Australasian College for Emergency Medicine
Recommendations from the Australasian College for Emergency Medicine on CT scans for head injury and renal colic, end-of-life care in emergency departments, cervical spine (neck) imaging and coagulation studies. ACEM is the not-for-profit organisation responsible for training emergency physicians and advancing professional standards in emergency medicine in Australia and New Zealand.
1.
Avoid requesting computed tomography (CT) imaging of kidneys, ureters and bladder (KUB) in otherwise healthy emergency department patients, age <50 years, with a known history of kidney stones, presenting with symptoms and signs consistent with uncomplicated renal colic.
Avoid requesting computed tomography (CT) imaging of kidneys, ureters and bladder (KUB) in otherwise healthy emergency department patients, age <50 years, with a known history of kidney stones, presenting with symptoms and signs consistent with uncomplicated renal colic.
Acute flank pain due to suspected renal colic is a common clinical presentation in the emergency department. While a CT-KUB allows a rapid, contrast-free diagnosis of kidney stones, it is a high ionizing-radiation technique. Younger patients with typical renal colic pain that remits spontaneously, or with analgesia, and have no features on history, examination or laboratory investigations that suggest complicated renal stones or a serious alternate diagnosis can be managed without repeated imaging. Concerning features include fever, features of urinary tract infection, lack of haematuria, ongoing high analgesia requirements, or palpable abdominal mass.
Supporting evidence
- Moore CL, Bomann S, Daniels B, Luty S, Molinaro A, Singh D, Gross CP. Derivation and validation of a clinical prediction rule for uncomplicated ureteral stone—the STONE score: retrospective and prospective observational cohort studies. BMJ. 2014;348:g2191.
- Katz SI, Saluja S, Brink JA, Forman HP. Radiation dose associated with unenhanced CT for suspected renal colic: impact of repetitive studies. Am J Roentolog. 2006;186(4):1120-4.
- Patatas K, Panditaratne N, Wah TM, Weston MJ, Irving HC. 2012. Emergency department imaging protocol for suspected acute renal colic: re-evaluating our service. Emergency. 2014;85(1016).
- Broder J, Bowen J, Lohr J, Babcock A, Yoon J. Cumulative CT exposures in emergency department patients evaluated for suspected renal colic. J Emerg Med. 2007;33(2):161-8.
- Smith-Bindman R, Aubin C, Bailitz, J, Bengiamin, RN, Camargo CA Jr, Corbo J, Dean AJ, Goldstein RB, Griffey RT, Jay GD, Kang TL, Kriesel DR, Ma OJ, Mallin M, Manson, W, Melnikow J, Miglioretti DL, Miller, SK, Mills LD, Miner JR, Moghadassi M, Noble VE, Press GM, Stoller ML, Valencia VE, Wang J, Wang RC, Cummings SR. Ultrasonography versus computed tomography for suspected nephrolithiasis. N Engl J Med. 2014. 371:12.
How this list was made
A Choosing Wisely Working Group of 9 emergency physicians identified an initial list of 10 potential items. All ACEM members were able to provide feedback on these items and suggest other issues for consideration. This feedback informed Working Group refinement of the initial list into 8 recommendations. Evidence reviews were then completed for each recommendation. These evidence reviews, frequency of use in ED, risks/benefit to patient and cost were used as criteria for Working Group member voting in order to determine the final 6 recommendations. These recommendations have been endorsed by ACEM's Council of Advocacy, Practice and Partnerships.
Following identification of two common recommendations with the Royal Australian and New Zealand College of Radiologists, it was agreed by both Colleges to jointly present these items.
-
1
Avoid requesting computed tomography (CT) imaging of kidneys, ureters and bladder (KUB) in otherwise healthy emergency department patients, age <50 years, with a known history of kidney stones, presenting with symptoms and signs consistent with uncomplicated renal colic.
-
2
Avoid coagulation studies in emergency department patients unless there is a clearly defined specific clinical indication, such as for monitoring of anticoagulants, in patients with suspected severe liver disease, coagulopathy, or in the assessment of snakebite envenomation*.
- 3 Avoid blood cultures in patients who are not systemically septic, have a clear source of infection and in whom a direct specimen for culture (e.g. urine, wound swab, sputum, cerebrospinal fluid, or joint aspirate) is possible.
- 4 For emergency department patients approaching end-of-life, ensure clinicians, patients and families have a common understanding of the goals of care.
- 5 Don’t request imaging of the cervical spine in trauma patients, unless indicated by a validated clinical decision rule.
- 6 Don’t request computed tomography (CT) head scans in patients with a head injury, unless indicated by a validated clinical decision rule.