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EMREMS: Radiology in Emergency Medicine

What’s Wrong: Answer

June 6, 2018

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CT Chest

There is air in the pulmonary artery!  This is an air embolus (probably iatrogenic from the IV contrast injection).

CT chest 2

Turns out there is also some air in the right ventricle.  Keep air embolism in mind as a very rare complication to imaging with IV contrast.

Author:  Russell Jones, MD

 

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What’s wrong?

May 30, 2018

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Here is a fun CT Chest:

CT Chest

Question:  What’s wrong?  Hint:  the aortic dissection is chronic.

Answer to follow.

Author:  Russell Jones, MD

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Trauma Devices

February 27, 2018

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Trauma Lines

This patient has four devices.

  1. There is an endotracheal tube that is malpositioned into the right mainstem bronchi.
  2. A right subclavian central line can be seen positioned in the right atrium
  3. A right sided chest tube is in good position
  4. Coursing up from the femoral area is a REBOA catheter.

What is a REBOA catheter?  REBOA = Resuscitative Endovascular Balloon Occlusion of the Aorta.  It is relatively new technology in which a specialized catheter is used with a balloon that occludes the aorta.  It is predominantly used in lieu of cross-clamping the aorta for severely ill trauma patients with uncontrolled abdominal hemorrhage as a temporizing device to allow time for transport to the OR and definitive control.

The patient’s lungs also appear with contusions and possibly a posterior hemothorax (patient is supine) on the left.

For a detailed discussion of REBOA including radiologic placement please refer to Life in the Fast Lane:

https://lifeinthefastlane.com/ccc/resuscitative-endovascular-balloon-occlusion-aorta-reboa/

Author:  Russell Jones, MD

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Trauma Lines

February 20, 2018

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Trauma Lines

Can you name all the lines and tubes on this patient?  HINT:  There four important devices, one is malpositioned.  Answer to follow.

 

Author:  Russell Jones, MD

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Crazy 5th finger fracture…

June 16, 2016

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This patient presented with pain after jamming their finger:

 

Interesting fracture pattern!

On the AP view the fracture is subtle; the distal end of the proximal 5th phalanx looks irregular and lacks a solid radial side.  On the lateral it is more obvious.  The fracture line appears to have travelled obliquely and it almost looks like there are two distal phalanx!  The distal portion of the finger is dislocated at the PIP joint.

Author:  Russell Jones, MD

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WWWTP #24 Answer…

July 1, 2015

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Trauma patient came in to the ED:

CXR 1

What’s Wrong With This Picture?

The patient’s chest tube is not inserted far enough.  It is also a bit high residing between ribs 3-4.

Chest tubes have a side port and a distal port for suctioning fluids, air from the pleural space.  There is a radiopaque line seen on the tube that is interrupted at the side port (see magnified image).  In this case the radiograph shows that the side port is subcutaneous and not inserted all the way into the pleural space.  The chest tube needs to be replaced!

Author:  Russell Jones, MD

Image Contributor:  David Barnes, MD

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What’s Wrong With This Picture #24 (WWWTP?)

June 26, 2015

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Trauma patient came in to the ED:

CXR 1

What’s Wrong With This Picture?

Author:  Russell Jones, MD

Image Contributor:  David Barnes, MD

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Anxiety Attack…

May 26, 2015

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This patient presented with the chief complaint of an “anxiety attack.”  They felt short of breath, onset after arguing with another person, and they had a history of panic attacks in the past.  Here’s what we found…

Saddle Embolus 1 Saddle embolus 2 Saddle embolus 3

This is a scary pathology that is on the differential of panic attack:  saddle pulmonary embolus.

“Saddle” refers to a main pulmonary artery involvement.  In the images above you can see a filling defect just as the main pulmonary artery branches off to the right and left sides (see red arrow below).

saddle-embolus-3 (edit)

Large main pulmonary emboli are life threatening diagnoses that can easily progress to sudden death.

History of present illness in this patient screamed panic disorder.  However, we had some clinical clues that altered the direction of the case:  hypoxia to the high 80s, tachycardia, and an EKG with a right axis.  On review of systems the patient said she had had vague calf pain over the last week.  Thus we ended up pursuing CT imaging as opposed to treating her “panic attack” with benzodiazepines…good call!

Author:  Russell Jones, MD

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Rare arm fracture…

April 21, 2015

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Elbow GF1 Elbow GF2 Wrist GF 1 Wrist GF2

This patient presented with arm pain after a fall.  The radiographs obtained showed a distal radius fracture along with a radial head fracture (irregularity and bone fragment seen at the radial head).

I haven’t seen this fracture pattern before.  I’m not sure if it can be classified as an Essex-Lopresti fracture (radial head fracture accompanied by dislocation of the radioulnar joint).  In looking at the radiographs I believe the radioulnar joint is still intact.  However, I’m wondering if the clinical principle of the Essex-Lopresti fracture is maintained:  is there a disruption of the interosseous membrane between the radius and ulna.  This disruption can lead to serious long-term disability including pain, loss of pronation, supination and extension range-of-motion (1).

Has someone out there seen this before?  Any pearls of wisdom regarding this fracture pattern?

Author:  Russell Jones, MD

Imaging Contributor:  Joe Barton, MD

 

References

1.  Essex Lopresti Fracture.  Wheelessonline.com.  Accessed 4/2015.

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Student Corner: CT Evaluation of Appendicitis

April 9, 2015

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Appendicitis is commonly encountered in the ER and is the leading cause of surgical emergency in the abdomen. The initial evaluation for a presentation that is concerning for appendicitis often includes history taking and exam, supplemented by labs. The Alvarado Score is a 10 point rating scale that is widely used as a tool to help decide whether or not a patient presenting with abdominal pain requires CT imaging (although it’s overall clinical usefulness is controversial). It is outlined here by MDCalc. According to the rule, a score of greater than 4 warrants CT evaluation and greater than 7 requires immediate surgical consult.  CT scan is a highly sensitive and specific tool in diagnosing appendicitis, however it comes with radiation, cost, and sometimes IV contrast risks.  In the pediatric patient population radiation from CT scans are not as desirable as the long-term consequences have theoretical potential to be deleterious (long discussion…for another post maybe!).

The purpose of this article is to go over characteristics of appendicitis that can be seen on a CT scan. The use of contrast is a long debated point of contention amongst the emergency medicine community and the usual practice varies between institutions. Medscape has a great rundown of the issue here, which notes that the use of contrast may be more beneficial in circumstances where appendicitis is a relatively less likely diagnosis because the contrast better helps characterize other possibilities.  Contrast studies are also more helpful in the patient not expected to have a large amount of intraperitoneal fat.

As usual, it is important to understand the local anatomy when analyzing radiological images of the abdomen. The image below is an example of an axial cut, non-contrast abdominal CT of a patient who came in with abdominal pain concerning for appendicitis. Try to identify the following structures: vertebrae, psoas major, IVC, iliac arteries, small bowel, colon and appendix.

Appy

And below is a labeled version of the same image:

Appendicitis labeled

Key: Blue arrow = bowel gas, ascending colon; Green arrows = small bowel; Purple arrows = L and R Iliac arteries; Yellow arrow = IVC; Red arrow = inflamed appendix

This image contains several signs that indicate that the appendix is inflamed. They include:

  • Diameter greater than 6mm–this usually implies the the appendix has either been twisted or blocked off from the cecum by an appendicolith, which causes inflammation
  • Periappendiceal fat stranding–seen as distinct lines that radiate out from the appendix in the image above, it is caused by inflammation of the appendix causes fluid accumulation around the wall of the appendix which turns the normally hypodense surrounding fat into a hyperdense area; note that the visceral fat around the appendix on the L side of the image looks much different than the visceral fat on the other side of the image
  • Appendiceal wall thickening–normally the wall of the appendix is thin and barely noticeable, but this image shows that the wall is generally thickened and may even be slightly more hyperdense than expected (more below)

Other signs that aid in the diagnosis of appendicitis include:

  • Appendiceal wall enhancement–the wall of the appendix becomes slightly more hyperdense when you compare it to the wall of any other loop of bowel, which is again a product of inflammation; note that this finding is usually more evident on contrast-enhanced CT
  • Abscess–the colon has a large reservoir of commensal bacteria, which can grow and wall off into an abscess if they are trapped in the appendix
  • Appendicolith–a calcified mass that is hyperdense on CT which can be an obstruction between the cecum and the appendix

Overall, CT has a high degree of sensitivity and specificity when used to evaluate the possibility of appendicitis. The clues outlined above, especially when seen together and as a part of a larger clinical picture that fits with appendicitis, are instrumental in confirming the diagnosis.

References:

Ohle R, O’Reilly F, O’Brien KK, Fahey T, Dimitrov BD. The Alvarado score for predicting acute appendicitis: a systematic review.BMC Med. 2011 Dec 28;9:139. doi: 10.1186/1741-7015-9-139. Review. PubMed PMID: 22204638; PubMed Central PMCID: PMC3299622.

Reich B, Zalut T, Weiner SG. An international evaluation of ultrasound vs. computed tomography in the diagnosis of appendicitis.Int J Emerg Med. 2011 Oct 29;4:68. doi: 10.1186/1865-1380-4-68. PubMed PMID: 22035447; PubMed Central PMCID: PMC3215954.

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