Tuesday, January 23, 2007

Educational Tips

I'd like to review the need for rib series x-rays. Rib series include 6 views. This is a pretty significant dose of radiation. Ergo, there are very specific criteria for when to order this test.
  • Suspected fx's to ribs 1 - 2
  • Suspected fx's to ribs 9-12
  • Multiple rib fx's
  • Preexisting pulmonary dz
  • Suspected pathologic fx
Thus, a healthy 22 yo w/ mid-CW pain doesn't need a rib series. A simple two-view CXR will provide you w/ all the info that's clinically important. In fact, I think the above list might be a little liberal. What are the questions you really want answered? For me, I want to know if a) they have a PTX or b) is there a flail chest. Pulm contusion and other signs of trauma will show up on the CXR. We don't typically see ribs 1 or 2 fx'd b/c it's typically from high-velocity trauma. Our usual pt population has rib fx's from 4-10. If there is a flail chest, I think most of it will see it on a CXR. And once a flail chest is diagnosed, what are the extra views going to tell you? I haven't dx'd a PTX w/ a rib series but missed it on a CXR.

So the next time you plan to order a rib series, ask yourself the question: will I be able to see what clinically matters on a two-view CXR and does the pt really need those extra views?

One other topic I'd like to touch on is when do you order a U/A in a febrile child without an obvious source of ifx? Remember that there's a much higher propensity of UTI's in females. A rule that I utilize for my patients who don't have a significant h/o UTI's/pyelo is the following:
  • Current recommendations say to check a U/A in any female pt less than 2 years. I will check a U/A in a female older than this b/c of it's frequency.
  • Circumcised males- I don't check a U/A in boys older than 6 months old. This I adhere to.
  • Non-circumcised males- I don't check a U/A in boys older than 12 months old. Again, I follow this policy.
I'd be interested in what other people do and their rationale. Josh- what's your algorithm?


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