Vården bör göra nytta för patienter. Ibland är största nyttan att vänta och se. Hur utvecklar sig symtomen? Ett stort antal sjukdomstillstånd är visserligen bra att hitta tidigt, men listan över dem man måste hitta akut är inte lika lång som de som lika gärna kan upptäckas något senare.
För akutsjukvård rekommenderar Canadas Choosing wisely följande 10 saker att ifrågasätta
CT skalle vid synkope
För synkope kardiell genes, se inlägget Synkope.
Indikation för CT vid synkope är primärt för att leta tex tonsillheriering / tumör / blödning / traumatisk skada, eller när synkopens i själva verket är ett tonisktkloniskt krampanfall.
Indikation för CT vid synkope:
- Skall / nacktrauma
- Huvudvärk och synkope
- Neurologiska bortfall
- Ålder > 65 (och synkopen inte bättre förklarad av andra orsaker)
- Patienter med antikoagulantia ( och synkopen inte bättre förklarad av andra orsaker)
- Känd malignitet
- Tillägg: Synkope / huvudvärk vid hostning, krystning
Referenser;
Goyal N, et al. The utility of head computed tomography in the emergency department evaluation of syncope. Intern Emerg Med. 2006;1(2):148-50. PMID: 17111790.
Grossman SA, et al. The yield of head CT in syncope: a pilot study. Intern Emerg Med. 2007 Mar;2(1):46-9. Epub 2007 Mar 31. PMID: 17551685.
Sheldon RS, et al. Standardized approaches to the investigation of syncope: Canadian Cardiovascular Society position paper. Can J Cardiol. 2011 Mar-Apr;27(2):246-53. PMID: 21459273.
Sweanor RAL, et. al. Multivariable risk scores for predicting short-term outcomes for emergency department patients with unexplained syncope: A systematic review. Acad Emerg Med. 2021 May;28(5):502-510. Epub 2021 Jan 28. PMID: 33382159.
CT skalle för minor head trauma / Rtg för trauma nacke
CT för minor head injury skall göras med stöd av beslutsregler, såsom PECARN för barn (känsligare än CATCH) eller Canadian CT head rule för vuxna
Röntgen av halsrygg efter trauma skall göras med stöd av beslutsregler, såsom Canadian C-spine rule.
Babl FE, et al. Accuracy of PECARN, CATCH, and CHALICE head injury decision rules in children: a prospective cohort study. Lancet. 2017; 389 (10087):2393-2402. PMID:28410792.
Osmond MH, et al. CATCH: a clinical decision rule for the use of computed tomography in children with minor head injury. CMAJ. 2010; 182(4):341-8. PMID: 20142371.
Michaleff ZA, et al. Accuracy of the Canadian C-spine rule and NEXUS to screen for clinically important cervical spine injury in patients following blunt trauma: a systematic review. CMAJ. 2012; 184(16):E867-76. PMID: 23048086.
Stiell IG, et al. Implementation of the Canadian C-Spine Rule: prospective 12 centre cluster randomised trial. BMJ. 2009; 339:b4146. PMID: 19875425.
Stiell IG, et al. The Canadian C-spine rule versus the NEXUS low-risk criteria in patients with trauma. N Engl J Med. 2003; 349(26):2510-8. PMID: 14695411.
Röntgen fotled
Patienter utan andra skador, med en skadad fotled senaste 10 dagarna skall röntgas om de faller ut på Ottawa Ancle rule, inte annars.
Plint AC, et al. Validation of the Ottawa Ankle Rules in children with ankle injuries. Acad Emerg Med. 1999 Oct;6(10):1005-9. PMID: 10530658.
Stiell IG. Ottawa Ankle Rules by Dr. Ian Stiell [Video file]. 2015 Jul 7 [cited 2015 Nov 23].
Stiell IG, et al. Implementation of the Ottawa ankle rules. JAMA. 1994 Mar 16;271(11):827-32. PMID: 8114236.
CT lungemboli
För lungembolidiagnostik använd beslutsregler Wells score PE, PERC score och pdDimer när det är indicerat. Sannolikheten att hitta lungemboli om patienten inte faller ut på beslutsregler är mycket liten.
Kline JA, et al. Prospective multicenter evaluation of the pulmonary embolism rule-out criteria. J Thromb Haemost. 2008 May;6(5):772-80. PMID: 18318689.
Singh B, et al. Diagnostic accuracy of pulmonary embolism rule-out criteria: a systematic review and meta-analysis. Ann Emerg Med. 2012 Jun;59(6):517-20.e1-4. PMID: 22177109.
Wells PS, et al. Excluding pulmonary embolism at the bedside without diagnostic imaging: management of patients with suspected pulmonary embolism presenting to the emergency department by using a simple clinical model and d-dimer. Ann Intern Med. 2001 Jul 17;135(2):98-107. PMID: 11453709.
Ländryggsmärta och radiologi
Radiologi av ländryggssmärta skall endast göras i närvaro av red flags.
- Cauda equina syndrome
- Vikt nedgång
- Cancer anamnes
- Feber
- Nattliga svettningar
- Kortisonbehandling
- Iv droger
- Debut av ryggsmärta efter 65 åår (50 åå)
- Neurologiska fynd: onormala reflexer, muskelsvaghet, känselpåverkan.
Chou R, et al. Imaging strategies for low-back pain: systematic review and meta-analysis. Lancet. 2009; 373(9662):463-72. PMID: 19200918.
Chou R, et al. Diagnosis and treatment of low back pain: a joint clinical practice guideline from the American College of Physicians and the American Pain Society. Ann Intern Med. 2007; 147(7):478-91. PMID: 17909209.
Toward Optimized Practice. Guideline for the evidence-informed primary care management of low back pain, 2nd Edition. Edmonton, AB: Toward Optimized Practice; 2011.
CT indikation vid huvudvärk
Nyligen debuterande, snabbt ökande frekvens och allvarlighet.
Huvudvärk som väcker patienten.
Huvudvärk med yrsel, koordinationssvårigheter, parestesier / känselnedsättning, neurologiska bortfall.
Nytillkommen huvudvärk hos patient med cancer eller immunosuppression.
Från Improving diagnosis in Health Care, e bok:
BOX 3-2Overutilization of Diagnostic Testing
While diagnostic testing has brought many improvements to medical care, advances in diagnostic testing have also led to some challenges, including an under-reliance on more traditional diagnostic tools, such as careful history taking and the physical exam, and the inappropriate utilization of diagnostic testing (Iglehart, 2009; Newman-Toker et al., 2013; Rao and Levin, 2012; Zhi et al., 2013). Inappropriate use has included both overutilization (testing when it is not indicated) and underutilization (not testing when it is indicated).
The use of diagnostic testing to rule out conditions, clinicians’ intolerance of uncertainty, an enthusiasm for the early detection of disease in the absence of symptoms, and concerns over medical liability can all contribute to overutilization (Grimes and Schulz, 2002; Newman-Toker et al., 2013; Plebani, 2014). In one survey of physicians in specialties at high risk of litigation (emergency medicine, general surgery, orthopedic surgery, neurosurgery, obstetrics/gynecology, and radiology), 59 percent of respondents reported that they ordered more tests than were medically indicated (Studdert et al., 2005). In an analysis that examined patient understanding of medical interventions, researchers identified a complex array of reasons for overuse, including payment systems that favor more testing over patient interaction, the ease of requesting tests, and patient beliefs that more testing and treatment is equivalent to better care (Croskerry, 2011; Hoffmann and Del Mar, 2015). When a clinician does not have enough time to discuss symptoms and potential diagnoses with a patient, ordering a test is sometimes considered more straightforward and less risky (Newman-Toker et al., 2013). Another contributing factor is an overestimation of the benefits of testing; for example, patients often overestimate the benefits of mammography screening (Gigerenzer, 2014; Hoffmann and Del Mar, 2015).
The overutilization of medical imaging techniques that employ ionizing radiation (such as computed tomography [CT]) is of special concern and has gained considerable attention in the wake of research showing a marked increase in radiation exposure from medical imaging in the U.S. population (Hricak et al., 2011). Epidemiological studies have found reasonable, though not definitive, evidence that exposure to ionizing radiation (organ doses ranging from 5 to 125 millisieverts) result in a very small but statistically significant increase in cancer risk (Hricak et al., 2011). Children are more radiosensitive than adults, and cancer risks increase with cumulative radiation exposure. In addition to age at exposure, genetic considerations, sex, and fractionation and protraction of exposure may influence the level of risk. Medical imaging needs to be justified by weighing its potential benefit against its potential risk. It is important to be sure that imaging is truly indicated and to consider alternatives to the use of ionizing radiation, especially for pediatric patients and those with a history of radiation exposure. In 2010 the Food and Drug Administration launched the Initiative to Reduce Radiation Exposure, aimed at promoting the justification of all imaging examinations and the optimization of imaging protocols so as to minimize radiation doses (FDA, 2015). Studies have shown that the use of clinical decision support and guidelines can minimize unnecessary radiation exposure and that they could prevent as many as 20 to 40 percent of CT scans without compromising patient care (Hricak et al., 2011).
Referenser
Choosing wisely rekommendationer per specialitet
Choosing wisely 10 råd för Akutsjukvård
Improving diagnosis in healthcare: perspectives from the American College of radiology
När välja UL istället för CT? Image wisely, Canada
SNS utredning av professorn i hälsoekonomi Mikael Svensson: höga kostnader och låg patientnytta – att värdera insatser i svensk hälso- och sjukvård
Svenska läkarsällskapets arbetsgrupp: Kloka kliniska val
LT artikel om SUS Malmö som minskat provtagning och CT på akuten vid svimning
Artiklar
CT scans och cancer risk: a systematic review and dose-repsonse meta-analysis
Konklusion av 116 miljoner patienter: ja, många undersökningar av flera delar av kroppen med CT ökar risken för cancer. PMID: 36451138, PMID: 36451138, DOI: 10.1186/s12885-022-10310-2Managing radiation in medical imaging, a mulifacettec challange, Hricak 2011, PMID: 21163918 DOI: 10.1148/radiol.10101157