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One area I struggle with as much as whom to scan is what scan to order in these patients. It is painful to order a full CTA chest/abdomen/pelvis in patients with isolated thoracic symptoms and get a negative read - I just ordered a completely normal pan-scan. At the same time, I once ordered a CTA chest only and it was positive and I didn't capture the inferior portion of the dissection and I had an unhappy surgeon. Are people going directly to pan-scan on all these patients. I guess I think a stratified system based on pre-test probability is reasonable - for the moderate risk patient with isolated thoracic symptoms get a chest only and for high risk do chest/abdomen/pelvis. Is there a place for chest/abdomen only (sans pelvis)? I hate for patients to get charged for a more extensive scan than is indicated.
Clay - I don't want to answer for Amal but my practice is that if I'm scanning with concern for dissection I go chest/abdomen/pelvis. There's no point in having to go back to CT once you've decided you need one. Not sure about charges. you'd have to ask your institution about that. Not sure that places separate abdomen and pelvis as separate studies
Thanks - that is typically my practice as well. Both hospitals I work at have options for abdomen without pelvis, but I'm not sure how much that saves in terms of radiation or cost and it is rare to order the abdomen without the pelvis.
Clay,I agree with Swami. If we are doing a dissection protocol, we do chest/abd/pelvis. Although it does expose the person to addl. radiation, if on the other hand you only get a chest and it turns out to be positive, then you'd have to go back and repeat the CT with an additional bolus of contrast which nobody is happy about.
If you're having a really lucky day, you can ask the radiologist to read the chest real-time and if he/she sees a concern, they extend the CT down; but if the chest is totally normal, they can stop at the chest. But that's rare you get that lucky!
Any thoughts on how you would approach test for an aortic dissection in a patient with a history of anaphylaxis reaction to contrast media? I had a patient like this recently. After performing a US for AAA amd CXR, I ended up pre-treating before getting the CT scan. This of course took multiple hours and I continually rechecked the patient, but is there a better way of approaching this problem?
Michael, I've had this issue a handful of times. On one occasion, it was 2 pm on a Tuesday and I got the patient a stat-TEE which showed dissection. Definitely unusual to get the TEE quickly.A couple of important points. Pre-treatment has never been shown to reduce the risk of severe reactions. If the patient had a severe anaphylactoid reaction in the past, pretreatment won't reduce the risk. It's also not a guarantee that the patient will have the reaction again.On the 2 occasions I really though the patient had a dissection and they had a history of severe reactions to contrast (throat closing requiring epinephrine in both cases) we consented the patient for intubation prior to CT. One patient had a dissection and went straight to the OR. The other patient had a negative scan. Neither patient had a severe reaction. We extubated the other patient about 1 hour after scan.
Michael, we've all had similar scenarios and it's really tough.If it's a severe rxn, then you have to pre-treat; if it's not a severe reaction and you have a high concern, then benefit potentially outweighs the risk.The alternative is TEE, which is not easily available. POCUS if you are really good, but that might still miss things.I don't think I've said anything you don't already know....in the end, you just do the best you can do in a given situation, document well, and I would try to treat the HR and BP until the dx is ruled out.
I too gave concerns with using an ADD score of 1 due to sensitivty, but then wonder why am I considering scanning for dissection if the ADD score is 0? Here is an important distinction. High risk pain is defined as "Chest, back, or abdominal pain described as abrupt onset, severe intensity, or ripping/tearing."
Note this does NOT include chest pain radiating to the back, which is something we all think of as high risk.
If you have chest pain radiating to the back, but it was say gradual in onset, moderate, comes and goes, and pressure like, you may be thinking that while this is most likely ACS or something else, you are boxed into scanning for dissection because it radiates to the back. This is a person that would get an ADD score of 0 and maybe be ok to use d-dimer on.
Leen Alblaihed, who works in Amal's shop, has given a few very cool lectures on ultrasound for dissections; last I saw was some excellent ones at the" Crashing Patient course", with Amal and gang from UMMC a few months back. she illustrated the supra-sternal notch for the aortic arch dissection, and of course the abdominal view. It's EXTREMELY helpful if you see it (and it can be done within seconds of the patient presenting the ED) and you can start making those important phone calls , but of course if it's equivocal or "negative" , then one needs to proceed as described here in this pod.
thank you Amal and Swami for another very cool pod.tom fiero, merced, ca.
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