The handout describes some brief practical points on emergency CT, particularly for emergency physicians. They include imaging utilisation trends, radiation dose, contrast reaction, contrast-induced nephropathy, use of oral contrast medium and some caveats on emergency CT (esp. abdomen)
Basic physics of multidetector computed tomography ( CT Scan) - how ct scan works, different generations of ct, how image is generated and displayed and image artifacts related to CT Scan.
Explain the non safe or harm aspects of CT scan on the patient,, particularly after multiple CT scans done for one patient. mentioned essentially the risk of cancer in later life, which reach 1/2000.
Also, mentioned the organs, age group, and gender which affected more by CT radiation
Finally , stressing on eliminating CT scan as possible
Basic physics of multidetector computed tomography ( CT Scan) - how ct scan works, different generations of ct, how image is generated and displayed and image artifacts related to CT Scan.
Explain the non safe or harm aspects of CT scan on the patient,, particularly after multiple CT scans done for one patient. mentioned essentially the risk of cancer in later life, which reach 1/2000.
Also, mentioned the organs, age group, and gender which affected more by CT radiation
Finally , stressing on eliminating CT scan as possible
Radiation Treatment of Rectal and Colon Cancer :: July 2017 #CRCWebinarFight Colorectal Cancer
Michael Bassetti, MD, Ph.D. from the University of Wisconsin Carbone Cancer Center discusses all you need to know about radiation. Dr. Bassetti will talk about what radiation treatment is, how it’s used for rectal and colon cancer patients, how to prepare for treatment, how to manage side effects and more.
The term acute abdomen defines a clinical syndrome characterized by the sudden onset of severe abdominal pain requiring emergency medical or surgical treatment.
It is one of the most frequent reasons for presentation of an adult to the emergency department, ranging from 4% to 10% of admissions.
A prompt and accurate diagnosis is essential to minimize morbidity and mortality in these patients.
The differential diagnosis includes a spectrum of infectious, inflammatory, ischemic, obstructive, hemorrhagic, and neoplastic disorders.
The acute abdomen can also reflect extra-abdominal conditions, including cardiac, pulmonary, endocrine, or metabolic disorders.
General suggestions in ordering body CT in ED; vascular occlusion; aneurysm/pseudoaneurysm; bleeding and active contrast extravasation; extraluminal air
Five pearls and pitfalls in using head CT for diagnosis of traumatic brain injury. This was presented at the 51st Annual Scientific Meeting of the Royal College of Radiologists of Thailand (6 Aug 2014)
Summary and illustrations of various traumatic brain injury including primary and secondary lesions as well as limited information on indications of brain imaging in trauma
One of the most developed cities of India, the city of Chennai is the capital of Tamilnadu and many people from different parts of India come here to earn their bread and butter. Being a metropolitan, the city is filled with towering building and beaches but the sad part as with almost every Indian city
Telehealth Psychology Building Trust with Clients.pptxThe Harvest Clinic
Telehealth psychology is a digital approach that offers psychological services and mental health care to clients remotely, using technologies like video conferencing, phone calls, text messaging, and mobile apps for communication.
CHAPTER 1 SEMESTER V - ROLE OF PEADIATRIC NURSE.pdfSachin Sharma
Pediatric nurses play a vital role in the health and well-being of children. Their responsibilities are wide-ranging, and their objectives can be categorized into several key areas:
1. Direct Patient Care:
Objective: Provide comprehensive and compassionate care to infants, children, and adolescents in various healthcare settings (hospitals, clinics, etc.).
This includes tasks like:
Monitoring vital signs and physical condition.
Administering medications and treatments.
Performing procedures as directed by doctors.
Assisting with daily living activities (bathing, feeding).
Providing emotional support and pain management.
2. Health Promotion and Education:
Objective: Promote healthy behaviors and educate children, families, and communities about preventive healthcare.
This includes tasks like:
Administering vaccinations.
Providing education on nutrition, hygiene, and development.
Offering breastfeeding and childbirth support.
Counseling families on safety and injury prevention.
3. Collaboration and Advocacy:
Objective: Collaborate effectively with doctors, social workers, therapists, and other healthcare professionals to ensure coordinated care for children.
Objective: Advocate for the rights and best interests of their patients, especially when children cannot speak for themselves.
This includes tasks like:
Communicating effectively with healthcare teams.
Identifying and addressing potential risks to child welfare.
Educating families about their child's condition and treatment options.
4. Professional Development and Research:
Objective: Stay up-to-date on the latest advancements in pediatric healthcare through continuing education and research.
Objective: Contribute to improving the quality of care for children by participating in research initiatives.
This includes tasks like:
Attending workshops and conferences on pediatric nursing.
Participating in clinical trials related to child health.
Implementing evidence-based practices into their daily routines.
By fulfilling these objectives, pediatric nurses play a crucial role in ensuring the optimal health and well-being of children throughout all stages of their development.
ICH Guidelines for Pharmacovigilance.pdfNEHA GUPTA
The "ICH Guidelines for Pharmacovigilance" PDF provides a comprehensive overview of the International Council for Harmonisation of Technical Requirements for Pharmaceuticals for Human Use (ICH) guidelines related to pharmacovigilance. These guidelines aim to ensure that drugs are safe and effective for patients by monitoring and assessing adverse effects, ensuring proper reporting systems, and improving risk management practices. The document is essential for professionals in the pharmaceutical industry, regulatory authorities, and healthcare providers, offering detailed procedures and standards for pharmacovigilance activities to enhance drug safety and protect public health.
Antibiotic Stewardship by Anushri Srivastava.pptxAnushriSrivastav
Stewardship is the act of taking good care of something.
Antimicrobial stewardship is a coordinated program that promotes the appropriate use of antimicrobials (including antibiotics), improves patient outcomes, reduces microbial resistance, and decreases the spread of infections caused by multidrug-resistant organisms.
WHO launched the Global Antimicrobial Resistance and Use Surveillance System (GLASS) in 2015 to fill knowledge gaps and inform strategies at all levels.
ACCORDING TO apic.org,
Antimicrobial stewardship is a coordinated program that promotes the appropriate use of antimicrobials (including antibiotics), improves patient outcomes, reduces microbial resistance, and decreases the spread of infections caused by multidrug-resistant organisms.
ACCORDING TO pewtrusts.org,
Antibiotic stewardship refers to efforts in doctors’ offices, hospitals, long term care facilities, and other health care settings to ensure that antibiotics are used only when necessary and appropriate
According to WHO,
Antimicrobial stewardship is a systematic approach to educate and support health care professionals to follow evidence-based guidelines for prescribing and administering antimicrobials
In 1996, John McGowan and Dale Gerding first applied the term antimicrobial stewardship, where they suggested a causal association between antimicrobial agent use and resistance. They also focused on the urgency of large-scale controlled trials of antimicrobial-use regulation employing sophisticated epidemiologic methods, molecular typing, and precise resistance mechanism analysis.
Antimicrobial Stewardship(AMS) refers to the optimal selection, dosing, and duration of antimicrobial treatment resulting in the best clinical outcome with minimal side effects to the patients and minimal impact on subsequent resistance.
According to the 2019 report, in the US, more than 2.8 million antibiotic-resistant infections occur each year, and more than 35000 people die. In addition to this, it also mentioned that 223,900 cases of Clostridoides difficile occurred in 2017, of which 12800 people died. The report did not include viruses or parasites
VISION
Being proactive
Supporting optimal animal and human health
Exploring ways to reduce overall use of antimicrobials
Using the drugs that prevent and treat disease by killing microscopic organisms in a responsible way
GOAL
to prevent the generation and spread of antimicrobial resistance (AMR). Doing so will preserve the effectiveness of these drugs in animals and humans for years to come.
being to preserve human and animal health and the effectiveness of antimicrobial medications.
to implement a multidisciplinary approach in assembling a stewardship team to include an infectious disease physician, a clinical pharmacist with infectious diseases training, infection preventionist, and a close collaboration with the staff in the clinical microbiology laboratory
to prevent antimicrobial overuse, misuse and abuse.
to minimize the developme
Defecation
Normal defecation begins with movement in the left colon, moving stool toward the anus. When stool reaches the rectum, the distention causes relaxation of the internal sphincter and an awareness of the need to defecate. At the time of defecation, the external sphincter relaxes, and abdominal muscles contract, increasing intrarectal pressure and forcing the stool out
The Valsalva maneuver exerts pressure to expel faeces through a voluntary contraction of the abdominal muscles while maintaining forced expiration against a closed airway. Patients with cardiovascular disease, glaucoma, increased intracranial pressure, or a new surgical wound are at greater risk for cardiac dysrhythmias and elevated blood pressure with the Valsalva maneuver and need to avoid straining to pass the stool.
Normal defecation is painless, resulting in passage of soft, formed stool
CONSTIPATION
Constipation is a symptom, not a disease. Improper diet, reduced fluid intake, lack of exercise, and certain medications can cause constipation. For example, patients receiving opiates for pain after surgery often require a stool softener or laxative to prevent constipation. The signs of constipation include infrequent bowel movements (less than every 3 days), difficulty passing stools, excessive straining, inability to defecate at will, and hard feaces
IMPACTION
Fecal impaction results from unrelieved constipation. It is a collection of hardened feces wedged in the rectum that a person cannot expel. In cases of severe impaction the mass extends up into the sigmoid colon.
DIARRHEA
Diarrhea is an increase in the number of stools and the passage of liquid, unformed feces. It is associated with disorders affecting digestion, absorption, and secretion in the GI tract. Intestinal contents pass through the small and large intestine too quickly to allow for the usual absorption of fluid and nutrients. Irritation within the colon results in increased mucus secretion. As a result, feces become watery, and the patient is unable to control the urge to defecate. Normally an anal bag is safe and effective in long-term treatment of patients with fecal incontinence at home, in hospice, or in the hospital. Fecal incontinence is expensive and a potentially dangerous condition in terms of contamination and risk of skin ulceration
HEMORRHOIDS
Hemorrhoids are dilated, engorged veins in the lining of the rectum. They are either external or internal.
FLATULENCE
As gas accumulates in the lumen of the intestines, the bowel wall stretches and distends (flatulence). It is a common cause of abdominal fullness, pain, and cramping. Normally intestinal gas escapes through the mouth (belching) or the anus (passing of flatus)
FECAL INCONTINENCE
Fecal incontinence is the inability to control passage of feces and gas from the anus. Incontinence harms a patient’s body image
PREPARATION AND GIVING OF LAXATIVESACCORDING TO POTTER AND PERRY,
An enema is the instillation of a solution into the rectum and sig
Health Education on prevention of hypertensionRadhika kulvi
Hypertension is a chronic condition of concern due to its role in the causation of coronary heart diseases. Hypertension is a worldwide epidemic and important risk factor for coronary artery disease, stroke and renal diseases. Blood pressure is the force exerted by the blood against the walls of the blood vessels and is sufficient to maintain tissue perfusion during activity and rest. Hypertension is sustained elevation of BP. In adults, HTN exists when systolic blood pressure is equal to or greater than 140mmHg or diastolic BP is equal to or greater than 90mmHg. The
The Impact of Meeting: How It Can Change Your Life
Practical Points in Emergency CT for Emergency Physicians
1. Rathachai Kaewlai, MD
Ramathibodi Hospital, Mahidol University, Bangkok
Annual Conference of Thai Emergency Physicians (ACTEP)
Greenery Resort Khao Yai, Nakhon Ratchasima | 28 Nov 2014
Practical Points in
Emergency CT for EP
2. Emergency Physician Tasks
• Perform a thorough history and physical
• Formulate a reasonable DDx
• Order imaging tests based on suspected
diagnosis
• Correctly perform the imaging test
• Correctly interpret the imaging test
• Correctly apply the test result to patient care
David T. Schwartz, MD. NYU
3. Outline
• Imaging utilization in ED
• Radiation dose from emergency CT
• IV contrast issues
• PO contrast issue
• What CT can diagnose and what it cannot
4. US
3%
MRI
0%
US
4%
CT Imaging Share Increases
Significantly in a Decade
U.S. Medicare Data
CT
18%
XR
78%
NM
1%
2002
CT
30%
XR
65%
MRI
1%
NM
0%
2012
Levin DC, et al. J Am Coll Radiol 2014;11:1044-1047.
5. CT per 1,000 ED visits Also Increases
from 6% to 15%
U.S. Medicare Data
Levin DC, et al. J Am Coll Radiol 2014;11:1044-1047.
Bundling of
upper/lowe
r abdomen
codes
2012: 150 CTs per
1000 ED visits
6. % of Visits with CT Performed
USA (15%) vs. Canada (8%)
Berdahl CT, et al. Ann Emerg Med 2013;62:486-494.
2012 2014
7. Fear of Lawsuits Does Not Drives
Unnecessary ED High-cost Imaging
Waxman DA, et al. N Eng J Med 2014;371:1518-1525.
8. Minimal Variations Found Amount
Emergency Physicians on Imaging
Utilization
Wong HJ, et al. Radiology 2013;268:779-789.
9. Advanced age
Arrived by ambulance
Higher acuity area
More secondary
diagnoses
More
High-cost imaging when
ED most busy
More
Low-cost imaging when
ED least busy
More ED Imaging Utilization in Certain
Patients’ and Visit Characteristics
Wong HJ, et al. Radiology 2013;268:779-789.
10. Lesson #1
• CT continues to be the main imaging
workhorse in ED, following x-ray
• CT utilization increases even in the midst of
cost-cutting reform and in States where
malpractice has been reformed
• What drives CT use in ED is likely multifactorial
and physicians’ characteristics might not be a
culprit
11. There is no safe dose of radiation.
- Edward P Radford, MD
Scholar of the Risks from Radiation
13. Tissue Sensitivity
Most sensitive
Bone marrow (red), colon, lung, stomach,
breast
Gonads
Bladder, esophagus, liver, thyroid
Bone surface, brain, salivary glands, skin
Least sensitive
Ref: ICRP 2007
Tissue Sensitivity
~ rate of cell proliferation
Inversely ~ to age
Inversely ~ to degree of cell
differentiation
Higher dose = more damage
Young = more damage
16. In an age in which we can download
movies and music from the cloud, it is
inexcusable to subject patients to
avoidable cost and radiation exposure
when the technology exists to ensure
that images are readily accessible.
Zane RD. JWatch Emergency Medicine
Avoid Unnecessary CT:
Import Outside Studies into PACS
Moore HB, et al. J Trauma 2013;74:813-817.
17. Lesson #2
• CT radiation dose is a real concern especially
in children and young adults who have longer
life expectancy
• High-radiation risk procedures: multiphase CT
and repeated CT
• Beside technical changes on Radiology side, EP
can help by selecting an appropriate imaging
for clinical question and avoid duplicated
exams whenever possible
18. High osmolarity (1500+)
IV Contrast
Ionic
Low osmolarity (300-900)
Non-ionic
OLD, IONIC, HYPEROSMOLAR AGENTS
NEW, NON-IONIC, LOW OSMOLAR AGENTS
19. Benefits of IV contrast
Visualization of structures and pathologies, focal pathology in solid organs and necessary for CT angio
21. No True Iodine Allergy
Iodine is a part of our body and important source of metabolism (thyroid hormone).
Seafood allergy is because of muscular proteins
22. OLD, IONIC, HYPEROSMOLAR AGENTS
NEW, NON-IONIC, LOW OSMOLAR AGENTS
5-15% 0.2-0.7%
Fatality ~ 2.1 per 1 million (US FDA)
Rate of Contrast Reaction
Lasser EC, et al. Radiology 1997;203:605-610.
23. Lesson #3
• Newer, non-ionic, low-osmolar contrast is
much safer than older ones
• Most reactions are mild, cutaneous
• There is no true iodine allergy
• What we should ask patients: prior history of
reaction to IV contrast (most substantial),
atopy and asthma
24. Definition of CIN | No control group on studies of CIN
No risk threshold of renal function test | Problem with sCr vs. eGFR
Contrast-induced Nephropathy
Controversies
25. Acute Kidney Injury: AKIN Definition
• Any one of these within 48 hours
of contrast
– Absolute increase of sCr >0.3 mg/dL
– % increase of sCr >50% (1.5 fold above
baseline)
– Urine output decrease to <0.5 mL/kg/h
for at least 6 hrs
26. • Serum creatinine limited by
– Influence of gender, muscle mass, nutritional status, age
– Can be “normal” until GFR decreases by 50%
• Estimated GFR with Cockcroft-Gault or
Modification of Diet in Renal Disease (MDRD)
27. Cardiac cath data (arterial injection)
IV (venous) injection
Acute Kidney Injury
from IV Contrast
Data from cardiac cath overestimates risk of intravenous contrast
Newhouse JH, et al. AJR Am J Roentgenol 2008;191:376-382.
28. Studies with a control group of patients NOT receiving IV contrast
>50% of 30,000 patients showed change in sCr
>40% showed change of at least 0.4 mg/dL
https://c2.staticflickr.com/6/5049/5241695367_aa1610e8e1_z.jpg
Acute Kidney Injury
from IV Contrast
Newhouse JH, et al. AJR Am J Roentgenol 2008;191:376-382.
29. Risk Threshold
• No universal agreement on threshold
• No agreement on how long from baseline to
use sCr before IV contrast
• Ramathibodi protocol
30. Lesson #4
• Controversies on IV contrast and renal toxicity
persist. Now it is best to follow local
standardized protocol
• Best method to reduce risk of CIN is adequate
hydration prior and after exposure
31. Jakebouma.com
V.S.
BARIUM
Thicker
Lower risk of aspiration
Not used if suspect perforation
WATER SOLUBLE
Higher aspiration risk
Better choice if suspect perforation
Oral Contrast Controversy
32. Oral Contrast: Benefits
better delineation of bowel, movement to rectum suggests incomplete obstruction or ileus
33. Oral Contrast
• New with MDCT, less need for PO contrast
• Dramatic decrease in ED time intervals in
patients receiving NCCT in evaluation of flank
pain (312 min for renal stone NCCT vs. 599
min for abd CT with PO contrast
Hunyh LN, et al. Emerg Radiol 2004;10:310-313.
34. Even without oral contrast, cancer of the colon and terminal ileum can be appreciated
35. Lesson #5
• Avoiding oral contrast can help speed up the
process of getting a CT
• This can be helpful in certain group of
patients: trauma, acute abdomen (not
suspected of perforation or fistula)
36. Select the Right Imaging Exam
• Selecting correct imaging modality can
affect patient outcome, prevent delay and
influence type and onset of Rx
• Acute abdominal imaging options: X-ray,
ultrasound, CT
46. Lesson #6: Disorders that can be
missed by CT -- Others
• Small SAH
• DAI
• Early cerebral contusion
• Early ischemic stroke
• Small lesions (tumors,
aneurysms)
• Posterior fossa
• Subsegmental PE
• PE in poorly performed
study
• Coronary cause (in non-coronary
CTA)
47. Conclusion
• CT is the main imaging workhorse in ED, following x-ray. What
drives CT use in ED is likely multifactorial
• CT radiation dose concern in people with longer life
expectancy
• Newer, non-ionic, low-osmolar contrast is much safer than
older ones
• Controversies on IV contrast and renal toxicity persist. Now it
is best to follow local standardized protocol
• Oral contrast can be avoided in certain scenarios
• Know things that can be diagnosed or missed on CT
Editor's Notes
10:20-11:05
3 reform states from 1997-2011. 5% random sample of Medicare beneficiaries. Comparing patient level outcomes, before and after legislation in reform and control states.
Outcome = policy attributable changes in use of CT or MR, per-visit ED charges and rate of hospital admissions.
Malpractice reform includes– Ordinary negligence willful and wanton negligence or gross negligence. Cap on non-economic damages.
To quantify interphysician variation in imaging use in ED.
Year 2011. 88851 ED visits at MGH
Imaging use depends on patients and visit-level factors (ED busyness, prior ED visit, referral source to ED, ED arrival mode).
Physician factors not correlate with imaging use
88851 visits in one year. 45.4% with imaging (36.2% with XR and US, 17.8% with CT/MR/NM, 8.6% with both).
Ionization: indirect effect
X-ray induces intermediary species that are the actual agent of biological damage
Use of Clinical Prediction Rules & Expert Recommendations
Patients transferred to trauma center often undergo repeat imaging soon after transfer
38/137 (28%) cases received duplicated scans in 24 hours
Most common reason for duplication = lack thin-section data on CD (37%)
Additional radiation 10.2 mSv
Additional charge $409
Older contrast agents: high osmolarity (1500+), ionic
Newer contrast agents
Low osmolarity (300-900), non-ionic
Less risks for patients
Improved visualization of normal structures, infection, inflammation, vascular pathology and neoplasm
Focal pathology in solid organs
CT angiography
Contrast molecule too small to provide true IgE antibody response
Anaphylactoid reaction
Mild – skin rash
Severe – laryngeal edema, bronchospasm, arrest
Patients allergic to seafood should not get IV contrast (??)
Iodine is a part of our body and important source of metabolism (thyroid hormone)
Allergy to muscular proteins (tropomyosin in crustaceans and parvalbumin in fish)
Older contrast 5-15%
Newer contrast 0.2-0.7%
Fatality very rare, quoted by US FDA* as 2.1 per 1 million injections
Delayed reaction 0.5-14%
Mostly cutaneous (urticaria, persistent rash, pruritus
Lack of clear definition
Most literature on incidence of CIN did not include a control group
Risk thresholds
Serum creatinine or eGFR
Unclear acceptable interval between baseline renal function and IV contrast
Cockcroft and MDRD limited by narrow populations (they were created from) –applicability only to stable levels of renal dysfunction.
http://www.safekidneycare.org/images/gfr_halfcircle.png
Data from cardiac cath likely overestimate risk of IV contrast
Many studies with a control group of patients not receiving IV contrast
Frequency and magnitude of sCr change similar to changes in patients receiving contrast
30,000 patients without IV contrast*
>50% change in sCr at least 25%
>40% change of at least 0.4 mg/dL
https://c2.staticflickr.com/6/5049/5241695367_aa1610e8e1_z.jpg
Barium sulfate: thicker, lower risk of aspiration, not used in suspected perf
Water soluble: increased aspiration risk, better choice in possible perf
Better structural delineation, esp. bowel
Theoretically better imaging of transition point, movement to rectum suggest incomplete obstruction or ileus
?improve imaging of appendix
SBO
Closed loop obstruction
Mesenteric ischemia
SBO
Closed loop obstruction
Mesenteric ischemia
SBO
Closed loop obstruction
Mesenteric ischemia
Gallstone pancreatitis
Ruptured AAA
Right UVJ stone