Emergency radiology Flashcards
- radiology of emergency medicine in child age
(try to actively recall anything from what you have studied) before flipping the card
- hypertrophic pyloric stenosis
- foreign body aspiration
- trauma imaging
- scrotal emergencies imaging
o Heart failure
o Galen vein malformation
o Testis torsion
o GI – intestinal obstruction, pylorostenosis, intussusception (onion on ultrasound), appendicitis
- hypertrophic pyloric stenosis
ultrasound: modality of choice
> hypoechoic : ht muscle ( thickness more than 3mm)
> hyperechoic : central mucosa
fluoroscopy : barium swallow
> delayed gastric emptying
> elongated pylorus + narrowed lumen
o Foreign body aspiration
- air enters bronchus around foreign body, but cannot exit
- important to exclude GIT perforation (CT + contrast)
- X-rays: expiration
no change in lung volume during resp cycle
affected lung appears overinflated and hyperluscent
o Trauma
- Sensitivity of ultrasound to detect a hemoperitoneum is only 56%, however only use CT when benefits of procedure justify the exposure to ionizing rays
o Genitourinary emergencies:
- Scrotal emergencies
- What to order: ultrasound with color Doppler
- When: acute scrotal pain – trauma to testis
- Traumatic causes of acute abdomen
- imaging modalities
- blunt abdominal trauma
- spleen, liver, pancreas, bowel and mesentery, kidneys
what do you remember !!
o Introduction:
- Abdomen ranks fourth among most common locations of traumatic injury preceded by skull, extremities and chest
- Associated with high mortality rate, escpecially when intraparenchymal organs or the large mediastinal vessels have been injured
- 95 % blunt injuries in western Europe, also penetrating
imaging
- Ultrasound golden standard (FAST) to locate free abdominal fluid (if not stable) - CT (if stable) – fast examination permitting exact diagnosis
- CTA is image procedure of choice for detection of vascular lesions (vessels of GI tract, mesentery, pelvic arteries).
o Blunt abdominal trauma:
- Contusion: bruising of tissue and diffuse intraparenchymatous hemorrhage - Subcapsular
- hematoma: accumulation of blood between organ and capsule
- Intraparencymatous laceration and hematoma: disruption of organ tissue with or without discharge of blood into abdominal cavity
- Cyst, seroma: cavity filled with lood as a post-traumatic residue
- Organs frequently affected: Liver, spleen! (most common), pancreas, mesentery, GI, kidneys, urinary tract
o Spleen:
- Not treated surgically unless hemodynamically unstable
- Children nearly 100% success without surgery, much lower in adults
o Liver:
- 5 different grades of injury according surface area involved
- Conservative usually (hemodynamically stable)
o Pancreas:
- rare and difficult to diagnose
- CT, but not always findings
o Bowel and mesentery:
- 10% or less
- Important to identify injury early because of risk of peritonitis and sepsis
o Kidney:
- first is usually ultrasound
- CT performed if marked injury or multiple
- Contusion, subcapsular hematoma, rupture of kidney
- Non-traumatic acute abdomen : inflammation
- cholecystitis
- pancreatitis
- IBD
- appendicitis
what do you remember ;)
Introduction:
- Acute abdomen is one of the most common syndromes in medicine
- Principle symptoms: pain, abdominal resistance, vomiting, nauseas, cold sweat, pallor, shock, hematemesis or melena
- Ultrasound is the method of choice to identify acute diseases of gallbladder and abdominal organs (cholecystitis, appendicitis, pancreatitis, IBD)
o Cholecystitis:
- Acute or chronic
- Common complication of cholecystolithiasis
- symptoms: colic attack in right-sided upper abdomen, fever, chills, vomiting, murphy sign, jaundice
- Signs: increased blood flow, acites
o Pancreatitis
- acute and chronic
- Bile duct stones and alcohol
- Contrast-enhanced MDCT is the method of choice for primary diagnosis
- Symptoms: Belt-like pain in upper abdomen, vomiting, paralytic ileus, edema - Signs: minor in start, swelling, fluid, necrosis and cysts after)
- Necrosis is hypoechoic!
o IBD:
- Structural changes
- Crohn´s disease: Transmural inflammation, ulcers, edema, cobblestone pattern, abcess/fistula
- Ulcerative cholitis: superficial inflammation, continuous course, colon
- Chrons: Enteroclysis (CT or MR)
- Ulcerative colitis: Ultrasound and CT
o Appendicitis:
- Most common indication for surgery in children of school age
- Ultrasound
- Diagnosis: clinical signs, laboratory dato, plain radiographs of abdomen and US/MRI - Signs: inflammatory thickened wall, hyperechoic appendicolith (intraluminal aspect)
- Non-traumatic acute abdomen : ileus in adult age
- mechanical (tumour, adhesions post surgical, volvulus, strangulated hernias) dilation of bowel before obstruction point
- neurogenic/paralytic (post surgical, ) all bowel dilate
CT - zone of transition
o Introduction:
- Bowel obstruction is diagnosed by clinical investigation
- The image procedure assists differentiation of mechanical and paralytic ileus - Also called bowel obstruction and paralysis
o Mechanical bowel obstruction:
- 60% arises from small bowel
- Adhesion and adhesive strangulation is the most common cause
- Usually a postoperative condition
- Hallmark of a bowel obstruction is seen at the zone of transition
- The contents of the bowel become congested before a hindrance, this is followed by pre stenotic dilatation.
- In the post-stenotic aspect, the bowel is of normal width or has collapsed o Paralytic ileus:
- Gas flatulence of the small or large bowel with no evidence of bowel obstruction - Typically occurs after surgery or during colic attacks due to calculi
o Diagnosis:
- To assess bowel dilatation: jejunum should not be wider than 3.5 cm
- Threshold value for ileum is 2.5 cm and 6 cm of colon
- Gas/fluid levels are formed (levels before the zone of transition)
- X-ray, ultrasound, CT and colonoscopy
o Symptoms:
- abdominal distension
- nausea/vomiting
- constipation
- Non-traumatic acute abdomen : ileus in child age
- intussuception (dg US)
- volvulus (dg X-rays, US) spiral mesentery + bowel
- meconium ( x-rays)
- hypertrophic pyloric stenosis /duodenal atresia ( similar presentation) (fluoroscopy + US)
brainstorm what you remember!!
o Invagination (intussusception):
- Are the most common cause of bowel obstruction in children
- 75% of invagination occur before the age of 2
- Most commonly occurring in ileoileal aspect, usually transient in contrast to ileocecal invaginations, and resolve spontaneously
- In children below 6, the cause is either unknown or due to inflammation with enlarged lymph nodes or peyer´s plaques
- In children older than 6, it is imperative to rule out a tumor (lymphoma). Clinically the patient will be in poor general condition, experiencing abdominal pain, mucosanguineous diarrhea in late stages
- diagnosis: ultrasound
- symptoms: poor general condition, abdominal pain, bloody stool, meningism - Treatment: radiologically by enema with isotoni saline or under ultrasound guidance
o Volvulus:
- Defined as small bowel loops, usually due to malposition of the bowel (rotation) - Diagnosis: can be established by Doppler ultrasound, which depicts the spiral arrangement of the otherwise parallel mesenteric vessels
- Also by non-contrast x-ray (marked spiral configuration of small bowel
- symptoms: peritoneal signs, hypovolemic shock
o Meconium ileus:
- Most common cause of a deep small bowel obstruction and is a typical initial manifestation of cystic fibrosis
- Also occur without an underlying disease, and is observed in combo with volvulus in 15% of cases
- treatment: rectal enema with gastrografin, if not working 🡪 surgery
- diagnosis: x-ray
o Hypertrophic pyloric stenosis:
- Most common disease in infants
- Thickening of muscles of the pyloric canal
- Ultrasonography (obsolete with x-ray techniques)
- Symptoms: vomiting, failure to thrive, palpable pylorus
- Diagnostic signs: Pyloric stenosis with hypertrophic pyloric muscles and collapsed duodenal bulb
- Non-traumatic acute abdomen : hemorrhage
generally :
- As long as a patient is hemodynamically stable,
ultrasound should be perfomed - CT should be
performed in acute abdomen if the patient is
hemodynamically unstable - Us - golden standard
- AAA rupture
- spontaneous retroperitoneal haemorrhage
- hemorrhaging pancreatitis (in severe necrotising)
o Introduction:
- Define acute abdomen (see previous tasks)
- Bleeding can occur because of tumors, inflammatory bowel disease, rupture of arteries, Mallory-Weiss tear, gastritis, duodenitis, varices
- Risk factors: warfarin, NSAID, corticosteroids, SSRI
- Depending on the severity of the condition, in exceptional cases it may be useful to perform a CT as the first image procedure, but ultrasound is golden standard
- Angiography and interventional procedures are also used to detect GI hemorrhage (e.g meckel´s diverticulum)
o AAA rupture:
- See earlier tasks for information about aortic rupture
- CT is indicated
- Hematoma masses with dense soft tissue in the retroperitoneum
o Spontaneous retroperitoneal hemorrhage:
- SRH is a pathology of retroperitoneal bleeding without history of trauma
- Clinical presentation may be vague and varied (hemodynamic instability, fall in hemoglobin, abdominal pain)
- Etio: Rupure of aortic or visceral artery aneurysm
- Etio: Rupture of a lesion in a retropertoneal organ (renal or adrenal)
- Etio: Anticoagulant states, coagulopathy
- Endovascular repair or open surgery
o Hemorrhagic pancreatitis:
- Possible uncommon complication occurring with pancreatitis
- Bleeding within or around the pancreas
- Occurs in patients with severe necrotizing pancreatitis or rupture of a pancreatic pseudoaneurysm
- CT or MRI (T1 high signal intensity methemoglobin, T2 low signal intensity hemosiderin rim) o Other:
- Hemorrhage may result from erosion of large vsessels in the base of the ulcer - Ulcer continues to penetrate deeply and erodes through the wall of duodenum - Acute pancreatitis may cause hemorrhage
- Rupture of an ectopic pregnancy 🡪 massive hemorrhage which may flood the peritoneal cavity and cause generalized peritoneal irritation
- Esophageal varices
o Generally:
- As long as a patient is hemodynamically stable, ultrasound should be perfomed - CT should be performed in acute abdomen if the patient is hemodynamically unstable
- Acute scrotum
- testicular torsion
- epididymitis
o Testicular torsion:
- Occurs when a testicle torts on the spermatic cord resulting in the cutting off of blood supply
- The most common symptoms is acute testicular pain
- Cause: most common underlying cause is a bell-clapper deformity
- Diagnosis: made clinically often, but ultrasound is helpful in confirming the diagnosis - Differential diagnosis: sometimes challenging with epidydimitis, since scrotal pain, swelling and redness or tenderness are clinical symptoms common to these two entities - two types:
1. Extra-vaginal (torsion occurs at level of the external inguinal ring, seen in neonates 2. Intra-vaginal (more common variety due to bell clapper derfomity, adolescent and young adults
Clinical presentation:
- Spontaneous or minor trauma
- Swollen or erythematous hemiscrotum
- Sudden onset of testicular pain, and relieved by elevation of it
Diagnosis:
- Ultrasound: assess structure and vascularity, twisting of spermatic cord, altered blood flow (Doppler), size of testis, hyperemia and increased flow on colour Doppler
- Surgery
o Epididymitis:
- Inflammation of the epididymis
- Associated with inflammation extending to the testis itself
- Under 2 years or over 6 years
- Mild tenderness to severe febrile process with acute unilateral scrotal pain
- Cause: infection of bladder or prostate spreading through ductus deferens
- Diagnosis: ultrasound (reactive hydrocele, wall thickening, increased size, increased bloodflow
- Complication: testicular abscess or epidydimal abscess
o Varicocele:
- Dilatation of pampiniform plexus of veins
- Most frequently encountered mass of spermatic cord
- 15 % of general male population
Symptoms:
- May be asymptomatic
- Scrotal mass/swelling
- Scrotal pain
- Testicular atrophy
- Infertility
Etiology:
- Congenital absent valves in testicular veins
- Left more commonly
Diagnosis:
- Ultrasound (Doppler also to assess grade of reflux)
- CT: may show dilated cluster of enhancing serpentine veins
- MRI: Incidentally noted during scrotal MR
- Angiography: venography
- Treatment: embolization of testicular vein
o Other:
- Testicular tumors
- Fournier´s gangrene
- Henoch-sconlein purpura vasculitis of scrotal wall
- Strangulated inguinal hernia with or without testicular ischemia
- radiology of emergency medicine in adult age
oh god
divide it in different cards
stroke CNS
hemorrhage (CNS ) skull/face(orbital injuries spinal chest + CVS /pericardial effusion abdominal /intestinal obstruction genitourinary + GYN DVT / peripheral limb ischemia
o Emergency radiology in adults:
- Stroke:
- Generally: leading cause of disability, cognitive impairment and death, in each minute 1,9 million neurons, 14 billion synapses and 12 km of myelinated fibers destroyed, F.A.S.T - NIHSS: national institute of health stroke scale, 0 – no stroke, 1-4 minor, 5-15 moderate, 15- 20 moderate/severe, 21-42 severe
- NIHSS: Below 12-14 will have 80% good or excellent outcome, above 20-26 have less than 20% good or excellent outcome, Lacunar infarct patients had best outcome
- Symptoms: - Broca´s aphasia (Broca´s – expressive aphasia, left posterior inferior frontal gyris) 2. Wernicke´s aphasia (wenicke´s – receptive aphasia, posterior part of the superior temporal gyrus, located on the dominant side of the brain
- CNS emergencies:
1. Cerebral infarction: - Order CT of the brain
- Order MRI: DWI
- When: Focal neurological defect – stroke
o Imaging: - CT-scan: Non-contrast CT remains the golden standard for IVH and ICH
- CT with contrasts help identify aneurysms, AVMs, or tumors, but not a tPa candidate
- MRI: superior for showing underlying structural lesions
- Acute infarction (4 h) – Subtle blurring of gray-white junction & sulcal effacement - Subacute infarction (4days)- Obvious dark changes & “mass effect” (e.g ventricle compression)
- Multimodal imaging: includes non-contrast CT, perfusion CT and CTA, 2 types of perfusion (1. Whole brain perfusion CT and 2. Dynamic perfusion CT)
- Multimodal imaging: Standard MRI sequences (T1 weighted, T2 weighted and proton density) are insensitive to changes in cerebral ischemia, DWI and PWI also
o Treatment:
tPa: - Tissue plasminogen activator (clot buster)
- IV tPa window 4.5 hours
- IA tPa window 6 hours
- Disability risk below 30% despite – 5 % symptomatic ICH risk
- Contraindications: hemorrhage, SBP > 185, or DBP > 110, recent surgery, trauma or stroke, coagulopathy, seizure at onset of symptoms, NIHSS > 21, Glucose
- Mechanical thrombolysis: often used in adjunct with tPa, MERCI designed to remove clots, PENUMBRA system aspirates the clot
- Supportive therapy: Glucose management (infarcation increases with hyperglycemia) and Antiepileptic drugs: seizures are commong after hemorrhagic CVAs, ICH seizures are
generally non-convulsive and are associated to with higher NIHSS scores, a midline shift and tend to predict poorer outcomes
hemorrhage CNS
o CNS emergencies:
1. Hemorrhage:
- Order: CT of the brain plain
- When: Head trauma – focal neurological defect
Hemorrhage traumatic
1. Findings in: Extradural blood, subdural blood, cerebral contusion
Hemorrhage non-traumatic:
1. Findings in: Subarachnoid blood, intraparenchymal blood, intraventricular blood SAH: bleeding around brain (5%):
- Worst headache of my life
- Cause: 85 % trauma, the rest is ruptures aneurysm
- AMS – altered mental status
- Photophobia
- Nuchal rigidity
- Seizures
- Nausea and vomiting
Intracerebral hemorrhage: bleeding into brain (10%)
- Etiology: Trauma or spontaneous (HT, amyloid angiopathy, aneurysmal rupture, AVM rupture, bleeding into tumor, cocaine and amphetamine use)
- Cerebellar hemorrhage: vomiting (more common in ICH than SAH or Ischemic CVA), ataxia, eye deviation toward the opposite side of the bleed, small pupils, AMS
skull / face / orbital injuries
o Skull fractures:
- What to order: Plain X-ray to the skull (AP-lateral view), CT of brain (axial-cornoal) (bone window)
- When: History of trauma – evident injury of the scalp
o Facial emergencies:
- What to order: Plain X-ray of skull (lateral view – PA view), CT of the facial bones – Bone window – Axial & coronal 3D recon.)
When: History of trauma to the face – disfigurement – severe facial contusion o Orbital injuries:
- what to order: plain x-ray of the skull (lateral view – PA view), CT of the orbit (axial coronal bone & soft tissue settings)
- When: History of trauma to the orbit and history of FB to the eye
spinal injuries
o Spinal emergencies:
- Trauma (vertebral fracture (varieties) and spinal cord injuries
- What to order (spinal trauma): Plain x-ray of spine (lateral view – AP view), CT of the spine (bone & soft tissue settings – 3D recon.), MRI of the spine (for cord injury) - When: history of trauma – falling from height
chest + CVS / pericard effusion
o Chest emergency radiology:
- includes: rib fractures, traumatic hemothorax, pneumothorax, pneumomediastinum, pulmonary contusion, laceration & hematoma, esophageal injury, diaphragmatic injury - What to order: Plain x-ray of chest (PA view – lateral view), CT of the chest, angiography (aortography)
- When: history of trauma – difficuly breathing
o Cardiovascular emergencies:
- includes aortic dissection, AAA rupture
- What to order: plain x-ray of the chest (PA view – lat. View), CT scan, MRI, aortography - When: sudden severe tearing substernal chest pain
o Pericardial effusion:
- What to order: Plain x-ray of the chest (PA view – lateral view), echocardiography - When: chest pain – friction rub- faint heart sounds on auscultation
abdominal / intestinal obs
o Abdominal emergencies:
- includes hemoperitoneum and visceral injuries (liver, spleen, kidney, UB) - What to order: Chest & abdominal radiographs, Ultrasound (FAST), CT scan, Arteriography - When: history of trauma to abdomen – motor vehicle accident
o Abdominal emergencies:
- GUT perforation (e.g perforated DU)
- What to order: Abdominal radiography, US, CT scan
- When: history of peptic ulceration – signs of peritonitis
o Intestinal obstruction:
- What to order: abdominal radiography, CT scan
- When: crampy abdominal pain – nausea & vomiting – abdominal tenderness
GUT / GYN
o Genitourinary emergencies:
- Includes urinary tract trauma (renal bladder, male urethra)
- What to order: Plain x-ray of urinary tract, ultrasound, intravenous urography, CT abdomen, Ascending urethrocystography
- When: history of blunt trauma to abdomen – falling astride
GYN & obstetric emergencies:
- What to order: Ultrasound (color Doppler)
- When: bleeding in early/late pregnancy, lower abdominal pain – fever –vaginal discharge 2. Trauma
3. Pneumothorax
4. Pulmonary embolism
5. Aorta (dissection/rupture)
6. Bleeding (acute pancreatitis)
7. Acute limb ischemia
8. GI (Bowel ischemia, perforation, intestinal obstruction)
9. GY (ectopic pregnancy, postpartum hemorrhage, ovarian torsion)
DVT / peripheral limb ischemia
o DVT:
- What to order: color Doppler ultrasound
- Venography – IR
- When: asymptomatic – pain – edema – skin discoloration
o Acute peripheral ischemia:
- What to order: Color Doppler ultrasound and arteriography
- When: sudden onset of severe pain, coldness, numbness or pallor in a portion of an extremity
