- Email: [email protected]
R-SCAN: Whole-Body Blunt Trauma CT Imaging
IMAGING STEWARDSHIP IN THE AGE OF VALUE MAX WINTERMARK, MD
R-SCAN: Whole-Body Blunt Trauma CT Imaging Jeffrey Shyu, MD, MPH, Reza Askari, MD, Bharti Khurana, MD Trauma is the leading cause of death in the United States for people between ages 1 and 44, and is the fifthleading cause of death overall [1]. Traumatic injuries account for 41 million emergency department visits and 2.3 million hospital admissions in the United States each year [1]. The economic burden, accounting for both health care costs and lost productivity, is estimated to be $671 billion a year [1]. Over the last several decades, trauma care has improved owing to a number of developments, including the implementation of multidisciplinary specialist teams, care standardization (eg, advanced trauma life support), and technological developments in imaging, such as CT. CT, in particular, has proven to be a vital tool in the trauma workup armamentarium, providing fast and accurate diagnoses to guide appropriate management [2–4]. Polytrauma, or multitrauma, is a subcategory that can be defined as a pattern of injuries involving at least two body parts, including the head, neck, chest, abdomen, pelvis, and one or more extremity, and with one of those injuries or a combination of them being potentially fatal to the patient. There is currently no medical consensus on when to obtain whole-body CT (WBCT). In addition to the clinical signs and symptoms, the decision to pursue WBCT
imaging, as opposed to selective imaging, depends also on considerations such as patient’s age and functional status, injury mechanism, patient stability, neurological status, and the results of initial imaging in the form of portable x-rays and focused assessment with sonography for trauma (“FAST”). Examples of mechanisms that may warrant WBCT include high-velocity motor vehicle collisions (>35 mph), motor vehicle collision with rollover or ejections, falls of 15 feet or greater, motorcycle or bicycle collisions, and automobile-versus-pedestrian traumas [5]. Practice patterns vary greatly, but WBCT imaging typically includes CT of the head and cervical spine without intravenous contrast, as well as CT of the chest, abdomen, and pelvis after administration of intravenous contrast, all acquired during a single acquisition setting [4]. A chest CT is typically obtained in the arterial phase to maximize detection of aortic/arterial injury [6], whereas an abdomen and pelvis CT is typically acquired in the portal venous phase to maximize detection of abdominal and pelvic visceral organ and vascular injuries [7]. A wide variety of additional images could be obtained for better detection or to characterize the injury [4]. A noncontrast maxillofacial CT may be performed if facial,
ª 2016 American College of Radiology 1546-1440/16/$36.00 n http://dx.doi.org/10.1016/j.jacr.2016.11.010
mandibular, orbital, and skull base injuries are suspected. A contrastenhanced CT of the neck in the arterial phase evaluates for blunt cerebrovascular injuries [8]. An arterial-phase CT of the abdomen and pelvis, in addition to a portal venous–phase CT, allows for greater detection of vascular injuries and the ability to characterize whether a type of vascular injury, such as active bleeding, is from an arterial or a venous source [9]. Delayed images of the abdomen and pelvis can further characterize whether active bleeding is present and/or detect ureteral injuries when contrast material is excreted into the urinary collecting system. A CT cystogram is used to assess and characterize the type of urinary bladder rupture [10]. Dedicated reformations of the thoracic and lumbar spine can be produced [11], and CTs of the affected extremities may also be obtained to further characterize bony and soft tissue injuries, including arterialphase imaging to assess vascular injuries of the extremities.
OBSTACLES TO CHANGE Although WBCT has become a widely used technique for the workup of a patient with multitrauma, the current evidence for the efficacy of whole-body trauma imaging over selected-body CT is limited. Selective CT differs from
1
WBCT because in selective CT, only one or selected body parts are scanned. Several recent studies have found that WBCT imaging in the setting of major trauma improves outcomes, including mortality outcomes, compared with selective CT [12–14], whereas others have shown no benefit [15,16]. WBCT is probably less beneficial in patients with minor trauma than in patients with major trauma [14]. Variations in practice patterns, heterogeneity of the patient populations, and methodological considerations make it difficult to conduct robust studies [17]. For certain types of trauma, evidence-based decision rules have been developed; notable examples include the Canadian C-Spine Rule and NEXUS criteria for imaging of the cervical spine and chest [6,18–20]. Currently, no consensus criteria exist for whole-body trauma CT imaging, and additional research is needed to determine and refine the imaging indications to create a robust, evidencebased decision tool [21]. The radiation exposure from WBCT is not insubstantial [22,23], but a variety of newer dose-reduction techniques have reduced radiation doses substantially [24]. It is important to avoid unnecessary imaging. Younger patients, in particular, are at higher risk of cancer from radiation exposure, given their potential for a long life expectancy, as carcinogenesis from ionizing radiation is thought to have a long latency period, on the order of decades [25,26]. Trauma WBCT imaging also results in the detection of incidental findings, such as lung nodules and renal masses, which can necessitate additional workup and added health care costs [27,28]. Workup of these incidental findings can lead to increased patient anxiety even if the finding turns out to be benign. 2
RESOURCES TO MAKE CHANGE Numerous resources are available on the R-SCAN website (https://rscan. org/topics#topic-specific-resources6) to help ordering clinicians decide whether imaging is necessary, as well as what imaging modality should be selected, if indicated. X-rays and CT scans use radiation. Educating clinicians on the radiation risks of whole-body trauma imaging is also needed. A variety of resources, such as Image Wisely and Image Gently, are available to help inform both providers and patients about the radiation effects of CT [29,30]. The R-SCAN website (https:// rscan.org/topics#topic-specific-resources6) also includes other resources to help with patient and clinician education. These high-value care cases are interactive patient care–related scenarios, with associated multiplechoice questions and debriefs. Most importantly, R-SCAN provides a framework for communication between radiologists and referring clinicians and clinical decision support tools to promote appropriate use of imaging in patients with polytrauma. Important resources can be found on the R-SCAN website as well as in the ACR Appropriateness Criteria guidelines for the management of incidental findings [31]. Educating providers on the appropriate indications for CT in trauma imaging is important for establishing uniform and appropriate practices.
CONCLUSION Imaging patients with trauma is complex and varied, and reflects the complex and varied nature of traumatic injuries. Given the significant amount of radiation exposure imparted by WBCT, as well as cost and the management of additional
incidental findings, WBCT should be reserved for patients with major trauma or multitrauma, and selective imaging considered for patients with minor or isolated images. Patients with isolated penetrating trauma usually do not require whole-body imaging. Also, it may be reasonable to closely monitor young patients and pregnant patients with low injury mechanisms/suspicion, rather than expose them and/or the fetus to ionizing radiation.
REFERENCES 1. Centers for Disease Control and Prevention, National Center for Injury Prevention and Control: Web-based Injury Statistics Query and Reporting System (WISQARS). Available at https://www.cdc.gov/injury/ wisqars. Accessed October 8, 2016. 2. Adiotomre A, Chopra A, Kirwadi A, et al. Results from the first year as a major trauma radiology unit in the UK. Clin Radiol 2014;69:812-21. 3. Shannon L, Peachey T, Skipper N, et al. Comparison of clinically suspected injuries with injuries detected at whole-body CT in suspected multi-trauma victims. Clin Radiol 2015;70:1205-11. 4. Gunn ML, Kool DR, Lehnert BE. Improving outcomes in the patient with polytrauma: a review of the role of wholebody computed tomography. Radiol Clin North Am 2015;53(4):639-56. 5. Treskes K, Saltzherr TP, Luitse JS, et al. Indications for total-body computed tomography in blunt trauma patients: a systematic review. Eur J Trauma Emerg Surg 2016. 6. Rodriguez RM, Anglin D, Langdorf MI, et al. NEXUS chest: validation of a decision instrument for selective chest imaging in blunt trauma. JAMA Surg 2013;148:940-6. 7. Peitzman AB, Makaroun MS, Slasky BS, et al. Prospective study of computed tomography in initial management of blunt abdominal trauma. J Trauma 1986;26:585-92. 8. Biffl WL, Egglin T, Benedetto B, et al. Sixteen-slice computed tomographic angiography is a reliable noninvasive screening test for clinically significant blunt cerebrovascular injuries. J Trauma 2006;60:745-51; discussion 751-2. 9. Uyeda JW, LeBedis CA, Penn DR, et al. Active hemorrhage and vascular injuries in splenic trauma: utility of the arterial phase in multidetector CT. Radiology 2014;70: 99-106. 10. Deck AJ, Shaves S, Tainer L, et al. Computerized tomography cystography for
Journal of the American College of Radiology Volume - n Number - n - 2016
11.
12.
13.
14.
15.
16.
the diagnosis of traumatic bladder rupture. J Urol 2000;164:43-6. Hauser CJ, Visvikis G, Hinrichs C, et al. Prospective validation of computed tomographic screening of the thoracolumbar spine in trauma. J Trauma 2003;55:228-35. Huber-Wagner S, Lefering R, Qvick LM, et al. Effect of whole-body CT during trauma resuscitation on survival: a retrospective, multicenter study. Lancet 2009;373:1455-61. Yeguiayan JM, Yap A, Freysz M, et al. Impact of whole-body computed tomography on mortality and surgical management of severe blunt trauma. Crit Care 2012:16. Wada D, Nakamori Y, Yamakawa K, et al. Impact on survival of whole-body computed tomography before emergency bleeding control in patients with severe blunt trauma. Crit Care 2013;17:R178. Sierink JC, Saltzherr TP, Reitsma JB, et al. Systematic review and meta-analysis of immediate total-body computed tomography compared with selective radiological imaging of injured patients. Br J Surg 2012;99(Suppl 1):52-8. Sierink JC, Treskes K, Edwards MJ, et al. Immediate total-body CT scanning versus conventional imaging and selective CT scanning in patients with severe trauma
17.
18.
19.
20.
21.
22.
23.
(REACT-2): a randomized controlled trial. Lancet 2016;388:673-83. Stengel D, Matthes G, Mutze S, et al. Primary pan-computed tomography for blunt multiple trauma: can the whole be better than its parts? Injury 2009;4054: 536-46. Hoffman JR, Mower MW, Wolfson AB, et al. Validity of a set of clinical criteria to rule out injury to the cervical spine in patients with blunt trauma. N Engl J Med 2000;343:94-9. Stiell IG, Wells GA, Vandemheen KL, et al. The Canadian C-spine rule for radiography in alert and stable trauma patients. JAMA 2001;286:1841-8. Stiell IG, Clement CM, McKnight RD, et al. The Canadian C-spine rule versus the NEXUS low-risk criteria in patients with trauma. N Engl J Med 2003;349:2510-8. Davies RM, Scrimshire AB, Sweetman L, et al. A decision tool for whole-body CT in major trauma that safely reduces unnecessary scanning and associated radiation risks: An initial exploratory analysis. Injury 2016;47:43-9. Gordic S, Alkadhi H, Hodel S, et al. Whole-body CT-based imaging algorithm for multiple trauma patients: radiation dose and time to diagnosis. Br J Radiol 2015:88. Linder F, Mani K, Juhlin C, et al. Routine whole body CT of high energy trauma
24.
25.
26.
27.
28.
29. 30. 31.
leads to excessive radiation exposure. Scand J Trauma Resusc Emerg Med 2016;24:7. Sodickson A. Strategies for reducing radiation exposure in multi-detector row CT. Radiol Clin North Am 2012;50:1-14. Health risks from exposure to low levels of ionizing radiation: BEIR VII Phase 2. Available at: http://www.nap.edu/openbook. php?record_id¼11340&page¼R1. Accessed October 8, 2016. Sodickson A, Baeyens PF, Andriole KP, et al. Recurrent CT, cumulative radiation exposure, and associated radiationinduced cancer risks from CT of adults. Radiology 2009;251:175-84. Munk MD, Peitzman AB, Hostler DP, et al. Frequency and follow-up of incidental findings on trauma computed tomography scans: experience at a level one trauma center. J Emerg Med 2010;38:346-50. van Vugt R, Dekker HM, Deunk J, et al. Incidental findings on routine thoracoabdominal computed tomography in blunt trauma patients. J Trauma 2011. Image Gently. Available at: http://www. imagegently.org. Accessed October 8, 2016. Image Wisely. Availableat http://www. imagewisely.org. Accessed October 8, 2016. ACR Appropriateness Criteria. Available at: http://www.acr.org/quality-safety/ appropriateness-criteria. Accessed October 8, 2016.
Jeffrey Shyu, MD, MPH, and Bharti Khurana, MD, are from the Department of Radiology, Brigham and Women’s Hospital, Boston, Massachusetts. Reza Askari, MD, is from the Department of Surgery, Brigham and Women’s Hospital, Boston, Massachusetts. The authors have no conflicts of interest related to the material discussed in this article. The Radiology Support, Communication, and Alignment Network (R-SCAN; www.rscan.org) is a CMS-sponsored effort leveraging the collaboration between radiologists and referring physicians to improve the appropriate utilization of imaging in patient care. R-SCAN is aligned with the American Board of Internal Medicine Foundation’s Choosing Wisely campaign and the American College of Physicians’ High Value Care Initiative, and targets a number of emergency and outpatient imaging topics, including trauma imaging. Jeffrey Y. Shyu, MD, MPH: Division of Emergency Radiology, Department of Radiology, Brigham and Women’s Hospital, 75 Francis Street, Boston, MA 02115; e-mail: [email protected].
Journal of the American College of Radiology Shyu, Askari, Khurana n Imaging Stewardship in the Age of Value
3
R-SCAN: Whole-Body Blunt Trauma CT Imaging Jeffrey Shyu, MD, MPH, Reza Askari, MD, Bharti Khurana, MD Trauma is the leading cause of death in the United States for people between ages 1 and 44, and is the fifthleading cause of death overall [1]. Traumatic injuries account for 41 million emergency department visits and 2.3 million hospital admissions in the United States each year [1]. The economic burden, accounting for both health care costs and lost productivity, is estimated to be $671 billion a year [1]. Over the last several decades, trauma care has improved owing to a number of developments, including the implementation of multidisciplinary specialist teams, care standardization (eg, advanced trauma life support), and technological developments in imaging, such as CT. CT, in particular, has proven to be a vital tool in the trauma workup armamentarium, providing fast and accurate diagnoses to guide appropriate management [2–4]. Polytrauma, or multitrauma, is a subcategory that can be defined as a pattern of injuries involving at least two body parts, including the head, neck, chest, abdomen, pelvis, and one or more extremity, and with one of those injuries or a combination of them being potentially fatal to the patient. There is currently no medical consensus on when to obtain whole-body CT (WBCT). In addition to the clinical signs and symptoms, the decision to pursue WBCT
imaging, as opposed to selective imaging, depends also on considerations such as patient’s age and functional status, injury mechanism, patient stability, neurological status, and the results of initial imaging in the form of portable x-rays and focused assessment with sonography for trauma (“FAST”). Examples of mechanisms that may warrant WBCT include high-velocity motor vehicle collisions (>35 mph), motor vehicle collision with rollover or ejections, falls of 15 feet or greater, motorcycle or bicycle collisions, and automobile-versus-pedestrian traumas [5]. Practice patterns vary greatly, but WBCT imaging typically includes CT of the head and cervical spine without intravenous contrast, as well as CT of the chest, abdomen, and pelvis after administration of intravenous contrast, all acquired during a single acquisition setting [4]. A chest CT is typically obtained in the arterial phase to maximize detection of aortic/arterial injury [6], whereas an abdomen and pelvis CT is typically acquired in the portal venous phase to maximize detection of abdominal and pelvic visceral organ and vascular injuries [7]. A wide variety of additional images could be obtained for better detection or to characterize the injury [4]. A noncontrast maxillofacial CT may be performed if facial,
ª 2016 American College of Radiology 1546-1440/16/$36.00 n http://dx.doi.org/10.1016/j.jacr.2016.11.010
mandibular, orbital, and skull base injuries are suspected. A contrastenhanced CT of the neck in the arterial phase evaluates for blunt cerebrovascular injuries [8]. An arterial-phase CT of the abdomen and pelvis, in addition to a portal venous–phase CT, allows for greater detection of vascular injuries and the ability to characterize whether a type of vascular injury, such as active bleeding, is from an arterial or a venous source [9]. Delayed images of the abdomen and pelvis can further characterize whether active bleeding is present and/or detect ureteral injuries when contrast material is excreted into the urinary collecting system. A CT cystogram is used to assess and characterize the type of urinary bladder rupture [10]. Dedicated reformations of the thoracic and lumbar spine can be produced [11], and CTs of the affected extremities may also be obtained to further characterize bony and soft tissue injuries, including arterialphase imaging to assess vascular injuries of the extremities.
OBSTACLES TO CHANGE Although WBCT has become a widely used technique for the workup of a patient with multitrauma, the current evidence for the efficacy of whole-body trauma imaging over selected-body CT is limited. Selective CT differs from
1
WBCT because in selective CT, only one or selected body parts are scanned. Several recent studies have found that WBCT imaging in the setting of major trauma improves outcomes, including mortality outcomes, compared with selective CT [12–14], whereas others have shown no benefit [15,16]. WBCT is probably less beneficial in patients with minor trauma than in patients with major trauma [14]. Variations in practice patterns, heterogeneity of the patient populations, and methodological considerations make it difficult to conduct robust studies [17]. For certain types of trauma, evidence-based decision rules have been developed; notable examples include the Canadian C-Spine Rule and NEXUS criteria for imaging of the cervical spine and chest [6,18–20]. Currently, no consensus criteria exist for whole-body trauma CT imaging, and additional research is needed to determine and refine the imaging indications to create a robust, evidencebased decision tool [21]. The radiation exposure from WBCT is not insubstantial [22,23], but a variety of newer dose-reduction techniques have reduced radiation doses substantially [24]. It is important to avoid unnecessary imaging. Younger patients, in particular, are at higher risk of cancer from radiation exposure, given their potential for a long life expectancy, as carcinogenesis from ionizing radiation is thought to have a long latency period, on the order of decades [25,26]. Trauma WBCT imaging also results in the detection of incidental findings, such as lung nodules and renal masses, which can necessitate additional workup and added health care costs [27,28]. Workup of these incidental findings can lead to increased patient anxiety even if the finding turns out to be benign. 2
RESOURCES TO MAKE CHANGE Numerous resources are available on the R-SCAN website (https://rscan. org/topics#topic-specific-resources6) to help ordering clinicians decide whether imaging is necessary, as well as what imaging modality should be selected, if indicated. X-rays and CT scans use radiation. Educating clinicians on the radiation risks of whole-body trauma imaging is also needed. A variety of resources, such as Image Wisely and Image Gently, are available to help inform both providers and patients about the radiation effects of CT [29,30]. The R-SCAN website (https:// rscan.org/topics#topic-specific-resources6) also includes other resources to help with patient and clinician education. These high-value care cases are interactive patient care–related scenarios, with associated multiplechoice questions and debriefs. Most importantly, R-SCAN provides a framework for communication between radiologists and referring clinicians and clinical decision support tools to promote appropriate use of imaging in patients with polytrauma. Important resources can be found on the R-SCAN website as well as in the ACR Appropriateness Criteria guidelines for the management of incidental findings [31]. Educating providers on the appropriate indications for CT in trauma imaging is important for establishing uniform and appropriate practices.
CONCLUSION Imaging patients with trauma is complex and varied, and reflects the complex and varied nature of traumatic injuries. Given the significant amount of radiation exposure imparted by WBCT, as well as cost and the management of additional
incidental findings, WBCT should be reserved for patients with major trauma or multitrauma, and selective imaging considered for patients with minor or isolated images. Patients with isolated penetrating trauma usually do not require whole-body imaging. Also, it may be reasonable to closely monitor young patients and pregnant patients with low injury mechanisms/suspicion, rather than expose them and/or the fetus to ionizing radiation.
REFERENCES 1. Centers for Disease Control and Prevention, National Center for Injury Prevention and Control: Web-based Injury Statistics Query and Reporting System (WISQARS). Available at https://www.cdc.gov/injury/ wisqars. Accessed October 8, 2016. 2. Adiotomre A, Chopra A, Kirwadi A, et al. Results from the first year as a major trauma radiology unit in the UK. Clin Radiol 2014;69:812-21. 3. Shannon L, Peachey T, Skipper N, et al. Comparison of clinically suspected injuries with injuries detected at whole-body CT in suspected multi-trauma victims. Clin Radiol 2015;70:1205-11. 4. Gunn ML, Kool DR, Lehnert BE. Improving outcomes in the patient with polytrauma: a review of the role of wholebody computed tomography. Radiol Clin North Am 2015;53(4):639-56. 5. Treskes K, Saltzherr TP, Luitse JS, et al. Indications for total-body computed tomography in blunt trauma patients: a systematic review. Eur J Trauma Emerg Surg 2016. 6. Rodriguez RM, Anglin D, Langdorf MI, et al. NEXUS chest: validation of a decision instrument for selective chest imaging in blunt trauma. JAMA Surg 2013;148:940-6. 7. Peitzman AB, Makaroun MS, Slasky BS, et al. Prospective study of computed tomography in initial management of blunt abdominal trauma. J Trauma 1986;26:585-92. 8. Biffl WL, Egglin T, Benedetto B, et al. Sixteen-slice computed tomographic angiography is a reliable noninvasive screening test for clinically significant blunt cerebrovascular injuries. J Trauma 2006;60:745-51; discussion 751-2. 9. Uyeda JW, LeBedis CA, Penn DR, et al. Active hemorrhage and vascular injuries in splenic trauma: utility of the arterial phase in multidetector CT. Radiology 2014;70: 99-106. 10. Deck AJ, Shaves S, Tainer L, et al. Computerized tomography cystography for
Journal of the American College of Radiology Volume - n Number - n - 2016
11.
12.
13.
14.
15.
16.
the diagnosis of traumatic bladder rupture. J Urol 2000;164:43-6. Hauser CJ, Visvikis G, Hinrichs C, et al. Prospective validation of computed tomographic screening of the thoracolumbar spine in trauma. J Trauma 2003;55:228-35. Huber-Wagner S, Lefering R, Qvick LM, et al. Effect of whole-body CT during trauma resuscitation on survival: a retrospective, multicenter study. Lancet 2009;373:1455-61. Yeguiayan JM, Yap A, Freysz M, et al. Impact of whole-body computed tomography on mortality and surgical management of severe blunt trauma. Crit Care 2012:16. Wada D, Nakamori Y, Yamakawa K, et al. Impact on survival of whole-body computed tomography before emergency bleeding control in patients with severe blunt trauma. Crit Care 2013;17:R178. Sierink JC, Saltzherr TP, Reitsma JB, et al. Systematic review and meta-analysis of immediate total-body computed tomography compared with selective radiological imaging of injured patients. Br J Surg 2012;99(Suppl 1):52-8. Sierink JC, Treskes K, Edwards MJ, et al. Immediate total-body CT scanning versus conventional imaging and selective CT scanning in patients with severe trauma
17.
18.
19.
20.
21.
22.
23.
(REACT-2): a randomized controlled trial. Lancet 2016;388:673-83. Stengel D, Matthes G, Mutze S, et al. Primary pan-computed tomography for blunt multiple trauma: can the whole be better than its parts? Injury 2009;4054: 536-46. Hoffman JR, Mower MW, Wolfson AB, et al. Validity of a set of clinical criteria to rule out injury to the cervical spine in patients with blunt trauma. N Engl J Med 2000;343:94-9. Stiell IG, Wells GA, Vandemheen KL, et al. The Canadian C-spine rule for radiography in alert and stable trauma patients. JAMA 2001;286:1841-8. Stiell IG, Clement CM, McKnight RD, et al. The Canadian C-spine rule versus the NEXUS low-risk criteria in patients with trauma. N Engl J Med 2003;349:2510-8. Davies RM, Scrimshire AB, Sweetman L, et al. A decision tool for whole-body CT in major trauma that safely reduces unnecessary scanning and associated radiation risks: An initial exploratory analysis. Injury 2016;47:43-9. Gordic S, Alkadhi H, Hodel S, et al. Whole-body CT-based imaging algorithm for multiple trauma patients: radiation dose and time to diagnosis. Br J Radiol 2015:88. Linder F, Mani K, Juhlin C, et al. Routine whole body CT of high energy trauma
24.
25.
26.
27.
28.
29. 30. 31.
leads to excessive radiation exposure. Scand J Trauma Resusc Emerg Med 2016;24:7. Sodickson A. Strategies for reducing radiation exposure in multi-detector row CT. Radiol Clin North Am 2012;50:1-14. Health risks from exposure to low levels of ionizing radiation: BEIR VII Phase 2. Available at: http://www.nap.edu/openbook. php?record_id¼11340&page¼R1. Accessed October 8, 2016. Sodickson A, Baeyens PF, Andriole KP, et al. Recurrent CT, cumulative radiation exposure, and associated radiationinduced cancer risks from CT of adults. Radiology 2009;251:175-84. Munk MD, Peitzman AB, Hostler DP, et al. Frequency and follow-up of incidental findings on trauma computed tomography scans: experience at a level one trauma center. J Emerg Med 2010;38:346-50. van Vugt R, Dekker HM, Deunk J, et al. Incidental findings on routine thoracoabdominal computed tomography in blunt trauma patients. J Trauma 2011. Image Gently. Available at: http://www. imagegently.org. Accessed October 8, 2016. Image Wisely. Availableat http://www. imagewisely.org. Accessed October 8, 2016. ACR Appropriateness Criteria. Available at: http://www.acr.org/quality-safety/ appropriateness-criteria. Accessed October 8, 2016.
Jeffrey Shyu, MD, MPH, and Bharti Khurana, MD, are from the Department of Radiology, Brigham and Women’s Hospital, Boston, Massachusetts. Reza Askari, MD, is from the Department of Surgery, Brigham and Women’s Hospital, Boston, Massachusetts. The authors have no conflicts of interest related to the material discussed in this article. The Radiology Support, Communication, and Alignment Network (R-SCAN; www.rscan.org) is a CMS-sponsored effort leveraging the collaboration between radiologists and referring physicians to improve the appropriate utilization of imaging in patient care. R-SCAN is aligned with the American Board of Internal Medicine Foundation’s Choosing Wisely campaign and the American College of Physicians’ High Value Care Initiative, and targets a number of emergency and outpatient imaging topics, including trauma imaging. Jeffrey Y. Shyu, MD, MPH: Division of Emergency Radiology, Department of Radiology, Brigham and Women’s Hospital, 75 Francis Street, Boston, MA 02115; e-mail: [email protected].
Journal of the American College of Radiology Shyu, Askari, Khurana n Imaging Stewardship in the Age of Value
3