Page 136 - Registrar Orientation Manual 2016

Reference:
1257
Effective date:
7 July 2015
Expiry date:
6 July 2018
Page:
19 of 35
Title:
Imaging Guidelines
Type:
Clinical Guideline
Version:
02
Authorising initials:
If a referral is declined the options include:
• offering alternative imaging if more appropriate, for example CT abdomen
• redirecting the referral for consideration of colonoscopy if the colonoscopy criteria are met, or
• declining the referral if the colonoscopy criteria are not met
The National Referral Criteria for Direct Access Outpatient Colonoscopy also state a referrer should:
• inform the patient about the procedure
• ensure they are willing to undergo the procedure
• consider the ability of the patient to tolerate both the bowel preparation and procedure
The CT colonography referral should indicate these have all been done. Please also check that the the patient is willing and fit enough to undergo treatment (surgery) should an abnormality be found.
Collapse, Loss of Consciousness and Syncope
CT is not usually indicated if a patient has fully recovered consciousness or in suspected syncope with no focal neurological signs.
Our Syncope Guidelines note: “neuro-imaging is rarely helpful unless neurological features” Clinical Urgency: Urgent imaging may be indicated if there is a reduced level of consciousness of
uncertain cause and the patient has not recovered.
The ‘Choosing Wisely’ recommendations include:
Avoid CT of the head in asymptomatic adult patients with syncope, insignificant trauma and a normal neurological evaluation.
Delirium
CT is not usually indicated in most patients with delirium.
Our Delirium Guidelines suggest to consider CT if:
• focal neurology
• new seizures
• head injury or fall
• on anticoagulants
• evidence raised ICP
MRI should only be performed if the CT has shown a lesion that requires further investigation and is rarely indicated if the CT is normal, unless there is a specific concern like suspected encephalitis.
Clinical Urgency: Urgent CT may be indicated if there is a reduced level of consciousness.
Dementia
The Dementia Imaging Pathway in the Australian imaging guidelines supports either CT or MRI as
the imaging modalities in dementia. We recommend CT is used for most cases.
While MRI may, ideally, be better than CT, a good quality CT scan is usually adequate and MRI is normally restricted in the public system in Waikato to patients who have had a CT that raised uncertainties and where further imaging is required to clarify the diagnosis.
The National Community Radiology Access Criteria include these indications for CT referral:
Undiagnosed cognitive impairment with one or more high-risk feature:
• age < 60 years
• rapid (ie, one or two months) unexplained decline in cognition or function
• recent and significant head trauma
• unexplained neurological symptoms (e.g. new onset of severe headache or seizures)