residency program. Respondents were asked about their institutions' use of oral, intravenous (i.v.), and rectal contrast for various abdominal/pelvic CT indications. Responses were compared with the approach given the highest appropriateness rating by the American College of Radiology. RESULTS: One hundred and six of 152 (70%) surveys were completed. Intravenous contrast was the most frequently cited contrast. At least 90% of respondents reported using i.v. contrast in 12 of 18 indications. Oral contrast use was more variable. In no indication did ≥90% of respondents indicate use of oral contrast, and in only two indications did ≥90% avoid its use. Rectal contrast was rarely used. The most common indications for which no contrast agent was used were suspected renal colic (79%), viscus perforation (19%), penetrating abdominal trauma (18%), and blunt abdominal trauma (15%). CONCLUSIONS: Contrast practices for abdominal/pelvic CT vary nationally, according to a survey of US academic EDs. For multiple indications, the contrast practices of a substantial number of respondents deviated from those recommendations given the highest clinical appropriateness rating by the American College of Radiology.
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Medios de Contraste/administración & dosificación , Servicio de Urgencia en Hospital , Pelvis/diagnóstico por imagen , Pautas de la Práctica en Medicina/estadística & datos numéricos , Radiografía Abdominal , Centros Médicos Académicos , Administración Oral , Administración Rectal , Adhesión a Directriz/estadística & datos numéricos , Humanos , Infusiones Intravenosas , Guías de Práctica Clínica como Asunto , Encuestas y Cuestionarios , Tomografía Computarizada por Rayos X , Estados UnidosAsunto(s)
Servicio de Urgencia en Hospital , Política de Salud , Trastornos Mentales/diagnóstico , Enfermedad Aguda , Adulto , Tratamiento de Urgencia/métodos , Tratamiento de Urgencia/tendencias , Medicina Basada en la Evidencia , Antagonistas de Aminoácidos Excitadores/uso terapéutico , Humanos , Ketamina/uso terapéutico , Trastornos Mentales/terapia , Guías de Práctica Clínica como Asunto , Medición de Riesgo/métodosRESUMEN
OBJECTIVE: Computed tomography (CT) imaging is frequently obtained for recurrent abdominal pain after a prior emergency department (ED) evaluation. We evaluate the utility of repeat CT imaging following an indeterminate index CT in low-risk abdominal pain adult ED patients. METHODS: An electronic search was designed for the patient-intervention-control-outcome-timing (PICOT) question: (P) adult patients with low-risk, recurrent, and previously undifferentiated atraumatic abdominal pain presenting to the ED after an index-negative CT within 12 months; (I) repeat CT versus (C) no repeat CT; for (O) abdominal surgery or other invasive procedure, mortality, identification of potentially life-threatening diagnosis, and hospital and intensive care unit admission rates; and return ED visit (T), all within 30 days. Four reviewers independently selected evidence for inclusion and then synthesized the results around the most prevalent themes of repeat CT timing, diagnostic yield, ionizing radiation exposure, and predictors of repetitive imaging. RESULTS: Although 637 articles and abstracts were identified, no direct evidence was found. Thirteen documents were synthesized as indirect evidence. None of the indirect evidence defined a low-risk subset of abdominal pain nor did investigators describe whether reimaging occurred for complaints similar to the initial ED evaluation. Included studies did not describe the index CT findings and some reported explanatory findings noted on the original CT for which repeat CTs might have been indicated. The time frame for a repeat CT ranged from hours to 1 year. The frequency of repeat CTs (2%-47%) varied across studies as did the yield of imaging to alter downstream clinical decision making (range = 5%-67%). CONCLUSION: Due to the absence of direct evidence our scoping review is unable to provide high-quality evidence-based recommendations upon which to confidently base an imaging practice guideline. There is no evidence to support or refute performing a CT for low-risk recurrent abdominal pain.
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Dolor Abdominal , Dolor Crónico , Dolor Abdominal/diagnóstico por imagen , Dolor Abdominal/etiología , Adulto , Servicio de Urgencia en Hospital , Humanos , Guías de Práctica Clínica como Asunto , Estudios Retrospectivos , Tomografía Computarizada por Rayos X/métodosRESUMEN
BACKGROUND: Recurrent abdominal pain in the emergency department (ED) might represent an opportunity for screening of depression and/or anxiety. METHODS: We systematically searched five databases for studies evaluating the effect of screening for depression and/or anxiety in ED patients with recurrent and undifferentiated abdominal pain. Given paucity of direct evidence, we also searched for indirect evidence including studies that assessed prevalence of depression and/or anxiety in EDs (not necessarily recurrent abdominal pain), diagnostic accuracy of screening tools, effectiveness of screening in other settings, and outcomes such as repeat ED visits of patients with abdominal pain who were screened in the ED. Two methodologists evaluated certainty in the evidence using the GRADE approach. RESULTS: A total of 4,337 citations were reviewed, and zero studies were found on the effect of screening in patients with recurrent and undifferentiated abdominal pain in the ED. A total of 35 studies were included as relevant indirect evidence. In studies of ED patients with abdominal pain, depression ranged from 10% to 29%, while anxiety ranged from 18% to 50%. False positives appear to be an issue given relatively low specificity of screening tools. One randomized trial including ED patients with vague symptoms evaluated the effect of depression screening on a composite outcome of depression recognition, psychiatric consultation, or referral by the emergency physician (risk ratio = 1.49, 95% confidence interval [CI] = 0.49 to 4.53, very low certainty). One study reported that patients with undifferentiated abdominal pain who screened positive for depression have had increased ED recidivism (odds ratio = 3.17, 95% CI = 1.14 to 8.85, very low certainty). CONCLUSIONS: We were unable to identify any evidence that confirms that depression or anxiety screening in ED patients with recurrent and undifferentiated abdominal pain improves outcomes or changes management downstream.
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Dolor Crónico , Depresión , Dolor Abdominal/diagnóstico , Dolor Abdominal/epidemiología , Dolor Abdominal/etiología , Ansiedad/diagnóstico , Ansiedad/epidemiología , Depresión/diagnóstico , Depresión/epidemiología , Servicio de Urgencia en Hospital , HumanosRESUMEN
This second Guideline for Reasonable and Appropriate Care in the Emergency Department (GRACE-2) from the Society for Academic Emergency Medicine is on the topic "low-risk, recurrent abdominal pain in the emergency department." The multidisciplinary guideline panel applied the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach to assess the certainty of evidence and strength of recommendations regarding four priority questions for adult emergency department patients with low-risk, recurrent, undifferentiated abdominal pain. The intended population includes adults with multiple similar presentations of abdominal signs and symptoms recurring over a period of months or years. The panel reached the following recommendations: (1) if a prior negative computed tomography of the abdomen and pelvis (CTAP) has been performed within 12 months, there is insufficient evidence to accurately identify populations in whom repeat CTAP imaging can be safely avoided or routinely recommended; (2) if CTAP with IV contrast is negative, we suggest against ultrasound unless there is concern for pelvic or biliary pathology; (3) we suggest that screening for depression and/or anxiety may be performed during the ED evaluation; and (4) we suggest an opioid-minimizing strategy for pain control. EXECUTIVE SUMMARY: The GRACE-2 writing group developed clinically relevant questions to address the care of adult patients with low-risk, recurrent, previously undifferentiated abdominal pain in the emergency department (ED). Four patient-intervention-comparison-outcome-time (PICOT) questions were developed by consensus of the writing group, who performed a systematic review of the literature and then synthesized direct and indirect evidence to formulate recommendations, following GRADE methodology. The writing group found that despite the commonality and relevance of these questions in emergency care, the quantity and quality of evidence were very limited, and even fundamental definitions of the population and outcomes of interest are lacking. Future research opportunities include developing precise and clinically relevant definitions of low-risk, recurrent, undifferentiated abdominal pain and determining the scope of the existing populations in terms of annual national ED visits for this complaint, costs of care, and patient and provider preferences.
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Dolor Crónico , Medicina de Emergencia , Dolor Abdominal/diagnóstico , Dolor Abdominal/etiología , Dolor Abdominal/terapia , Adulto , Dolor en el Pecho , Servicio de Urgencia en Hospital , HumanosRESUMEN
RATIONALE AND OBJECTIVES: Two-dimensional (2D) ultrasound (US) is operator dependent, requiring operator skill and experience to selectively identify and record planes of interest for subsequent interpretation. This limits the utility of US in settings in which expert sonographers are unavailable. Three-dimensional (3D) US acquisition of an anatomic target, which enables reconstruction of any plane through the acquired volume, might reduce operator dependence by providing any desired image plane for interpretation, without identification of target planes of interest at the time of acquisition. We applied a low-cost 3DUS technology because of the wider potential application compared with dedicated 3DUS systems. We chose second trimester fetal biometric parameters for study because of their importance in maternal-fetal health globally. We hypothesized that expert and novice interpretations of novice-acquired 3D volumes would not differ from each other nor from expert measurements of expert-acquired 2D images, the clinical reference standard. MATERIALS AND METHODS: This was a prospective, blinded, observational study. Expert sonographers blinded to 3DUS volumes acquired 2DUS images of second trimester fetuses from 32 subjects, and expert readers performed interpretation, during usual care. A novice sonographer blinded to other clinical data acquired oriented 3DUS image volumes of the same subjects on the same date. Expert readers blinded to other data assessed placental location (PL), fetal presentation (FP), and amniotic fluid volume (AFV) in novice-acquired 3D volumes. Novice and expert raters blinded to other data independently measured biparietal diameter (BPD), humerus length (HL), and femur length (FL) for each fetus from novice-acquired 3D volumes. Corresponding gestational age (GA) estimates were calculated. Inter-rater reliability of measurements and GAs (expert 3D versus expert 2D, novice 3D versus expert 2D, and expert 3D versus novice 3D) were assessed by intraclass correlation coefficient (ICC). Mean inter-rater measurement differences were analyzed using one-way ANOVA. RESULTS: 3D volume acquisition and reconstruction required mean 30.4 s (±5.7) and 70.0 s (±24.0), respectively. PL, FP, and AFV were evaluated from volumes for all subjects; mean time for evaluation was 16 s (±0.0). PL, FP, and AFV could be evaluated for all subjects. At least one biometric measurement was possible for 31 subjects (97%). Agreement between rater pairs for a composite of all measures was excellent (ICCs ≥ 0.95), and for individual measures was good to excellent (ICCs ≥ 0.75). Inter-rater differences were not significant (p > .05). CONCLUSIONS: Expert and novice interpretations of novice-acquired 3DUS volumes of second trimester fetuses provided reliable biometric measures compared with expert interpretation of expert-acquired 2DUS images. 3DUS volume acquisition with a low-cost system may reduce operator dependence of ultrasound.
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Imagenología Tridimensional , Ultrasonografía Prenatal , Femenino , Edad Gestacional , Humanos , Placenta/diagnóstico por imagen , Embarazo , Segundo Trimestre del Embarazo , Estudios Prospectivos , Reproducibilidad de los ResultadosRESUMEN
Head trauma (ie, head injury) is a significant public health concern and is a leading cause of morbidity and mortality in children and young adults. Neuroimaging plays an important role in the management of head and brain injury, which can be separated into acute (0-7 days), subacute (<3 months), then chronic (>3 months) phases. Over 75% of acute head trauma is classified as mild, of which over 75% have a normal Glasgow Coma Scale score of 15, therefore clinical practice guidelines universally recommend selective CT scanning in this patient population, which is often based on clinical decision rules. While CT is considered the first-line imaging modality for suspected intracranial injury, MRI is useful when there are persistent neurologic deficits that remain unexplained after CT, especially in the subacute or chronic phase. Regardless of time frame, head trauma with suspected vascular injury or suspected cerebrospinal fluid leak should also be evaluated with CT angiography or thin-section CT imaging of the skull base, respectively. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.
Asunto(s)
Medios de Contraste , Traumatismos Craneocerebrales , Niño , Traumatismos Craneocerebrales/diagnóstico por imagen , Medicina Basada en la Evidencia , Humanos , Neuroimagen , Sociedades Médicas , Estados UnidosAsunto(s)
Aorta Abdominal/diagnóstico por imagen , Fístula Intestinal/diagnóstico por imagen , Intestino Delgado/diagnóstico por imagen , Síncope/etiología , Tomografía Computarizada por Rayos X , Fístula Vascular/diagnóstico por imagen , Anciano , Humanos , Fístula Intestinal/complicaciones , Masculino , Fístula Vascular/complicacionesRESUMEN
STUDY OBJECTIVE: Computed tomography (CT) is increasingly used for emergency department (ED) patients with abdominal tenderness. CT-related radiation contributes to 2% of US cancers. We hypothesized that in the ED patient with nontraumatic abdominal tenderness, the tender region accurately delineates acute pathology. z axis-restricted CT guided by this region could detect pathology while reducing radiation dose. METHODS: This was a prospective double-blinded observational trial with informed consent and was institutional review board-approved and registered with ClinicalTrials.gov. A convenience sample of ED patients undergoing abdominal CT was recruited, excluding pregnant women, patients with altered mental status or abdominal sensation, preverbal children, and patients with abdominal trauma or surgery in the previous month. Before standard CT, physicians demarcated the tender region with labels invisible to radiologists on abdominal windows. Radiologists blinded to the tender region recorded cephalad-caudad limits of pathology on CT. Personnel blinded to pathology location recorded label positions on lung windows. Two hypothetical CT strategies were then explored: CT restricted to the tender region and CT from the cephalad skin marker to the lower caudad limit of the usual CT. The percentage of the pathologic region contained within the extent of the 2 hypothetical z axis restricted CTs was calculated. z axis reduction, which is linearly related to radiation reduction, from the restricted CTs was determined. RESULTS: One hundred two subjects were enrolled, 93 with complete data for analysis. Fifty-one subjects had acute pathology on CT. CT limited to the tender region would reduce z axis (radiation exposure) by 69% (95% confidence interval [CI] 60% to 78%). All acute pathology was included within these boundaries in 17 of the 51 abnormal cases (33%; 95% CI 22% to 47%). CT from the cephalad marker through the caudad abdomen and pelvis would reduce z axis (radiation exposure) by 38% (95% CI 29% to 48%). All acute pathology was included within these boundaries in 36 of 51 abnormal cases (71%; 95% CI 57% to 81%). With both strategies 1 and 2, the pathologic region was at least partially included within the CT region in the majority of cases (84% and 92%, respectively). CONCLUSION: CT with z axis restriction based on abdominal tenderness could reduce radiation exposure but with a potentially unacceptably high rate of misdiagnosis, using our current methods. Further prospective study may be warranted to determine the diagnostic utility of partially visualized pathology.
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Dolor Abdominal/diagnóstico por imagen , Pelvis/diagnóstico por imagen , Dosis de Radiación , Tomografía Computarizada por Rayos X/métodos , Adolescente , Adulto , Anciano , Anciano de 80 o más Años , Niño , Método Doble Ciego , Servicio de Urgencia en Hospital , Femenino , Humanos , Masculino , Persona de Mediana Edad , Evaluación de Resultado en la Atención de Salud , Estudios Prospectivos , Sensibilidad y Especificidad , Tomografía Computarizada por Rayos X/normas , Adulto JovenRESUMEN
Seizures and epilepsy are a set of conditions that can be challenging to diagnose, treat, and manage. This document summarizes recommendations for imaging in different clinical scenarios for a patient presenting with seizures and epilepsy. MRI of the brain is usually appropriate for each clinical scenario described with the exception of known seizures and unchanged semiology (Variant 3). In this scenario, it is unclear if any imaging would provide a benefit to patients. In the emergent situation, a noncontrast CT of the head is also usually appropriate as it can diagnose or exclude emergent findings quickly and is an alternative to MRI of the brain in these clinical scenarios. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.