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“What Test is Best” Choosing Radiology Exams in Emergency Settings

“What Test is Best” Choosing Radiology Exams in Emergency Settings. Dr. C. Freeman PGY-4 Dr. A. Olivier. Objectives. To provide a guide to selecting the appropriate imaging studies in common emergency settings.

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“What Test is Best” Choosing Radiology Exams in Emergency Settings

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  1. “What Test is Best”Choosing Radiology Exams in Emergency Settings Dr. C. Freeman PGY-4 Dr. A. Olivier

  2. Objectives • To provide a guide to selecting the appropriate imaging studies in common emergency settings Please note: the goal of this talk is NOT to review how to read radiological exams.

  3. Modalities • Plain Films • Based on differential attenuation of X-rays by different tissues • Ultrasound • Uses sound waves • Real time • Very accessible • No radiation

  4. CT • Computer reconstruction of 2 dimensional X-ray data • reconstructions in any plane • Accessible, fast

  5. WHAT IS A “SPIRAL CT”?????? • Helical movement (patient and gantry move at the same time) • Almost all modern CT’s are helical • Exceptions: Head CT, High Resolution CT of the chest

  6. MRI • Soft tissue differentiation (e.g. Soft tissue tumors) • many other specialized indications (e.g. acute stroke) • limited accessibility, expensive • Expanding role in many clinical situations

  7. CHEST“the patient who is short of breath” • Common Causes… • CHF, atelectasis, pneumonia, pneumothorax, pulmonary embolus • start with a Chest X Ray

  8. Left diaphragm now seen Left diaphragm silhouetted Atelectasis

  9. Complete Collapse

  10. Pneumothorax Inspiration-expiration may increase sensitivity

  11. Pneumothorax

  12. Tension pneumothorax • ***EMERGENCY • place needle in 2nd intercostal space (mid clavicular line)

  13. Pneumonia Air bronchograms Silhouette sign

  14. Pneumonia: Air Bronchogram

  15. Congestive Heart Failure

  16. Pulmonary Emboli • CXR • non specific, non sensitive • V/Q Scan • useful if high probability or low probability • CT Pulmonary Angiogram

  17. CXR: HAMPTON’S HUMP • Chest X-ray not useful to rule in or rule out PE • BUT may help to find other cause of SOB (e.g. CHF)

  18. V/Q Scan VENTILATION POSTERIOR PERFUSION LATERAL • High probability: Treat (anticoagulate) • Low probability: unlikely to have PE • Intermediate Probability: ??? CT Angiogram

  19. CT ANGIOGRAPHYACUTE THROMBOEMBOLI

  20. Aortic Dissection • CT • Trans-esophageal echo

  21. CT Reconstruction: Aortic Dissection

  22. GI/GU • Again, begin with a plain film • Remember utility of upright and decubitus films for identifying free air and air fluid levels • Often move on to another exam depending on plain film findings

  23. ^^^ ^ ^ Free Air • Upright Chest X-Ray is the most sensitive test for free air

  24. Free Air: Decubitus View

  25. FREE AIR • we see both sides of the bowel wall • “Riegler’s sign”

  26. Renal Colic Plain Films CT IVP (ultrasound sometimes useful…e.g. if pregnant)

  27. Ureteric calculus • note how well a calcified stone is seen on plain films.

  28. “Left flank pain” • IVP • Shows function and obstruction • HOWEVER…largely replaced by CT

  29. Renal Colic: CT Now Preferred Modality

  30. RLQ Pain, Fever, WBC……? Appendicitis • Plain film of limited utility • may see appendicolith • Ultrasound • No radiation • In females, can also see adnexa • Especially good in thin patients • CT • If overweight

  31. ..? Appendicitis • RLQ PAIN • appendicolith

  32. Appendicitis: CT

  33. Bowel Obstruction “distended abdomen with obstipation and peritoneal signs” • start with a plain film • supine and upright views • lateral decubitus if upright not possible

  34. Small Bowel Obstruction • Multiple air-fluid levels • distended bowel loops • note the value of upright (or decubitus) view

  35. Large Bowel Obstruction: Contrast Enema • Confirms the site of abrupt narrowing at the splenic flexure (large arrow)

  36. Bowel Obstruction…after the plain film • Depends on the clinical scenario • May monitor patient • May go directly to the Operating Room • May proceed to CT • helps to define location and cause of obstruction

  37. Pancreatitis • Clinical/Biochemical Diagnosis • Ultrasound to identify cause (i.e. biliary stones) • CT is used to identify and follow complications • ***NOT TO DIAGNOSE • Will MISS diagnosis in 30% of cases

  38. Scrotal Pain History and Physical first May proceed directly to the OR Ultrasound is the modality of choice Can identify status of blood supply

  39. Testicular Ultrasound

  40. RUQ Pain • Ultrasound is the modality of choice • CT can miss acute cholecystitis or cholelithiasis

  41. Ultrasound: Cholelithiasis

  42. Neuroradiological Emergencies Start with a CT **Except cord compression May ultimately need an MRI

  43. Clinical Settings • Seizures • Trauma • Headache • Stroke

  44. Seizures: CT---Neoplasm

  45. Seizure: MRI---Neoplasm

  46. CT: Stroke • Some advanced CT techniques …”CT Perfusion” helpful • In the USA, many centers MRI is the initial exam • Some specialized MRI Techniques can identify brain at risk (“penumbra”) vs. dead brain

  47. Intra - Cranial Bleeds • Subarachnoid Hemorrhage • Subdural Hemorrhage • Epidural Hemorrhage CT

  48. CT: Subarachnoid Hemorrhage

  49. Epidural Hematoma

  50. Subdural Hematoma

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