Looking at the radiation dose from multitrauma CT.

2. The Rate of Normal findings Vs
Abnormal findings in Trauma CT’s done
at AAH: Do we need to assess our
current practice?
KEY PERFORMANCE AND QUALITY INDICATORS
22/08/2016
AL Ain Hospital
Clinical Imaging Institute
CT Scan Department
By: Fathima Hasan Mohamed
Senior radiographer

3. Introduction:
• Computed Tomography( CT ) is increasingly
used in the evaluation of trauma patients. The
use of CT in trauma has increased dramatically
over the last two decades.
• The term “ Trauma CT” means CT of the brain
to the mid-femurs ( face optional)
• Our facility uses a 64 slice scanner to perform
Trauma CT procedures.

4. Introduction
• An urgent Trauma CT is required for the rapid
diagnosis of life threatening injury which
requires prompt intervention.
• Literature shows that CT is an excellent tool to
show specific anatomical injury and is
excellent at showing vessel injury and active
bleeding and its use has improved patient
outcomes.

5. Introduction
• Ionising radiation from CT can increase
lifetime cancer risk, especially in the very
young.
• CT exposes the patient to significant doses of
radiation and concern arises about the
possible biological effects of these cumulative
radiation doses.

6. Clinical Imaging Institute/CT section
Key Performance Indicator :
The Rate of Normal findings Vs Abnormal findings in Trauma CT’s
done at our institute.
Objectives: To analyze the number of normal findings from Trauma
CT done and show the impact on patient dose.
Audit Plan: Annually
Place of study: CT Scan Section/Clinical Imaging Institute/Al Ain
Hospital.
Duration of study: 4 months of the year was chosen( every
quarter)
Sample size: 197 patients were evaluated in this study.

7. Method
• Patients who had Trauma CT were identified
through the Cerner online worklist and clinical
history and reports through PACS.
• Data was compiled in excel format.(see excel
sheet) and descriptive analysis was performed.
• Study was focused on adult male and female
patients < 35years and children < 12 years.
• Our organization uses a 64 slice scanner to
perform Trauma CT.

12. Data Analysis & Result :

13. Data Analysis & Result :

14. Data Analysis & Result :
• Percentage(%)
• 55% = men< 35 years
• 8%= women<35 years
• 6.5%= children

15. Data Analysis & Result :

16. Discussion
• The aim of this clinical audit was to describe
that the greater percentage of Trauma CT’s
ordered by ER physicians are normal and to
identify gaps to reduce these large amounts
of radiation exposure to patients.
• This is the first clinical audit from CT and
although we focused on just 4 months, the
findings are still useful to improve service
delivery at our hospital.

17. Discussion
• Ionising radiation exposure:
• Benefit to the patient must outweigh the risk
with increased radiation exposure from CT
compared tp conventional radiography.
• Lifetime potential cancer risk may be
significant especially in young patients.
• Is the benefit of of the diagnostic accuracy of
whole-body CT worth the potential risk?

18. Discussion:

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What is the dose from CT? How high?
 The effective dose in chest CT is in the order of 8
mSv (around 400 times more than chest
radiograph dose) and in some CT examinations
like that of pelvic region, it may be around 20 mSv
The absorbed dose to tissues from CT can
often approach or exceed the levels known
to increase the probability of cancer as
shown in epidemiological studies

20. Discussion
• Organ doses in CT
• Breast dose in thorax CT may be as much as
30-50 mGy, even though breasts are not the
target of imaging procedure.
• Eye lens dose in brain CT, thyroid in brain or in
thorax CT and gonads in pelvic CT receive high
doses

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Tissues in the field although they are not the area of
interest for the procedure
Lens of the eye Breast tissue

22. Discussion
• Radiation exposure to the abdomen and pelvis
is most significant when calculating whole-
body effective radiation dose.
• Exposure to thyroid, breast and gonads carry a
relatively high potential cancer risk.
• Therefore consideration of the need for
whole-body CT is essential to prevent
unnecessary harm.

23. Discussion: Dose report

24. Discussion:
• CT dose index ( CTDI )- represents the dose in
a single slice.
• Dose report displays the dose length product
( DLP ) index, which represents the integrated
radiation dose for a specific CT examination.
The DLP is then multiplied by conversion
factors for different areas of the body to
determine the effective dose in millisieverts to
the entire body.

25. Recommendations
• For ordering of Trauma CT, decision guidelines
should be put in place and followed- 20-40%
of CT’s can be avoided.
• Trauma CT should not replace careful clinical
examination and should only be used only in
appropriate patients (severely injured).

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Actions for physician & radiologist…
• Justification: Ensure that patients are not irradiated
unjustifiably.
• The physician is responsible for weighing the benefits
against risks.
• Physicians need to understand the radiation doses of
imaging modalities.
• Clinical guidelines advising which examinations are
appropriate and acceptable should be available to
clinicians and radiologists.
• Clinician has the responsibility to thoroughly
communicate information on patient condition to the
radiologist.

27. What can we do in Clinical Imaging
Institute?
• Be more proactive:
Need to involve non-imagers- training on
radiation dose and possible risks. Need to
educate all involved in the management of the
trauma patient.
Control- SAY NO!
Engage our community- patient information
leaflets.

28. Recommendations
• Trauma CT workflow:
Trauma management from two centers in UAE:
Rashid Hospital (Dubai) - poly-trauma patient received in A/E go throw a series of steps:
• 1- Initial screening and physical examinations in resuscitation unit.
• 2- Full body scan using a Statscan (Lodox) machine will performed on the patient in resuscitation
unit.
• 3- Statscan (Lodox) protocol includes:
• · AP full Body (from head to toe)
• · Lateral Head and Cervical Spine
• · Lateral Full Spine
• 4- After the initial management, Patient will be sent to CT unit.
• 5- CT scan poly-trauma protocol will be performed, including:
• · CT Brain, Face and Cervical Spine
• · CT Chest, Abdomen, Pelvis, Dorsal and Lumber
• 6- Patient will then sent back to resuscitation to complete his treatment
•

29. Statscan machine (Lodox Systems)

30. Statscan Images

31. Recommendations
• Tawam Hospital – Multitrauma CT policy:
• Indications for Trauma CT:
1. High energy trauma with clinical suspicion of
severe internal injury.
2. Any significant history with a Revised Trauma
Score of 10 or less on arrival in ED.

32. Recommendations
• Contraindications for immediate Trauma CT
1. Hemodynamic instability.
2. Un-resuscitated patient.
3. Airway is not safe.
4. Low oxygen saturation.

33. Recommendations
• Prior to performing a Trauma CT:
• Do x-ray of chest (supine in ED).

34. Recommendations

35. Conclusions
• We should evaluate our current practice that if a
trauma patient’s GCS is 14 or 15/15 and the
patient is stable( BP, Pulse and respiration), do we
really need to subject the patient to Trauma CT?
The patient may have had a trauma which is
trivial and not high energy.
• Is it not better to wait and observe these patients
and subject to Trauma CT if needed?
• Do we need to revisit our protocol for the
ordering of Trauma CT examinations?

36. Acknowlegements:
• CT Radiographers: Pulapadi Somanathan,
Monir Khan, Illyn Bregonia.
• Radiology Manager: Mr Anthony Bedson for
his continuous support.

37. References:

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Web sites for additional information on
radiation sources and effects
• European Commission (radiological protection pages):
europa.eu.int/comm/environment/radprot
• International Atomic Energy Agency: www.iaea.org
• International Commission on Radiological Protection:
www.icrp.org
• United Nations Scientific Committee on the Effects of
Atomic Radiation: www.unscear.org
• World Health Organization:
www.who.int

39. Further References:
• Control of patient dose- Al Ain Hospital policy
manager.