Hostname: page-component-78c5997874-8bhkd Total loading time: 0 Render date: 2024-11-02T20:26:08.276Z Has data issue: false hasContentIssue false

Adverse events are rare among adults 50 years of age and younger with flank pain when abdominal computed tomography is not clinically indicated according to the emergency physician

Published online by Cambridge University Press:  04 March 2015

Norman Epstein*
Affiliation:
Department of Emergency Medicine, Credit Valley Hospital, Thornhill, ON
Paul Rosenberg
Affiliation:
Department of Emergency Medicine, Etobicoke General Hospital, Etobicoke, ON
Marianne Samuel
Affiliation:
Department of Emergency Medicine, Credit Valley Hospital, Thornhill, ON
Jacques Lee
Affiliation:
Department of Emergency Medicine, Sunnybrook Research Institute, Toronto, ON
*
Credit Valley Hospital, 107 Pico Crescent, Thornhill, ON L4J 8P3; [email protected]

Abstract

Core share and HTML view are not available for this content. However, as you have access to this content, a full PDF is available via the ‘Save PDF’ action button.
Objective:

Many emergency physicians (EPs) order “confirmatory” abdominal computed tomography (CT) in young flank pain patients, despite a high clinical suspicion of renal colic and the risk of radiation exposure. We measured the adverse outcome rate among flank pain patients identified as not requiring abdominal CT by the EP on a data form, regardless of whether CT was eventually ordered. Our secondary objective was to describe diagnoses other than renal colic identified by CT in this population.

Methods:

We conducted a prospective observational study at two community EDs. We asked staff EPs to complete a data sheet on patients ages 18 to 50 years with a first episode of flank pain, recording 1) if the flank pain was consistent with renal colic and 2) if the EP felt abdominal CT was indicated. Adverse outcomes (defined a priori as urgent surgical procedures, disability, or death) were assessed by research assistants at 4 weeks using telephone follow-up and a hospital records search.

Results:

We enrolled 389 patients; 353 completed follow-up (91%). The average age was 38.8 years, and 72.0% were male. Of 212 patients identified in the “CT not indicated” group, 2 had another diagnosis identified (unruptured diverticulitis and a ruptured ovarian cyst), but none had adverse outcomes (95% CI 0-1.4).

Conclusions:

Adverse events were rare (< 1.5%) among patients < 50 years old with flank pain when CT was not required according to the clinical assessment of the EP. Future research should assess the adverse outcomes of withholding CT in low-risk patients using a larger patient sample.

Type
Original Research • Recherche originale
Copyright
Copyright © Canadian Association of Emergency Physicians 2013

References

REFERENCES

1.Lindqvist, K, Hellstrom, M, Holmberg, G, et al. Immediate versus deferred radiological investigation after acute renal colic: a prospective randomized study. Scand J Urol Nephrol 2006;40:119–24, doi:10.1080/00365590600688203.Google Scholar
2.Stamatelou, KK, Francis, ME, Jones, CA, et al. Time trends in reported prevalence of kidney stones in theUnited States:1976–1994. Kidney Int 2003;63:1817–23.CrossRefGoogle Scholar
3.Huang, CC, Lo, HC, Huang, HH, et al. ED presentations of acute renal infarction. Am J Emerg Med 2007;25:164–9, doi:10.1016/j.ajem.2006.06.010.Google Scholar
4.Sidhu, R, Bhatt, S, Dogra, V. Renal colic. Ultrasound Clin North Am 2008;3:159–70.Google Scholar
5.Pierre, J, Nadel, N. Emergency provider’s ability to stratify risk of renal calculi prior to CT scan confirmation. Acad Emerg Med 2009;16(4 (Supp1):S23.Google Scholar
6.Miller, JC, Maher, MM, Grocela, JA, et al. Imaging for renal colic and hematuria. J Am Coll Radiol 2006;3:814–7, doi:10.1016/j.jacr.2006.02.038.Google Scholar
7.Epstein, N, Chin, S, Pereira, M. The need for CT scans in patients under 50 years presenting with symptoms of renal colic. CJEM 2006;8(3 Suppl):213.Google Scholar
8.Epstein, N, Chin, S, Pereira, M. The need for CT scans in patients under 50 years presenting with symptoms of renal colic. CJEM 2006;8(3 Suppl):178228.Google Scholar
9.Katz, DS, Scheer, M, Lumerman, JH, et al. Alternative or additional diagnoses on unenhanced helical computed tomography for suspected renal colic: experience with 1000 consecutive examinations. Urology 2000;56:53–7, doi:10.1016/S0090-4295(00)00584-7.Google Scholar
10.Rucker, CM, Menias, CO, Bhalla, S. Mimics of renal colic: alternative diagnoses at unenhanced helical CT. Radiographics 2004;24 Suppl 1:S11-28; discussion S28-33, doi:10.1148/rg.24si045505.CrossRefGoogle ScholarPubMed
11.Baskerville, JR, Chang, JH, Viator, M, et al. Dose versus diagnosis: iatrogenic radiation exposure by multidetector computerised tomography in an academic emergency department with measurement of clinically actionable results and emergently treatable findings. Emerg Med J 2009;26:15–9, doi:10.1136/emj.2008.059543.Google Scholar
12.Brink, JA, Goodman, TR. Fourth Annual Warren K. Sinclair Keynote Address: The use and misuse of radiation in medicine. Health Phys 2008;95:495501, doi:10.1097/01.HP.0000326344.60097.4c.CrossRefGoogle Scholar
13.Brenner, DJ, Hall, EJ. Computed tomography—an increasing source of radiation exposure. N Engl J Med 2007;357:2277–84, doi:10.1056/NEJMra072149.Google Scholar
14.Quirke, M, Divilly, F, O—Kelly, P, et al. Imaging patients with renal colic: a comparative analysis of the impact of noncontrast helical computed tomography versus intravenous pyelography on the speed of patient processing in the emergency department. Emerg Med J 2011;28:197200, doi:10.1136/emj.2009.084806.CrossRefGoogle ScholarPubMed
15.Lee, JS, Stiell, IG, Wells, GA, et al. Adverse outcomes and opioid analgesic administration in acute abdominal pain. Acad Emerg Med 2000;7:980–7, doi:10.1111/j.1553-2712.2000.tb02087.x.CrossRefGoogle ScholarPubMed
16.Armitage, P, Berry, G. The planning of statistical investigations. In: Statistical methods in medical research. 2nd ed. Oxford (UK): Blackwell Scientific Publications; 1988. p. 160–85.Google Scholar
17.Ury, HK, Fleiss, JL. On approximate sample sizes for comparing two independent proportions with the use of Yates’ correction. Biometrics 1980;36:347–51, doi:10.2307/2529991.CrossRefGoogle ScholarPubMed
18.Hanley, JA, Lippman-Hand, A. If nothing goes wrong, is everything all right? Interpreting zero numerators. JAMA 1983;249:1743–5, doi:10.1001/jama.1983.03330370053031.Google Scholar
19.Jellison, FC, Smith, JC, Heldt, JP, et al. Effect of low dose radiation computerized tomography protocols on distal ureteral calculus detection. J Urol 2009;182:2762–7, doi:10.1016/j.juro.2009.08.042.Google Scholar
20.Ha, M, MacDonald, RD. Impact of CT scan in patients with first episode of suspected nephrolithiasis. J Emerg Med 2004; 27:225–31, doi:10.1016/j.jemermed.2004.04.009.CrossRefGoogle ScholarPubMed
21.Potretzke, AM, Monga, M. Imaging modalities for urolithiasis: impact on management. Curr Opin Urol 2008;18:199204, doi:10.1097/MOU.0b013e3282f46b11.Google Scholar
22.Stiell, IG, Wells, GA, Vandemheen, K, et al. The Canadian CT Head Rule for patients with minor head injury. Lancet 2001;357:1391–6, doi:10.1016/S0140-6736(00)04561-X.Google Scholar
23.Ather, MH, Memon, WA. Stones: impact of dose reduction on CT detection of urolithiasis. Nat Rev Urol 2009;6:526–7, doi:10.1038/nrurol.2009.196.CrossRefGoogle Scholar
24.Grumbach, MM, Biller, BM, Braunstein, GD, et al. Management of the clinically inapparent adrenal mass (“incidentaloma”). Ann Intern Med 2003;138:424–9.Google Scholar
25.Ontario Ministry of Health and Long-Term Care. Schedule of benefits. 2012. Available at: http://www.health.gov.on.ca/english/providers/program/ohip/sob/sob_mn.html (accessed December 13, 2012).Google Scholar
26.Ferrandino, MN, Bagrodia, A, Pierre, SA, et al. Radiation exposure in the acute and short-term management of urolithiasis at 2 academic centers. J Urol 2009;181:668–72;discussion 673, doi:10.1016/j.juro.2008.10.012.Google Scholar
27.Keeley, FX Jr, Thornton, M. Radiation safety: implications for urologists and patients. J Urol 2009;181:443–4, doi:10.1016/j.juro.2008.11.051.CrossRefGoogle ScholarPubMed
28.McCarney, R, Warner, J, Iliffe, S, et al. The Hawthorne Effect: a randomised, controlled trial. BMC Med Res Methodol 2007;7:30, doi:10.1186/1471-2288-7-30.CrossRefGoogle ScholarPubMed
29.Pierre, J, Nadel, N. Emergency provider’s ability to stratify risk of renal calculi prior to CT. Acad Emerg Med 2009;16(4 Suppl 1):523.Google Scholar
30.Gambaro, G, Favaro, S, D’Angelo, A. Risk for renal failure in nephrolithiasis. Am J Kidney Dis 2001;37:233–43, doi:10.1053/ajkd.2001.21285.Google Scholar
31.Rule, AD, Lieber, MM, Jacobsen, SJ. Is benign prostatic hyperplasia a risk factor for chronic renal failure? J Urol 2005;173:691–6, doi:10.1097/01.ju.0000153518.11501.d2.Google Scholar