This person came in after a high speed motor vehicle collision. Their main complaint was neck pain near C-7:
As you can see under bone windows there is a fracture of C7. One could stop here and be satisfied that you see the primary pathology in which you were interested. However, anytime you look at a CT you should pay attention to all parts of the image. Secondary findings are very common, especially in trauma. When assessing a CT image, one should change windows on the image to adequately look at all types of tissue that are present. In a cervical spine CT, the top of the lungs are usually visualized in the catchment area as you get to the upper t-spine. If you change the window to “lung” windows this is what you’ll see:
This person also has an anterior, small pneumothorax! This could have easily been missed if not changing the window to look at the lungs.
One of the basics of CT imaging is to change windows for all types of tissue. In the head, your main window change will be from “brain” to “bone” to adequately visualize bony structures of the calavarium. In the abdomen you should switch to “lungs” to visualize the lungs as well as switch to “bone” to visualize the ribs, pelvis, and spine. There are many other examples of this principle, but we will leave it at this for now.
Author: Russell Jones, MD
Chief Complaint: ”My right side hurts”
On a busy night in the ED you encounter a 48-year-old male with right flank pain. Onset was sudden, severe, 10/10, waxing and waning pain. You obtain a urine dip which shows 3+ blood.
Here is his non-contrast CT abdomen/pelvis:
What is the diagnosis?
This man has a 0.6cm stone in his ureter. The CT scan shows two slices, one visualizing a hyper dense spherical structure in the ureter and the other demonstrating hydronephrosis with perinephric stranding. This is considered an obstructing stone.
Kidney stone causing acute pain is one of the most common, most satisfying ED diagnoses. These patients usually are in significant pain, sometimes sweating bullets from their pain! And we can and usually make them better. In fact, IV ketorolac is one of the most efficacious medicines available for stones. I personally love the kidney stone…I feel like I can make a difference with this diagnosis.
Emergency Medicine Practice (one of my favorite CME publications) in July 2011 provided a great review of renal calculi. In particular it quoted an an article which found a 98.3% sensitivity and a 100% specificity of ultrasound in patients suspected of having renal colic. CT had a sensitivity and specificity approaching 100%. The article also discusses admission criteria, special cases such as pregnancy and pediatrics, as well as recommendations for those patients sent home from the ED. I will refer you to the article for details.
1. Carter MR, Green BR. Renal Calculi: Emergency Department Diagnosis and Treatment. Emergency Medicine Practice; 13 (7), 2011.
Author: Russell Jones, M.D.
Imaging Study: CT abdomen/pelvis without contrast
“Done got stabbed doc”
Chief Complaint: ”I done got stabbed in the neck doc.” (He actually said this…I can’t make this stuff up).
This gentleman was “roughing up” his wife when she decided she had enough and stabbed him in the neck with a kitchen knife. He had a “Zone I” area laceration just above the clavicle on the right side roughly 4cm lateral to the sternal notch.
Here is his Chest X-ray:
This patient has…