Munk Marc-David, Peitzman Andrew B, Hostler David P, Wolfson Allan B
Department of Emergency Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania 15213, USA.
J Emerg Med. 2010 Apr;38(3):346-50. doi: 10.1016/j.jemermed.2008.01.021. Epub 2008 Sep 19.
Incidental findings found on computed tomography (CT) scan during the Emergency Department evaluation of trauma patients are often benign, but their presence must always be communicated to patients, who should be referred for follow-up care. Our objective was to quantify the frequency of these incidental CT findings in trauma patients. A secondary goal was to determine how often these lesions were communicated to patients and how often patients were referred for follow-up.
We performed a retrospective chart review of 500 consecutive patients presenting as trauma activations. Subjects received head, chest, or abdomen/pelvis CT scans at our hospital. Patients were identified using our trauma registry. Final CT reports were examined and discharge summaries were reviewed for basic demographics. Scans with incidental findings prompted detailed secondary review of discharge summaries to determine follow-up. Investigators reviewed incidental findings and classified them into three groups by clinical importance, using predetermined criteria.
Of the 500 patient charts identified for review, 480 (96%) were available, yielding 1930 CT reports for analysis. Incidental findings were noted in 211 of 480 (43%) patients and on 285 (15%) of the 1930 CT studies performed for the 480 patients. Of available patient records, only 27% of patient charts had mention of the finding in the discharge summary, had documentation of an in-hospital workup, or had documentation of a referral for follow-up. Most-concerning lesions, such as suspected malignancies or aortic aneurysms, accounted for 15% of all incidental findings and were referred for follow-up in only 49% of cases.
Incidental findings were noted in 15% of trauma CT scans. Follow-up was poor, even for potentially serious findings. Further studies should examine the long-term outcome of patients with these findings.
在急诊科对创伤患者进行评估期间，计算机断层扫描（CT）检查中发现的偶然发现通常为良性，但必须始终告知患者，并应将患者转诊进行后续护理。我们的目的是量化创伤患者中这些偶然CT发现的频率。第二个目标是确定这些病变告知患者的频率以及患者被转诊进行随访的频率。
我们对500例连续因创伤就诊的患者进行了回顾性病历审查。受试者在我院接受了头部、胸部或腹部/骨盆CT扫描。使用我们的创伤登记系统识别患者。检查最终CT报告，并审查出院小结以获取基本人口统计学信息。有偶然发现的扫描促使对出院小结进行详细的二次审查以确定随访情况。研究人员审查偶然发现，并根据预定标准按临床重要性将其分为三组。
在确定要审查的500份患者病历中，有480份（96%）可用，产生了1930份CT报告用于分析。在480例患者中的211例（43%）以及为这480例患者进行的1930次CT检查中的285次（15%）发现了偶然发现。在可用的患者记录中，只有27%的患者病历在出院小结中提及了该发现、有住院检查的记录或有转诊进行随访的记录。最令人担忧的病变，如疑似恶性肿瘤或主动脉瘤，占所有偶然发现的15%，仅在49%的病例中被转诊进行随访。
在15%的创伤CT扫描中发现了偶然发现。即使对于潜在的严重发现，随访情况也很差。进一步的研究应检查有这些发现的患者的长期结局。
