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“What Test is Best”
Choosing Radiology Exams in Emergency Settings
Dr. C. Freeman PGY-4
Dr. A. Olivier
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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.
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Modalities
• Plain Films– Based on differential attenuation of X-rays by different
tissues
• Ultrasound– Uses sound waves
– Real time
– Very accessible
– No radiation
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CT
• Computer reconstruction of 2 dimensional X-ray data
• reconstructions in any plane
• Accessible, fast
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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
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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
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CHEST “the patient who is short of breath”
Common Causes…– CHF, atelectasis, pneumonia, pneumothorax,
pulmonary embolus
start with a Chest X Ray
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Atelectasis
Left diaphragm now seenLeft diaphragm silhouetted
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Complete Collapse
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Pneumothorax
Inspiration-expiration
may increase
sensitivity
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Pneumothorax
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Tension pneumothorax
***EMERGENCY
•place needle in 2nd intercostal space (mid clavicular line)
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Pneumonia
Silhouette sign
Air bronchograms
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Pneumonia: Air Bronchogram
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Congestive Heart Failure
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Pulmonary Emboli
• CXR– non specific, non sensitive
• V/Q Scan – useful if high probability or low probability
• CT Pulmonary Angiogram
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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)
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V/Q Scan
VENTILATIONPOSTERIOR
PERFUSIONLATERAL
•High probability: Treat (anticoagulate)
•Low probability: unlikely to have PE
•Intermediate Probability: ??? CT Angiogram
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CT ANGIOGRAPHYACUTE THROMBOEMBOLI
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Aortic Dissection
• CT
• Trans-esophageal echo
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CT Reconstruction: Aortic Dissection
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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
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^^^^ ^
Free Air
•Upright Chest X-Ray is the most sensitive test for free air
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Free Air: Decubitus View
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FREE AIR•we see both sides of the bowel wall
“Riegler’s sign”
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Renal Colic
•Plain Films
•CT
•IVP
•(ultrasound sometimes useful…e.g. if pregnant)
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Ureteric calculus
•note how well a calcified stone is seen on plain films.
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“Left flank pain”
IVP
•Shows function and obstruction
•HOWEVER…largely replaced by CT
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Renal Colic: CT
Now Preferred Modality
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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
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..? Appendicitis
•RLQ PAIN•appendicolith
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Appendicitis: CT
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Bowel Obstruction
“distended abdomen with obstipation and peritoneal signs”
•start with a plain film
•supine and upright views
•lateral decubitus if upright not possible
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•Multiple air-fluid levels
•distended bowel loops
•note the value of upright (or decubitus) view
Small Bowel Obstruction
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•Confirms the site of abrupt narrowing at the splenic flexure (large arrow)
Large Bowel Obstruction: Contrast Enema
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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
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Pancreatitis
• Clinical/Biochemical Diagnosis
• Ultrasound to identify cause (i.e. biliary stones)
• CT is used to identify and follow complications ***NOT TO DIAGNOSEWill MISS diagnosis in 30% of cases
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Scrotal Pain
•History and Physical firstMay proceed directly to the OR
•Ultrasound is the modality of choice
•Can identify status of blood supply
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Testicular Ultrasound
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RUQ Pain
• Ultrasound is the modality of choice
• CT can miss acute cholecystitis or cholelithiasis
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Ultrasound: Cholelithiasis
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Neuroradiological Emergencies
•Start with a CT–**Except cord compression
•May ultimately need an MRI
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Clinical Settings
• Seizures
• Trauma
• Headache
• Stroke
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Seizures: CT---Neoplasm
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Seizure: MRI---Neoplasm
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CT: Stroke
•In the USA, many centers MRI is the initial exam
•Some specialized MRI Techniques can identify brain at risk (“penumbra”) vs. dead brain
•Some advanced CT techniques …”CT Perfusion” helpful
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CT
Intra - Cranial Bleeds
• Subarachnoid Hemorrhage
• Subdural Hemorrhage
• Epidural Hemorrhage
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CT: Subarachnoid Hemorrhage
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Epidural Hematoma
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Subdural Hematoma
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SPINE Emergencies
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C-Spine Trauma• Plain films:
– If minor trauma, plain films including flexion and extension views can suffice
• CT– For significant injury– From skull base to T1 – Sagital and coronal reconstructions
• MRI– Unexplained neurologic deficit– Unconscious for prolonged period of time
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Normal C-Spine with CT
Axial Sagital Coronal
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Hangman’s #
Axial Sagital
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C5-6 dislocation
Axial Sagital
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C5-6 dislocation withLeft Vertebral Artery dissection
MR Angiogram
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Suspected Spine Infection
• Plain films – may be diagnostic– Do not demonstrate compression of thecal sac
• MRI is optimal • CT can be adequate• Fluoroscopic or CT guided
aspiration/biopsy• We follow these cases with MRI
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Discitis
Sagital AxialCoronal
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Discitis, osteomyelitisprevertebral & epidural phlegmon
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Cord Compression: MRI
Metastatic
Melanoma
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Spine Emergencies: Summary
• MRI is generally the best exam for the spine
• CT is excellent in many indications
• Plain films have a limited role
• MRI access is quite limited, so we compromise and do a lot more CT
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MSK
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Fractures
• Remember that acute fractures may not be seen on plain films for up to 7- 10 days.
• Bone scan is more sensitive
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Plain Film: Ankle Fracture
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Sacral Fracture: CT
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? Septic Joint
• Plain film may be suggestive
• MUST aspirate joint– This is a medical emergency
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Necrotizing Fasciitis
• Ultimately a clinical diagnosis
• Plain FilmsGas in the soft tissues
• MRIFor surgical planning
• CT may give a false negative (not sufficient to rule out diagnosis)
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Summary
• Almost always start with the plain film
• There are some exceptions– Neurological Emergencies
• If you are unsure as to what test is appropriate…talk to the Radiologist
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Thank you!!Dr. C. Freeman
Dr. A. Olivier