G Model
JINJ-6571; No. of Pages 4 Injury, Int. J. Care Injured xxx (2016) xxx–xxx
Contents lists available at ScienceDirect
Injury journal homepage: www.elsevier.com/locate/injury
Incidental findings on whole-body trauma computed tomography: Experience at a major trauma centre Matthew K.T. Seah a,*, Colin G. Murphy a, Scott McDonald b, Andrew Carrothers a a b
Orthopaedic Trauma Unit, Addenbrooke’s Hospital, United Kingdom Addenbrooke’s Hospital, United Kingdom
A R T I C L E I N F O
A B S T R A C T
Article history: Accepted 10 January 2016
Introduction: The use of total-body computed tomography (CT) scanning in the evaluation of multiply injured patients is increasing, and their liberal use has stirred debate as to the added benefit relative to the risk of radiation exposure and inappropriate use of limited healthcare resources. Findings unrelated to the clinician’s reasons for requesting the radiological examination are often uncovered due to the comprehensive nature of the evaluation at a trauma centre. However, some of these findings are outside the expertise of the trauma team who initially organised the scan and this may lead to uncertainty over who is best qualified to follow-up the incidental finding. We aim to evaluate the frequency of incidental findings on whole body trauma CT scans in a consecutive series of trauma admissions to our unit. Materials and methods: We identified 104 consecutive major trauma patients who received a wholebody trauma CT (head, cervical spine, chest, abdomen and pelvis) from Jan 2013 to Dec 2013 in our unit (out of a total of 976 trauma admissions in the same year). Patient-specific information was extracted from computerised hospital databases containing admission and progress notes, radiological reports, operation notes and pathology reports. Results: 57 patients (54.8%) had incidental findings identified on the radiologist report, with a total of 114 individual incidental findings. 6 (5.8%) patients had potentially severe findings that required further diagnostic work up; 65 (62.5%) patients had diagnostic workup dependant on their symptoms, and 43 (41.3%) patients had incidental findings of minor concern which required no follow up. Discussion and conclusions: Our findings reflect the literature noting that incidental findings are increasingly common due to the central diagnostic role of CT imaging in trauma care, but also due to advances in imaging techniques and quality. In keeping with published literature, we note that increased age is associated with an increased incidence of ‘‘incidental findings’’ and this will continue to rise with the ageing population and the mandatory nature of trauma CTs. ß 2016 Elsevier Ltd. All rights reserved.
Keywords: Incidental findings Trauma Computed tomography
Introduction The use of total-body computed tomography (CT) scanning in the evaluation of multiply injured patients is increasing, and their liberal use has stirred debate as to the added benefit relative to the risk of radiation exposure and inappropriate use of limited healthcare resources [1]. Findings unrelated to the clinician’s reasons for requesting the radiological examination are often uncovered due to the comprehensive nature of the evaluation at a trauma centre. However, some of these findings are outside the
* Corresponding author at: 9B Linton House, Puddicombe Way, Cambridge CB2 0AE, United Kingdom. Tel.: +44 7774520438. E-mail address: [email protected] (Matthew K.T. Seah).
expertise of the trauma team who initially organised the scan and this may lead to uncertainty over who is best qualified to follow-up the incidental finding [2]. With multiple parties involved in the care of the severely injured patient, it is perhaps not surprising that incidental findings (even those deemed clinically significant) may not always be documented clearly on patients’ charts, follow-up not organised or appropriate referrals not made [3]. The presence of incidental findings or ‘incidentalomas’ on CTs has been documented in several studies and may have a reported incidence of greater than 50% [3,4]. These incidental findings may be beneficial to patients in the case of earlier detection of other significant pathology (e.g. malignancy); conversely, they may result in increased anxiety and healthcare costs due to additional investigations for abnormalities that ultimately might not affect patients’ health [5]. Fear of missing significant pathology resulting
http://dx.doi.org/10.1016/j.injury.2016.01.012 0020–1383/ß 2016 Elsevier Ltd. All rights reserved.
Please cite this article in press as: Seah MKT, et al. Incidental findings on whole-body trauma computed tomography: Experience at a major trauma centre. Injury (2016), http://dx.doi.org/10.1016/j.injury.2016.01.012
G Model
JINJ-6571; No. of Pages 4 M.K.T. Seah et al. / Injury, Int. J. Care Injured xxx (2016) xxx–xxx
2
Table 1 Number of patients and incidental findings by age group.
30
Number of paents
25
20
15
10
5
0 0-9
10 - 19
20 - 29
30 - 39
40 - 49
50 - 59
60 - 69
70 - 79
80 - 89
Paent age (years) Number of paents
Number of incidental findings
in serious complications or outcomes and the worry of medicolegal ramifications are legitimate concerns. We are therefore asked to consider, ‘‘What is the responsible use of information that nobody asked for?’’ [6] The evaluation and surveillance of incidental findings have been cited as among the causes for the increased utilisation of cross-sectional imaging [4,7]. Indeed, incidental findings may be serious but when and how to evaluate them are unclear. The workup of incidental findings varies between clinician and region, and some concordance is desirable in light of the current need to limit excessive spending in the health service and to reduce risk to patients through unnecessary investigations. In this series, we aim to evaluate the frequency of incidental findings on whole body trauma CT scans in a consecutive series of trauma admissions to our unit, as well as the proportion of these which are potentially clinically significant.
Patients and methods Patient selection Addenbrooke’s Hospital is the Major Trauma Centre for the East of England Trauma Network. The network serves the six counties of the region (Norfolk, Suffolk, Cambridgeshire, Bedfordshire, Hertfordshire and Essex), an area of approximately 19,000 square kilometres with a population of 5.95 million residents [8,9]. The population served is typical of stable urban populations. As a Major Trauma Centre, referrals comprise primary and secondary transfers of all major trauma patients where the Injury Severity Score is expected to be greater than 15. A trauma triage tool is also used to determine whether the patient can be transferred to the closest trauma unit or the Major Trauma Centre. Using our trauma database, we identified 104 consecutive major trauma patients who received a whole-body trauma CT (head, cervical spine, chest, abdomen and pelvis) from Jan 2013 to Dec 2013 in our unit (out of a total of 976 trauma admissions in the same year). Patient-specific information was extracted from computerised hospital databases containing admission and progress notes, radiological reports, operation notes and pathology reports. All patients without a whole-body trauma CT scan were excluded from this study.
Image interpretation The CT scans were initially reviewed by an appropriately trained on-call radiologist as well as the trauma service. Following this initial review, senior radiologists retrospectively reviewed all CT scans. The findings were compared against the presenting complaint, the mechanism of injury, and medical history when present to determine the presence of incidental findings (which we defined as previously unknown pathology, not attributable to the Table 2 Incidental findings in 104 consecutive patients (by anatomical location). Head/neck
Abdomen/pelvis
Arachnoid cyst (3) Hydrocephalus (2) Small vessel disease (2)
Renal cyst (5) Splenic cyst (5) Diverticulosis/diverticular disease (4) Bulky mesenteric nodes (2) Hernias (2) Ovarian cyst (2) Atrophic pancreas Fatty liver Hepatic cyst Pancreatic lesion (intraductal papillary mucinous neoplasm) Retroaortic left renal vein Small bowel dilation
Acute infarct Carotid artery calcifications Ethmoiditis Foreign bodies Previous brain trauma/infarct Pneumocephaly Mastoiditis
Thyroid nodule Retroclival swelling White matter changes Chest
Spine
Emphysema (8) Chronic artherosclerotic disease (5)
Degenerative changes (10) Wedge compression fractures (3) Diffuse idiopathic skeletal hyperostosis Disc prolapse (2) Fusion right lateral process C1 to occipital condyle (likely congenital) Hypoplastic 1st rib Ossification posterior longitudinal ligament Pars defect Spondylosis
Pulmonary nodules (4) Mural thrombus of the large vessels (3) Coronary artery calcifications (2)
Bulky mediastinal lymph nodes Cardiomegaly Pleural plaques Pleural scarring Pulmonary emboli Pulmonary fibrosis Ventricular hypertrophy
Please cite this article in press as: Seah MKT, et al. Incidental findings on whole-body trauma computed tomography: Experience at a major trauma centre. Injury (2016), http://dx.doi.org/10.1016/j.injury.2016.01.012
G Model
JINJ-6571; No. of Pages 4 M.K.T. Seah et al. / Injury, Int. J. Care Injured xxx (2016) xxx–xxx
presenting injuries). The presence of incidental findings in the radiology report and the clinical consequences were determined by an un-blinded investigator. Incidental findings were divided into three categories based on clinical importance: (1) potentially severe finding that required further diagnostic work up (e.g. additional blood tests, consultation of other specialties, radiologic imaging or invasive diagnostic procedures); (2) diagnostic workup dependant on patient’s symptoms; and (3) findings of minor concerns which required no specific follow-up. These categories are similar to those proposed in other studies in the literature [10–12] and the first two categories were considered clinically significant. Results 104 trauma patients required a whole body CT scan at presentation to our unit in 2013. 89 patients were involved in a motor vehicle accident, 14 patients fell from a height of greater than 2 metres and 1 patient was assaulted. The average age was 38.2 years. 57 patients (54.8%) had incidental findings identified on
3
the radiologist report, with a total of 114 individual incidental findings. 6 (5.8%) patients had potentially severe findings that required further diagnostic work up; 65 (62.5%) patients had diagnostic workup dependant on their symptoms, and 43 (41.3%) patients had incidental findings of minor concern which required no follow up. The number of incidental findings per age group is shown in Table 1. The breakdown of the incidental findings are shown in Table 2. Discussion Our findings reflect the literature noting that incidental findings are increasingly common due to the central diagnostic role of CT imaging in trauma care, but also due to advances in imaging techniques and quality. In keeping with published literature, we note that increased age is associated with an increased incidence of ‘‘incidental findings’’ and this will continue to rise with the ageing population and the mandatory nature of trauma CTs. This is an important problem that requires a coordinated effort by trauma services. The integration of trauma care and the overall manage-
Trauma CT organised by receiving team on arrival at the Emergency Department
CT scans reviewed by an appropriately trained on-call radiologist as well as the trauma service (all formal reports issued will be reviewed and countersigned by a Consultant Radiologist if inial report was not issued by a Consultant)
Verbal report given to receiving teams and formal report issued online Any crical, urgent or significant unexpected findings are communicated verbally as well as highlighted in the reports, as well as the degree of urgency of acng on these
Tracking of electronic radiology reports to ensure audit trail Lead clinician idenfied on paent admission has overall responsibility for acng on any incidental findings
Safety neng: 1. documentaon on our MDT service worklist of the finding and the action needed, including follow-up 2. informing paent of the findings 3. documentaon in the discharge summary to the GP of the findings, the acon taken and any follow-up needed Fig. 1. Approach to the reporting and management of incidental findings at our institution.
Please cite this article in press as: Seah MKT, et al. Incidental findings on whole-body trauma computed tomography: Experience at a major trauma centre. Injury (2016), http://dx.doi.org/10.1016/j.injury.2016.01.012
G Model
JINJ-6571; No. of Pages 4 4
M.K.T. Seah et al. / Injury, Int. J. Care Injured xxx (2016) xxx–xxx
ment of the patient’s other problems is an important task to achieve after the management of the presenting injuries, and a reliable system of documenting and managing and or referring these incidental findings is required. Inadequate documentation or communication of potentially significant incidental findings, leading to lack of further diagnostics or follow-up can have ethical and legal ramifications. Paluska et al. [3] noted in their study that while incidental findings on CT scans were common, a review of patient admission documentation revealed that there was insufficient documentation and subsequent referral of these findings. This represents a significant area for quality improvement and how best to deal with these findings deserves further study. Audits of practice can be undertaken at the local level to ensure that documentation of incidental findings are adequate and appropriately actioned. Critics will contend that many of these incidental findings are of little or no clinical consequence and patients often undergo unnecessary additional testing in the context of limited resources, with no change in ultimate management. This is true for the majority of patients but several studies have shown that a small but significant number of these ‘incidentalomas’ are malignant and early identification and treatment are associated with increased survival and less morbidity [13,14]. Nevertheless, there remains a relative lack of research and guidance about the management of incidental findings and disparity in clinicians’ attitudes may be partly driven by the paucity of data, the lack of clear guidelines with regard to diagnostic and treatment strategies and fear of potential malpractice litigation. Whole body CTs have been shown to be a predictor of survival in severely injured patients when compared to no or targeted CT [15], and our protocols for whole body CT scanning in trauma patients are in keeping with the guidelines described by the Royal College of Radiologists [16]. Nevertheless, the average radiation dose for a typical whole body trauma CT is equivalent to receiving 760 chest radiographs, or over 5 years of natural background radiation in the UK [17]. In the United States, medical imaging is quoted to be responsible for 50% of the total radiation exposure to the population [18]. There are growing concerns with regards to the risks of ionising radiation exposure in trauma scans and the subsequent investigations that may result from the detection of incidental findings [7,19]. This is especially due to the young average age of trauma patients that we see. Our data suggest that the number of incidental findings increases with the patient’s age at presentation. This is in keeping with other studies [20] and might be expected as degenerative processes and the risk of neoplastic change increases with age. However, due to the variation in numbers of patients (of each age range) and the small numbers of our study, a larger study must be performed to draw more accurate inferences. It is also important to recognise that younger patients also have incidental findings which may be clinically significant. The National Patient Safety Agency highlights the importance of communicating radiological findings in their publication ‘Safer practice notice 16. Early identification of failure to act on radiological imaging reports’. We suggest a standardised approach to incidental findings detected in the course of trauma patient evaluation (Fig. 1). In our institution, this includes the following
elements: (1) documentation in patient records that the finding has been noted; (2) documentation on our service worklist of the finding and the action needed, including follow-up; (3) appropriate management for findings that require attention prior to discharge including appropriate consultation; (4) informing the patient and/ or family of these findings as described by the radiologist, and (5) documentation in the discharge summary of the findings, the action taken and any follow-up needed. Conflict of interest statement All the authors state that they have no financial or personal relationships with other people or organisations that could inappropriately influence this submission. References [1] Salim A, Sangthong B, Martin M, Brown C, Plurad D, Demetriades D. Whole body imaging in blunt multisystem trauma patients without obvious signs of injury: results of a prospective study. Arch Surg 2006;141(May (5)):468–73. [2] Levine MB, Moore AB, Franck C, Li J, Kuehl DR. Variation in use of all types of computed tomography by emergency physicians. Am J Emerg Med 2013;31(October (10)):1437–42. [3] Paluska TR, Sise MJ, Sack DI, Sise CB, Egan MC, Biondi M. Incidental CT findings in trauma patients: incidence and implications for care of the injured. J Trauma 2007;62(January (1)):157–61. [4] Maizlin ZV, Barnard SA, Gourlay WA, Brown JA. Economic and ethical impact of extrarenal findings on potential living kidney donor assessment with computed tomography angiography. Transpl Int 2007;20(April (4)):338–42. [5] Berlin L. Potential legal ramifications of whole-body CT screening: taking a peek into Pandora’s box. AJR Am J Roentgenol 2003;180(February (2)):317–22. [6] Fletcher RH, Pignone M. Extracolonic findings with computed tomographic colonography: asset or liability? Arch Intern Med 2008;168(April (7)):685–6. [7] Brenner DJ, Hall EJ. Computed tomography – an increasing source of radiation exposure. N Engl J Med 2007;357(November (22)):2277–84. [8] Office for National Statistics. Census gives insights into characteristics of the East of England’s population; 2012. [9] Trauma Audit and Research Network. Addenbrooke’s hospital the trauma audit and research network; 2015. [10] Sierink JC, Saltzherr TP, Russchen MJ, de Castro SM, Beenen LF, Schep NW, et al. Incidental findings on total-body CT scans in trauma patients. Injury 2014;45(May (5)):840–4. [11] van VR, Dekker HM, Deunk J, van der Vijver RJ, van Vugt AB, Kool DR, et al. Incidental findings on routine thoracoabdominal computed tomography in blunt trauma patients. J Trauma 2011;(April). [12] Barrett TW, Schierling M, Zhou C, Colfax JD, Russ S, Conatser P, et al. Prevalence of incidental findings in trauma patients detected by computed tomography imaging. Am J Emerg Med 2009;27(May (4)):428–35. [13] Shetty SK, Maher MM, Hahn PF, Halpern EF, Aquino SL. Significance of incidental thyroid lesions detected on CT: correlation among CT, sonography, and pathology. AJR Am J Roentgenol 2006;187(November (5)):1349–56. [14] Eskandary H, Sabba M, Khajehpour F, Eskandari M. Incidental findings in brain computed tomography scans of 3000 head trauma patients. Surg Neurol 2005;63(June (6)):550–3. [15] Huber-Wagner S, Lefering R, Qvick LM, Korner M, Kay MV, Pfeifer KJ, et al. Effect of whole-body CT during trauma resuscitation on survival: a retrospective, multicentre study. Lancet 2009;373(April (9673)):1455–61. [16] The Royal College of Radiologists. Standards of practice and guidance for trauma radiology in severely injured patients. London: The Royal College of Radiologists; 2011. [17] The Royal College of Radiologists. iRefer: Making the best use of clinical radiology. London: The Royal College of Radiologists; 2012. [18] Brenner DJ. Medical imaging in the 21 st century – getting the best bang for the rad. N Engl J Med 2010;362(March (10)):943–5. [19] Brenner DJ, Doll R, Goodhead DT, Hall EJ, Land CE, Little JB, et al. Cancer risks attributable to low doses of ionizing radiation: assessing what we really know. Proc Natl Acad Sci U S A 2003;100(November (24)):13761–66. [20] Baugh KA, Weireter LJ, Collins JN. The trauma pan scan: what else do you find? Am Surg 2014;80(September (9)):855–9.
Please cite this article in press as: Seah MKT, et al. Incidental findings on whole-body trauma computed tomography: Experience at a major trauma centre. Injury (2016), http://dx.doi.org/10.1016/j.injury.2016.01.012
JINJ-6571; No. of Pages 4 Injury, Int. J. Care Injured xxx (2016) xxx–xxx
Contents lists available at ScienceDirect
Injury journal homepage: www.elsevier.com/locate/injury
Incidental findings on whole-body trauma computed tomography: Experience at a major trauma centre Matthew K.T. Seah a,*, Colin G. Murphy a, Scott McDonald b, Andrew Carrothers a a b
Orthopaedic Trauma Unit, Addenbrooke’s Hospital, United Kingdom Addenbrooke’s Hospital, United Kingdom
A R T I C L E I N F O
A B S T R A C T
Article history: Accepted 10 January 2016
Introduction: The use of total-body computed tomography (CT) scanning in the evaluation of multiply injured patients is increasing, and their liberal use has stirred debate as to the added benefit relative to the risk of radiation exposure and inappropriate use of limited healthcare resources. Findings unrelated to the clinician’s reasons for requesting the radiological examination are often uncovered due to the comprehensive nature of the evaluation at a trauma centre. However, some of these findings are outside the expertise of the trauma team who initially organised the scan and this may lead to uncertainty over who is best qualified to follow-up the incidental finding. We aim to evaluate the frequency of incidental findings on whole body trauma CT scans in a consecutive series of trauma admissions to our unit. Materials and methods: We identified 104 consecutive major trauma patients who received a wholebody trauma CT (head, cervical spine, chest, abdomen and pelvis) from Jan 2013 to Dec 2013 in our unit (out of a total of 976 trauma admissions in the same year). Patient-specific information was extracted from computerised hospital databases containing admission and progress notes, radiological reports, operation notes and pathology reports. Results: 57 patients (54.8%) had incidental findings identified on the radiologist report, with a total of 114 individual incidental findings. 6 (5.8%) patients had potentially severe findings that required further diagnostic work up; 65 (62.5%) patients had diagnostic workup dependant on their symptoms, and 43 (41.3%) patients had incidental findings of minor concern which required no follow up. Discussion and conclusions: Our findings reflect the literature noting that incidental findings are increasingly common due to the central diagnostic role of CT imaging in trauma care, but also due to advances in imaging techniques and quality. In keeping with published literature, we note that increased age is associated with an increased incidence of ‘‘incidental findings’’ and this will continue to rise with the ageing population and the mandatory nature of trauma CTs. ß 2016 Elsevier Ltd. All rights reserved.
Keywords: Incidental findings Trauma Computed tomography
Introduction The use of total-body computed tomography (CT) scanning in the evaluation of multiply injured patients is increasing, and their liberal use has stirred debate as to the added benefit relative to the risk of radiation exposure and inappropriate use of limited healthcare resources [1]. Findings unrelated to the clinician’s reasons for requesting the radiological examination are often uncovered due to the comprehensive nature of the evaluation at a trauma centre. However, some of these findings are outside the
* Corresponding author at: 9B Linton House, Puddicombe Way, Cambridge CB2 0AE, United Kingdom. Tel.: +44 7774520438. E-mail address: [email protected] (Matthew K.T. Seah).
expertise of the trauma team who initially organised the scan and this may lead to uncertainty over who is best qualified to follow-up the incidental finding [2]. With multiple parties involved in the care of the severely injured patient, it is perhaps not surprising that incidental findings (even those deemed clinically significant) may not always be documented clearly on patients’ charts, follow-up not organised or appropriate referrals not made [3]. The presence of incidental findings or ‘incidentalomas’ on CTs has been documented in several studies and may have a reported incidence of greater than 50% [3,4]. These incidental findings may be beneficial to patients in the case of earlier detection of other significant pathology (e.g. malignancy); conversely, they may result in increased anxiety and healthcare costs due to additional investigations for abnormalities that ultimately might not affect patients’ health [5]. Fear of missing significant pathology resulting
http://dx.doi.org/10.1016/j.injury.2016.01.012 0020–1383/ß 2016 Elsevier Ltd. All rights reserved.
Please cite this article in press as: Seah MKT, et al. Incidental findings on whole-body trauma computed tomography: Experience at a major trauma centre. Injury (2016), http://dx.doi.org/10.1016/j.injury.2016.01.012
G Model
JINJ-6571; No. of Pages 4 M.K.T. Seah et al. / Injury, Int. J. Care Injured xxx (2016) xxx–xxx
2
Table 1 Number of patients and incidental findings by age group.
30
Number of paents
25
20
15
10
5
0 0-9
10 - 19
20 - 29
30 - 39
40 - 49
50 - 59
60 - 69
70 - 79
80 - 89
Paent age (years) Number of paents
Number of incidental findings
in serious complications or outcomes and the worry of medicolegal ramifications are legitimate concerns. We are therefore asked to consider, ‘‘What is the responsible use of information that nobody asked for?’’ [6] The evaluation and surveillance of incidental findings have been cited as among the causes for the increased utilisation of cross-sectional imaging [4,7]. Indeed, incidental findings may be serious but when and how to evaluate them are unclear. The workup of incidental findings varies between clinician and region, and some concordance is desirable in light of the current need to limit excessive spending in the health service and to reduce risk to patients through unnecessary investigations. In this series, we aim to evaluate the frequency of incidental findings on whole body trauma CT scans in a consecutive series of trauma admissions to our unit, as well as the proportion of these which are potentially clinically significant.
Patients and methods Patient selection Addenbrooke’s Hospital is the Major Trauma Centre for the East of England Trauma Network. The network serves the six counties of the region (Norfolk, Suffolk, Cambridgeshire, Bedfordshire, Hertfordshire and Essex), an area of approximately 19,000 square kilometres with a population of 5.95 million residents [8,9]. The population served is typical of stable urban populations. As a Major Trauma Centre, referrals comprise primary and secondary transfers of all major trauma patients where the Injury Severity Score is expected to be greater than 15. A trauma triage tool is also used to determine whether the patient can be transferred to the closest trauma unit or the Major Trauma Centre. Using our trauma database, we identified 104 consecutive major trauma patients who received a whole-body trauma CT (head, cervical spine, chest, abdomen and pelvis) from Jan 2013 to Dec 2013 in our unit (out of a total of 976 trauma admissions in the same year). Patient-specific information was extracted from computerised hospital databases containing admission and progress notes, radiological reports, operation notes and pathology reports. All patients without a whole-body trauma CT scan were excluded from this study.
Image interpretation The CT scans were initially reviewed by an appropriately trained on-call radiologist as well as the trauma service. Following this initial review, senior radiologists retrospectively reviewed all CT scans. The findings were compared against the presenting complaint, the mechanism of injury, and medical history when present to determine the presence of incidental findings (which we defined as previously unknown pathology, not attributable to the Table 2 Incidental findings in 104 consecutive patients (by anatomical location). Head/neck
Abdomen/pelvis
Arachnoid cyst (3) Hydrocephalus (2) Small vessel disease (2)
Renal cyst (5) Splenic cyst (5) Diverticulosis/diverticular disease (4) Bulky mesenteric nodes (2) Hernias (2) Ovarian cyst (2) Atrophic pancreas Fatty liver Hepatic cyst Pancreatic lesion (intraductal papillary mucinous neoplasm) Retroaortic left renal vein Small bowel dilation
Acute infarct Carotid artery calcifications Ethmoiditis Foreign bodies Previous brain trauma/infarct Pneumocephaly Mastoiditis
Thyroid nodule Retroclival swelling White matter changes Chest
Spine
Emphysema (8) Chronic artherosclerotic disease (5)
Degenerative changes (10) Wedge compression fractures (3) Diffuse idiopathic skeletal hyperostosis Disc prolapse (2) Fusion right lateral process C1 to occipital condyle (likely congenital) Hypoplastic 1st rib Ossification posterior longitudinal ligament Pars defect Spondylosis
Pulmonary nodules (4) Mural thrombus of the large vessels (3) Coronary artery calcifications (2)
Bulky mediastinal lymph nodes Cardiomegaly Pleural plaques Pleural scarring Pulmonary emboli Pulmonary fibrosis Ventricular hypertrophy
Please cite this article in press as: Seah MKT, et al. Incidental findings on whole-body trauma computed tomography: Experience at a major trauma centre. Injury (2016), http://dx.doi.org/10.1016/j.injury.2016.01.012
G Model
JINJ-6571; No. of Pages 4 M.K.T. Seah et al. / Injury, Int. J. Care Injured xxx (2016) xxx–xxx
presenting injuries). The presence of incidental findings in the radiology report and the clinical consequences were determined by an un-blinded investigator. Incidental findings were divided into three categories based on clinical importance: (1) potentially severe finding that required further diagnostic work up (e.g. additional blood tests, consultation of other specialties, radiologic imaging or invasive diagnostic procedures); (2) diagnostic workup dependant on patient’s symptoms; and (3) findings of minor concerns which required no specific follow-up. These categories are similar to those proposed in other studies in the literature [10–12] and the first two categories were considered clinically significant. Results 104 trauma patients required a whole body CT scan at presentation to our unit in 2013. 89 patients were involved in a motor vehicle accident, 14 patients fell from a height of greater than 2 metres and 1 patient was assaulted. The average age was 38.2 years. 57 patients (54.8%) had incidental findings identified on
3
the radiologist report, with a total of 114 individual incidental findings. 6 (5.8%) patients had potentially severe findings that required further diagnostic work up; 65 (62.5%) patients had diagnostic workup dependant on their symptoms, and 43 (41.3%) patients had incidental findings of minor concern which required no follow up. The number of incidental findings per age group is shown in Table 1. The breakdown of the incidental findings are shown in Table 2. Discussion Our findings reflect the literature noting that incidental findings are increasingly common due to the central diagnostic role of CT imaging in trauma care, but also due to advances in imaging techniques and quality. In keeping with published literature, we note that increased age is associated with an increased incidence of ‘‘incidental findings’’ and this will continue to rise with the ageing population and the mandatory nature of trauma CTs. This is an important problem that requires a coordinated effort by trauma services. The integration of trauma care and the overall manage-
Trauma CT organised by receiving team on arrival at the Emergency Department
CT scans reviewed by an appropriately trained on-call radiologist as well as the trauma service (all formal reports issued will be reviewed and countersigned by a Consultant Radiologist if inial report was not issued by a Consultant)
Verbal report given to receiving teams and formal report issued online Any crical, urgent or significant unexpected findings are communicated verbally as well as highlighted in the reports, as well as the degree of urgency of acng on these
Tracking of electronic radiology reports to ensure audit trail Lead clinician idenfied on paent admission has overall responsibility for acng on any incidental findings
Safety neng: 1. documentaon on our MDT service worklist of the finding and the action needed, including follow-up 2. informing paent of the findings 3. documentaon in the discharge summary to the GP of the findings, the acon taken and any follow-up needed Fig. 1. Approach to the reporting and management of incidental findings at our institution.
Please cite this article in press as: Seah MKT, et al. Incidental findings on whole-body trauma computed tomography: Experience at a major trauma centre. Injury (2016), http://dx.doi.org/10.1016/j.injury.2016.01.012
G Model
JINJ-6571; No. of Pages 4 4
M.K.T. Seah et al. / Injury, Int. J. Care Injured xxx (2016) xxx–xxx
ment of the patient’s other problems is an important task to achieve after the management of the presenting injuries, and a reliable system of documenting and managing and or referring these incidental findings is required. Inadequate documentation or communication of potentially significant incidental findings, leading to lack of further diagnostics or follow-up can have ethical and legal ramifications. Paluska et al. [3] noted in their study that while incidental findings on CT scans were common, a review of patient admission documentation revealed that there was insufficient documentation and subsequent referral of these findings. This represents a significant area for quality improvement and how best to deal with these findings deserves further study. Audits of practice can be undertaken at the local level to ensure that documentation of incidental findings are adequate and appropriately actioned. Critics will contend that many of these incidental findings are of little or no clinical consequence and patients often undergo unnecessary additional testing in the context of limited resources, with no change in ultimate management. This is true for the majority of patients but several studies have shown that a small but significant number of these ‘incidentalomas’ are malignant and early identification and treatment are associated with increased survival and less morbidity [13,14]. Nevertheless, there remains a relative lack of research and guidance about the management of incidental findings and disparity in clinicians’ attitudes may be partly driven by the paucity of data, the lack of clear guidelines with regard to diagnostic and treatment strategies and fear of potential malpractice litigation. Whole body CTs have been shown to be a predictor of survival in severely injured patients when compared to no or targeted CT [15], and our protocols for whole body CT scanning in trauma patients are in keeping with the guidelines described by the Royal College of Radiologists [16]. Nevertheless, the average radiation dose for a typical whole body trauma CT is equivalent to receiving 760 chest radiographs, or over 5 years of natural background radiation in the UK [17]. In the United States, medical imaging is quoted to be responsible for 50% of the total radiation exposure to the population [18]. There are growing concerns with regards to the risks of ionising radiation exposure in trauma scans and the subsequent investigations that may result from the detection of incidental findings [7,19]. This is especially due to the young average age of trauma patients that we see. Our data suggest that the number of incidental findings increases with the patient’s age at presentation. This is in keeping with other studies [20] and might be expected as degenerative processes and the risk of neoplastic change increases with age. However, due to the variation in numbers of patients (of each age range) and the small numbers of our study, a larger study must be performed to draw more accurate inferences. It is also important to recognise that younger patients also have incidental findings which may be clinically significant. The National Patient Safety Agency highlights the importance of communicating radiological findings in their publication ‘Safer practice notice 16. Early identification of failure to act on radiological imaging reports’. We suggest a standardised approach to incidental findings detected in the course of trauma patient evaluation (Fig. 1). In our institution, this includes the following
elements: (1) documentation in patient records that the finding has been noted; (2) documentation on our service worklist of the finding and the action needed, including follow-up; (3) appropriate management for findings that require attention prior to discharge including appropriate consultation; (4) informing the patient and/ or family of these findings as described by the radiologist, and (5) documentation in the discharge summary of the findings, the action taken and any follow-up needed. Conflict of interest statement All the authors state that they have no financial or personal relationships with other people or organisations that could inappropriately influence this submission. References [1] Salim A, Sangthong B, Martin M, Brown C, Plurad D, Demetriades D. Whole body imaging in blunt multisystem trauma patients without obvious signs of injury: results of a prospective study. Arch Surg 2006;141(May (5)):468–73. [2] Levine MB, Moore AB, Franck C, Li J, Kuehl DR. Variation in use of all types of computed tomography by emergency physicians. Am J Emerg Med 2013;31(October (10)):1437–42. [3] Paluska TR, Sise MJ, Sack DI, Sise CB, Egan MC, Biondi M. Incidental CT findings in trauma patients: incidence and implications for care of the injured. J Trauma 2007;62(January (1)):157–61. [4] Maizlin ZV, Barnard SA, Gourlay WA, Brown JA. Economic and ethical impact of extrarenal findings on potential living kidney donor assessment with computed tomography angiography. Transpl Int 2007;20(April (4)):338–42. [5] Berlin L. Potential legal ramifications of whole-body CT screening: taking a peek into Pandora’s box. AJR Am J Roentgenol 2003;180(February (2)):317–22. [6] Fletcher RH, Pignone M. Extracolonic findings with computed tomographic colonography: asset or liability? Arch Intern Med 2008;168(April (7)):685–6. [7] Brenner DJ, Hall EJ. Computed tomography – an increasing source of radiation exposure. N Engl J Med 2007;357(November (22)):2277–84. [8] Office for National Statistics. Census gives insights into characteristics of the East of England’s population; 2012. [9] Trauma Audit and Research Network. Addenbrooke’s hospital the trauma audit and research network; 2015. [10] Sierink JC, Saltzherr TP, Russchen MJ, de Castro SM, Beenen LF, Schep NW, et al. Incidental findings on total-body CT scans in trauma patients. Injury 2014;45(May (5)):840–4. [11] van VR, Dekker HM, Deunk J, van der Vijver RJ, van Vugt AB, Kool DR, et al. Incidental findings on routine thoracoabdominal computed tomography in blunt trauma patients. J Trauma 2011;(April). [12] Barrett TW, Schierling M, Zhou C, Colfax JD, Russ S, Conatser P, et al. Prevalence of incidental findings in trauma patients detected by computed tomography imaging. Am J Emerg Med 2009;27(May (4)):428–35. [13] Shetty SK, Maher MM, Hahn PF, Halpern EF, Aquino SL. Significance of incidental thyroid lesions detected on CT: correlation among CT, sonography, and pathology. AJR Am J Roentgenol 2006;187(November (5)):1349–56. [14] Eskandary H, Sabba M, Khajehpour F, Eskandari M. Incidental findings in brain computed tomography scans of 3000 head trauma patients. Surg Neurol 2005;63(June (6)):550–3. [15] Huber-Wagner S, Lefering R, Qvick LM, Korner M, Kay MV, Pfeifer KJ, et al. Effect of whole-body CT during trauma resuscitation on survival: a retrospective, multicentre study. Lancet 2009;373(April (9673)):1455–61. [16] The Royal College of Radiologists. Standards of practice and guidance for trauma radiology in severely injured patients. London: The Royal College of Radiologists; 2011. [17] The Royal College of Radiologists. iRefer: Making the best use of clinical radiology. London: The Royal College of Radiologists; 2012. [18] Brenner DJ. Medical imaging in the 21 st century – getting the best bang for the rad. N Engl J Med 2010;362(March (10)):943–5. [19] Brenner DJ, Doll R, Goodhead DT, Hall EJ, Land CE, Little JB, et al. Cancer risks attributable to low doses of ionizing radiation: assessing what we really know. Proc Natl Acad Sci U S A 2003;100(November (24)):13761–66. [20] Baugh KA, Weireter LJ, Collins JN. The trauma pan scan: what else do you find? Am Surg 2014;80(September (9)):855–9.
Please cite this article in press as: Seah MKT, et al. Incidental findings on whole-body trauma computed tomography: Experience at a major trauma centre. Injury (2016), http://dx.doi.org/10.1016/j.injury.2016.01.012
