挑戰ＡＴＬＳ指引：省略pelvis plain film

An Algorithm for Minimizing Pelvic X-Rays in Blunt Trauma

Implementation of the algorithm reduced pelvic x-ray charges at the study institution by $207,000 over 6 months.

The current Advanced Trauma Life Support protocol recommends anteroposterior plain pelvic radiographs for blunt trauma patients. However, if patients are undergoing abdominal pelvic computed tomography (AP-CT), pelvic radiographs are less accurate and redundant. These authors developed an algorithm for obtaining pelvic radiographs and conducted a prospective observational study of its effects during a 6-month period at a single level I trauma center in California. The algorithm dictated that blunt trauma patients undergoing AP-CT would forgo pelvic radiographs unless systolic blood pressure was <90 mm Hg, hemoglobin was <8 mg/dL, hemoglobin fell >3 mg/dL in the emergency department (ED), and significant pelvic examination findings were present. The algorithm could be overridden by the attending physician.

Of 978 consecutive blunt trauma patients scheduled for AP-CT, 57 (6%) underwent pelvic radiography. Reasons for ordering radiographs were severe pelvic pain (61%), proximal fractures (25%), unexplained hypotension (9%), and hip dislocation (5%). Patients who underwent pelvic radiography were older (mean, 46 vs. 37), had higher mean Injury Severity Scores (12 vs. 7), and required more transfusions (10.5% vs. 1.6%). Pelvic radiographs changed management in two patients: One received an immediate blood transfusion despite normotension, and one had a pelvic binder placed before undergoing AP-CT. There were no complications, including hypotension in the ED, delayed administration of blood products or pelvic binder, or delay in contacting interventional radiology.

Comment:
Healthcare imaging costs have risen from US$7 billion to $14 billion in 6 years in the U.S. Compared with abdominal pelvic CT scans, pelvic radiographs have a sensitivity of 55% for identifying pelvic fractures. This simple algorithm eliminated 94% of pelvic radiographs, with a projected annual reduction in charges of nearly $400,000 at a single hospital. Implementing the algorithm makes sense and saves cents.

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John A. Marx, MD, FAAEM
Published in Journal Watch Emergency Medicine October 21, 2011

Citation(s):Barleben A et al. Implementation of a cost-saving algorithm for pelvic radiographs in blunt trauma patients. J Trauma 2011 Sep; 71:582.