Emergency Chest Radiology

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					                                                                                                  ALGORITHMIC EVALUATION OF
                                                                                                 COMPLEX NEUROLOGIC INJURIES

                Advances in Emergency                                                            I.
                                                                                                 II.
                                                                                                      Introduction
                                                                                                      Neurologic Injury: Catastrophic and Critical
                    Neuroradiology:                                                                   Diagnoses
                                                                                                 III. Strategic Pathways for Diagnostic Imaging
                An Algorithmic Approach                                                                 Craniofacial
                                                                                                        Axial Skeleton and Spinal Cord Injuries
                                                                                                        Appendicular Skeleton and Peripheral Neural Injuries
                                                                                                 IV:      Case Illustrations
                                                                                                 V.       Conclusions
                    Martin Kernberg, MD, Asst. Clinical Professor
                                                                                                 VI.      References
                    Steve Polevoi, MD, Assoc. Clinical Professor

                            Division of Emergency Medicine
                                Department of Medicine
                         University of California, San Francisco
           Div. of Emergency Medicine, UCSF                                                     Div. of Emergency Medicine, UCSF




                                                                                                         Neurologic Injury: Parallel Processing of
           Introduction                                                                                                            Information
          Neurologic injury remains one of the leading causes of death and long term
             functional deficits despite recent advances in management. The
             contemporary evaluation and management of the neurologic patient
             require parallel efforts to assess the patient clinically and radiologically.      1.     Consider the high risk differential diagnosis, on
             The timing and selection of radiological investigations remains a source
             of controversy. Advancing imaging modalities yield diagnoses previously                   the basis of clinical history, physical
             overlooked; medicolegal concerns influence clinical decisions; decision
             rules and protocols designed to reduce unnecessary costs, radiation
                                                                                                       examination, and laboratory studies.
             exposure, and clinical delays can seem complex, contradictory, and
             excessively rigid; resources are progressively limited. In reviewing these
                                                                                                2.     Concurrently stabilize, initiate imaging
             issues, a system is described that may prove useful in clinical practice,                 sequence, and/or contact appropriate surgical
             with a critical review of the advantages and disadvantages of various
             radiological modalities. While a set of algorithms is advocated, it is                    consultants.
             underscored that this will vary depending on the facilities available. It is
             appropriate however to be aware of the limitations of the radiological             3.     Confirm benign etiologies directly, or indirectly
             techniques that are utilized on a daily basis and to have a knowledge of
             how selective use of advanced imaging modalities will improve patient
                                                                                                       after formal exclusion of the catastrophic
             care.                                                                                     differential diagnosis.
              Modified from P Jaye, ME Kernberg, and T Green, “Trauma Radiology,” The Lancet,
              in press, 2007.

           Div. of Emergency Medicine, UCSF                                                     Div. of Emergency Medicine, UCSF




                                                                                                       3 Catastrophic conditions
              How are neurologic catastrophic                                                        Intracranial hemorrhage
                   conditions defined?                                                                    Traumatic
                                                                                                               Subdural hematoma
                                                                                                               Epidural hematoma
               Catastrophic conditions are those which                                                         Intraventricular hemorrhage

               have a significant risk of mortality, if the                                               Vascular etiologies
                                                                                                               Aneurysm rupture
               diagnosis is emergently missed.                                                                 Hemorrhagic arterio-venous malformation
               Critical traumatic conditions are those                                                         Hemorrhagic Venous angioma

               which have a significant risk of morbidity,                                           Acute intra-axial ischemia and infarction
               if the diagnosis is delayed (e.g., cervical                                           Intracranial and axial infection
                                                                                                          Meningitis
               spine injuries, subacute hemorrhage, or
                                                                                                          Diskitis
               transient cerebral ischemia).                                                              Abscess

           Div. of Emergency Medicine, UCSF                                                     Div. of Emergency Medicine, UCSF




Emergency Chest Radiology
                      2 Critical Injuries:                          General Vital Sign Indications for
                Axial and Intra-axial Trauma                       Catastrophic Differential Diagnosis
                Axial fractures                                   1. Tachycardia or bradycardia (heart rate <50)
                    C-spine                                       2. Tachypnea or bradypnea (respiratory rate
                    T-spine                                       <7)
                    Lumbosacral
                                                                  3. Significant pyrexia or hypothermia
                Intra-axial
                    Contusions                                    4. Hypotension and hypertension
                    Concussions                                   5. Acute hypoxia
                    Petechial hemorrhage                          6. Pain severity
                                                                  7. Weight loss

           Div. of Emergency Medicine, UCSF                   Div. of Emergency Medicine, UCSF




              Local Vital Sign Indications for               Clinical Catastrophic Criteria
             Neurologic Differential Diagnosis                    Acuity, severity, progression, persistence,
                                                                  refractory, atypical or unexplained:
           1.     Glasgow Coma Score                                    Critical acute symptoms (e.g., severe headache, neck
                 1.    Adult                                            pain, back pain; palpitations or respiratory
                                                                        irregularity; nausea, vomiting, distension; paresthesia,
                 2.    Pediatric                                        weakness, or paralysis)
           2.     Cranial nerve functional deficits                     Selective physical findings (neurologic deficits; blood
                 1.    Visual acuity                                    pressure fluctuation, rhythm disorders, bradypnea or
                                                                        tachypnea; altered bowel or urinary function
                 2.    Hearing loss                                     (incontinence or retention); loss of reflexes, motor
                 3.    Anosmia…                                         function, or sensation; hemotympanum, periorbital
                                                                        ecchymosis).
           3.     Motor strength                                        Aberrant laboratory, electrocardiographic, or plain
           4.     Reflex changes                                        radiographic abnormalities (e.g., axial imaging).
           5.     Peripheral sensory deficits
           Div. of Emergency Medicine, UCSF                   Div. of Emergency Medicine, UCSF




                                                                                        Craniofacial Injury: Strategy
                                   Imaging Modalities
                                                                                                 Catastrophic
                                                                                              Craniofacial Findings

                Conventional Radiographs and Special Views
                                                                                                   Standard                   Advanced Imaging
                                                             Clinical Information
                                                                                               Diagnostic Testing                  Options
                CT: Incremental, Spiral, Angiographic

                US: Gray Scale, Color Doppler, Amplitude                        Vital Signs                     1. Laboratory                    1. CT/CTA

                Angiography
                                                                                    History                           2. XR                       2. MRI
                MR: MRI and MRA
                                                                               Neurologic
                Arterial Catheterization                                       Examination
                                                                                                                                            3. Angiography




           Div. of Emergency Medicine, UCSF                   Div. of Emergency Medicine, UCSF




Emergency Chest Radiology
           Principles of facial imaging
                                                                                              Case 1
               If you can name the particular bone, plain film imaging is   30 year old homeless
               appropriate:
                     Nasal spine                                            male, intoxicated, is
                     Mandible series (preferred: orthopantomogram)          involved in fistfight,
                                                                            with multiple facial
               If two or more bones are involved, CT is indicated. Do not
               order (but your institution may require):                    abrasions, and
                     Facial films                                           paranasal sinus
                     Sinus series
                                                                            tenderness.
                     Orbit series
                     TMJ series
                     Skull series

           Div. of Emergency Medicine, UCSF




                                              Case 1                                          Case 1




                                              Case 1                                          Case 1




Emergency Chest Radiology
          Principles of Cranial Imaging
               Universal decision rule:                                                     CT versus MRI: Controversy
                     Acuity, severity, progression, persistence, refractory,
                     atypical and unexplained
                          Symptoms                                                          CT vs. MR                      MRI                       CT
                                 Headache, nausea and vomiting, confusion, vertigo,         Sensitivity (ICH)              100%                      97%
                                 sensory deficit; weakness, paresthesia, ataxia; bleeding
                                 from the ear, new rhinorrhea.                              Radiation dose                 0                         1/1000 cancer rate
                          Physical findings
                                                                                            IQ impact                      No known change           Diminished IQ
                                 GCS decline
                                 Neurologic deficits                                        HS graduation rate             No known change           Diminished rate
                                 Supraclavicular injuries
                          Laboratory, electrocardiographic, or plain film findings,
                          such as
                                 Respiratory acidosis
                                 ST segment depression or elevation
                                 Associated injuries: C-spine fractures


           Div. of Emergency Medicine, UCSF                                                 Div. of Emergency Medicine, UCSF




           CT versus MRI: Controversy                                                       SAH: Emerging controversy
           CT versus MRI                      MRI                   CT                      Imaging sequence                   CT                    MRI
           Sedation                           Often in children     Often in children                                          1. Non-contrast CT    1. MRI
           Cost per machine                   0.25 million          1.0 million                                                2. Lumbar puncture    2. CTA if MRI + ICH.
           Cost per study                     High                  Intermediate                                               3. CTA if LP + ICH.
           After hours access                 Difficult             Easy




           Div. of Emergency Medicine, UCSF                                                 Div. of Emergency Medicine, UCSF




          Types of Intracranial Hemorrhage
              Epidural hematoma
                    Common mechanism: meningeal artery laceration,
                    often associated with temporo-parietal fractures
              Intraparenchymal hematoma
                    Common mechanism: contusion with potential for
                    progression
              Subdural hematoma
                    Common mechanism: injury to bridging dural veins
              Subarachnoid hemorrhage
                    Common mechanism: traumatic aneurysm rupture
              Intraventricular hemorrhage
                    Common mechanism: extension of intraparenchymal
                    hematoma

           Div. of Emergency Medicine, UCSF                                                 Div. of Emergency Medicine, UCSF




Emergency Chest Radiology
                                                       Case 2
                                                        75 yo Chinese-
                                                        American male, with
                                                        no prior medical
                                                        history, awoke at
                                                        2300 hours with n/v
                                                        and left sided
                                                        weakness,
                                                        progressing to
                                                        witnessed seizures.


           Div. of Emergency Medicine, UCSF




           Case 2: CT and MRI                          Case 3

                                                        61 year old Hispanic
                                                        female with severe
                                                        headache and
                                                        nausea, become
                                                        apneic in transport,
                                                        with run of
                                                        ventricular
                                                        tachycardia.




                                              Case 3                     Case 3




Emergency Chest Radiology
                                                  Case 3
                                                                                                          Contusions and Intracerebral
                                                                                                                  Hematomas
                                                                                                            Contusions can, in a period of hours or
                                                                                                            days, evolve or coalesce to form an
                                                                                                            intracerebral hematoma requiring
                                                                                                            immediate surgical evacuation.
                                                                                                            This occurs in approximately 20% of
                                                                                                            patients and is best detected by
                                                                                                            repeating the head CT scan within 12 to
                                                                                                            24 hours after the initial scan. ATLS
                                                                                                        Div. of Emergency Medicine, UCSF




                      Axial Skeletal Trauma: Diagnostic Strategy
                                                                                                             C-spine interpretation:
                                                                                                             Architectural principles
                                            Catastrophic
                                       Axial Skeletal Findings



                                                                                                         Lateral projections                    Anterior projections
                                               Standard                  Advanced Imaging
          Clinical Information
                                           Diagnostic Testing                 Options
                                                                                                               Counting (Marshall’s law)           Symmetry
                                                                                                                    Are all the vertebral              Dens and C1
                                                                                                                    bodies visible, including          C1 and C2
                             Vital Signs                   1. Laboratory                    1. CT/CTA               T1?
                                                                                                               Continuity                          Sinusoidal configuration
                                                                                                                    Are anatomic curves                Lateral masses
                                                                                                                    continuous?
                                 History                         2. XR                       2. MRI            Conformance                         Scoliosis
                                                                                                                    Are the transitions
                                                                                                                    between vertebral bodies           Muscle spasm
                                                                                                                    regular, with respect to           Ligamentous injury
                            Neurologic                                                                              size and intervertebral            Occult fracture
                            Examination
                                                                                       3. Angiography               spaces?


           Div. of Emergency Medicine, UCSF                                                             Div. of Emergency Medicine, UCSF




                          C-spine interpretation
                                guidelines                                                                   C-spine: the lateral view of
                                                                                                                 the lateral masses
                                                                    Prevertebral STS                        Contour transitions
                                                                    Anterior longitudinal
                                                                    line
                                                                    Posterior longitudinal
                                                                    line
                                                                    Spinolaminar line
                                                                    Posterior process line
                                                                    Dens-basion distance

           Div. of Emergency Medicine, UCSF                                                             Div. of Emergency Medicine, UCSF




Emergency Chest Radiology
                C-spine: the AP view of the                          C-spine: the AP view of the
                           dens                                                 dens
               Symmetry                                             Symmetry




           Div. of Emergency Medicine, UCSF                     Div. of Emergency Medicine, UCSF




                                                                    Indications for C-spine Films:
                C-spine: the AP view of the                                                           Severe pain
                                                                                                      Midline tenderness*
                      lateral masses                                                                  Unrestrained occupant
                                                                                                           Ejection
                                                                                                      Neurologic deficit*
               Sinusoidal contour                                                                     Radiculopathy
                                                                                                      Intoxication*
                                                                                                      Altered level of consciousness*
                                                                                                      Mechanism
                                                                                                           Velocity
                                                                                                           Intrusion
                                                                                                           Rollover
                                                                                                      Other injuries
                                                                                                           Brain
                                                                                                           Distracting pain*



                                                                                                   *= NEXUS exclusion criteria (NEJM Jul,
                                                                                                      2000): implicit indications for imaging.


           Div. of Emergency Medicine, UCSF                     Div. of Emergency Medicine, UCSF




           NEXUS                                                NEXUS

               N Engl J Med 2000 Jul 13;343(2):94-9.                Five criteria to be classified as low probability of
                                                                    injury:
               Validity of a set of clinical criteria to rule             no midline cervical tenderness
               out injury to the cervical spine in patients               no focal neurologic deficit
               with blunt trauma. National Emergency                      normal alertness
               X-Radiography Utilization Study Group.                     no intoxication
                                                                          no painful, distracting injury
               Hoffman JR, Mower WR, Wolfson AB,
                                                                    Individual criteria not compared
               Todd KH, Zucker MI.                                  NPV 99.8%
               34,069 patients
           Div. of Emergency Medicine, UCSF                     Div. of Emergency Medicine, UCSF




Emergency Chest Radiology
                                                            Canadian C-Spine Rule (I)
           Nexus Study                                         8924 Adults
                                                               100% Sensitivity and 42.5% Specificity
           34,000 Patients, 23 Centers                         1) Is there any high-risk factor that mandates
                                                               radiography (i.e. age > 65, dangerous
           5 Criteria: No posterior midline tenderness,        mechanism of injury, or paresthesias)?
             intoxication, altered consciousness,               2) Is there any low-risk factor present that
             neurological deficits, distracting injuries.      allows safe assessment of range of motion (i.e.
                                                               simple rear-end motor vehicle collision, sitting
             99.6% Sensitivity, but 12% Specificity.           position in ED, ambulatory at any time since
                                                               injury, delayed onset of neck pain, or absence
                                                               of midline tenderness?

           Div. of Emergency Medicine, UCSF                 Div. of Emergency Medicine, UCSF




           Canadian C-Spine Rule (II)                                       C-spine: dens injury

               3) Is the patient able to actively rotate        Asymmetry
               neck 45 degrees to left and right
               regardless of pain?




           Div. of Emergency Medicine, UCSF                 Div. of Emergency Medicine, UCSF




           CT C-spine: the lateral view of                     CT C-spine: the axial view of
                     the dens                                           the dens
               Technique:                                       Asymmetry
                     Finest possible cuts of
                     level of abnormality
                     Beware of motion
                     artifacts
               Cortical discontinuity
               Double density sign



           Div. of Emergency Medicine, UCSF                 Div. of Emergency Medicine, UCSF




Emergency Chest Radiology
          CT of C1-C2 More Sensitive Than
                    Plain Films
              Study of 202 patients with traumatic brain
              injury, Link, et al, found 5.4% of patients had
              C1 or C2 fractures and 4% had occipital condyle
              fractures not visualized on three-view
              radiographs.
              Blacksin and Lee evaluated 100 consecutive
              trauma patients, found 8% frequency of
              fractures of the occipital condyle (3%) and C1-
              C2 (5%) not detected on cross-table lateral c-
              spine.
              http://www.east.org
           Div. of Emergency Medicine, UCSF                        Div. of Emergency Medicine, UCSF




           Flexion-extension Films: ATLS
                     guidelines                                   PEDIATRIC C-SPINE

               Persistent neck pain, without                           Increased cranial size, with increased
               radiographic changes                                    ligamentous laxity
               Non-acute CT scan, with suspected                       Pseudosubluxation of C2 on C3 and C3
               degenerative or chronic spondylolisthesis               on C4 OK below age 8. Use posterior
               The degree of angulation must be                        cervical line to rule out pathology
               determined by the patient, and limited by
               level of tolerance.

           Div. of Emergency Medicine, UCSF                        Div. of Emergency Medicine, UCSF




                    Thoracic Imaging: Radiologic                              Thoracic and Neurologic Trauma: Strategy
                              Sequence                                                         Catastrophic Chest
                                                                                                    Findings



              Imaging evaluation of acute chest trauma divides    Clinical Information
                                                                                                   Standard                  Advanced Imaging

              into five typical paths:
                                                                                               Diagnostic Testing                 Options


              1. Chest Radiograph: general survey
              2. Thoracic spine series
                                                                                     Vital Signs               1. Laboratory                      1. US


              3. US (e.g., myocardial contusion and pericardial
                 effusions)                                                     Cardiovascular and
                                                                                Pulmonary History
                                                                                                                    2. ECG                      2. CT/CTA

              4. CT/CTA (e.g., pulmonary contusion, aortic
                 transection, pericardial injury)
                                                                                    Auscultation                    3. CXR                 3. Angiography
              5. MRI: assessment of cord injury

           Div. of Emergency Medicine, UCSF                        Div. of Emergency Medicine, UCSF




Emergency Chest Radiology
                             T and LS-spine interpretation:                                                                  Classical Algorithm for Abdominal Trauma
                                                                                                                                            Acute Abdomen


                             Architectural principles                                                                                                         History and PDx



                         Lateral projections                                     Anterior projections                                                            Laboratory


                               Counting (Marshall’s law)                                                                                                 Conventional Imaging
                                    Are all the vertebral bodies visible                 Symmetry
                                    for the selected level?                                   Vertebral bodies
                                    Are the vertebral bodies the same                         Transverse processes                                              Consultation
                                    height anteriorly and posteriorly?
                                    Are the vertebral bodies the same                         Posterior processes
                                    density throughout?                                              Regular transitions                                     Initial X-sectional
                               Continuity                                                            Bifid artifacts
                                                                                                                                                                   Imaging
                                    Are anatomic curves continuous?
                                    Assess subluxation.                                                                                                 CT                         US
                               Conformance                                               Scoliosis
                                    Are the transitions between                               Muscle spasm
                                    vertebral bodies regular, with                                                                                           Secondary Imaging
                                    respect to size and intervertebral                        Ligamentous injury
                                    spaces?
                                                                                              Occult fracture
                                                                                                                                     Nuclear Medicine        GI Contrast Studies        Angiography




                        Div. of Emergency Medicine, UCSF                                                                   Div. of Emergency Medicine, UCSF




                                 Parallel Algorithm for Abdominal                                                                                                    Case 4
                                              Trauma                                                                       71 year old with hx of
                                                                                                                           chronic back pain,
                                                                                                                           depression, and seizures,
                                                        Acute Abdomen
                                                                                                                           increasing over the past
                                                                                                                           several months, and
      History and PDx             Laboratory         Conventional Imaging
                                                           1. CXR
                                                                                    Imaging                Consultation    worse today.
                                                     2. Abdominal Series
                                                                                                                           PDx: extreme weakness.
                                                                             US                    CT
                                                                      1. Color Doppler     1. IV, Oral, Rectal
                                                                      2. Power Doppler     2. CT Angiography




                        Div. of Emergency Medicine, UCSF




                                                                                                                                                                     Case 4
                                                               Case 4




Emergency Chest Radiology
                                                                                                            Universal Decision Rule in Axial and
                             Severe Pelvic Fractures                                                                 Extremity Injuries
                                                                                                            If focal skeletal tenderness is demonstrated, conventional
                                                                                                            radiographs.
                                                                                                                  Comparison view in children (or use of Keats).
              Early transfer to                                                                                   CT (or MRI) for atypical, asymmetric, askew, or avulsed findings.
                                                                                                                  Advise patients that “occult fractures and internal derangements
              a Trauma Center                                                                                     cannot be excluded, and interval evaluation may be required.”
                                                                                                            Splint
              Strongly                                                                                            Hard collar for cervical spine strain.
              recommended                                                                                         Appropriate splint for extremity injuries.
                                                                                                            Formal radiologic interpretation in less than 24 hours.
              (ATLS)                                                                                        Formal follow-up:
                                                                                                                  Diminished or asymmetric range of motion in children, concurrent
                                                                                                                  orthopedic discussion or consultation.
                                                                                                                  Neurologic deficits, central or peripheral: emergent consultation.
                                                                                                                  Instability: concurrent orthopedic discussion or consultation.
                                                                                                                  Interval evaluation in adults in <7 days with appropriate specialist
                                                                                                                  (e.g., orthopedist, maxillofacial, neurosurgical, or otolaryngologist).

           Div. of Emergency Medicine, UCSF                                                            Div. of Emergency Medicine, UCSF




                             Appendicular Skeletal Trauma
                                          Catastrophic
                                       Appendicular Findings
                                                                                                               2 Catastrophic neurologic
                                                                                                                        injuries
                                               Standard                 Advanced Imaging
          Clinical Information
                                           Diagnostic Testing                Options
                                                                                                            Child abuse, with potential fatal outcome
                                                                                                            Neurologic compromise from fracture-
                             Vital Signs                   1. Laboratory                   1. CT/CTA
                                                                                                            dislocations

                                 History                        2. XR                       2. MRI




                             Extremity
                                                                                      3. Angiography
                            Examination



           Div. of Emergency Medicine, UCSF                                                            Div. of Emergency Medicine, UCSF




                    Critical Injuries:
                                                                                                             Local Vital Sign Indications for
              Axial and Extremity Trauma
                                                                                                            Traumatic Differential Diagnosis

              Fractures                                                                                1.    Injury site related pain or tenderness
              Dislocations                                                                             2.    Aberrant range of motion
                                                                                                       3.    Aberrant muscle strength (scale of 5)
              Subluxation
                                                                                                       4.    Aberrant sensation
                                                                                                       5.    Aberrant pulses
                                                                                                             1.    Diminished pulse to palpation
                                                                                                             2.    Peripheral capillary refill
                                                                                                             3.    Peripheral pulse oximetry


           Div. of Emergency Medicine, UCSF                                                            Div. of Emergency Medicine, UCSF




Emergency Chest Radiology
                                                                                                                                   Imaging Modalities
          Clinical Catastrophic Criteria
                                                                                                            Conventional Radiographs and Special Views
               Acuity, severity, progression, persistence,
               refractory, atypical or unexplained:
                                                                                                            CT: Incremental, Spiral, Angiographic
                     Critical acute symptoms (i.e., pain at rest, pain with
                     motion, immobility, subjective paresthesia)
                     Selective physical findings (diminished range of                                       US: Gray Scale, Color Doppler, Amplitude
                     motion, severe tenderness to palpation, loss of motor                                  Angiography
                     function, loss of sensation, loss of pulses, pallor,
                     presence of extensive hematoma).
                                                                                                            MR: MRI and MRA
                     Aberrant laboratory (declining Hematocrit, aberrant
                     peripheral or central pulse oximetry; plain radiographic
                     abnormalities).                                                                        Arterial Catheterization

           Div. of Emergency Medicine, UCSF                                                              Div. of Emergency Medicine, UCSF




              Universal Decision Rule in Axial and                                                                         Appendicular Skeletal Trauma
                       Extremity Injuries                                                                                               Catastrophic
                                                                                                                                     Appendicular Findings
               If focal skeletal tenderness is demonstrated, conventional
               radiographs.
                     Comparison view in children (or use of Keats).                                                                          Standard                 Advanced Imaging
                                                                                                        Clinical Information
                     CT (or MRI) for atypical, asymmetric, askew, or avulsed findings.                                                   Diagnostic Testing                Options
                     Advise patients that “occult fractures and internal derangements
                     cannot be excluded, and interval evaluation may be required.”
               Splint
                                                                                                                                                         1. Laboratory                   1. CT/CTA
                     Hard collar for cervical spine strain.                                                                Vital Signs
                     Appropriate splint for extremity injuries.
               Formal radiologic interpretation in less than 24 hours.
               Formal follow-up:
                                                                                                                               History                        2. XR                       2. MRI
                     Diminished or asymmetric range of motion in children, or
                     neurovascular compromise, concurrent orthopedic discussion or
                     consultation.
                     Instability: concurrent orthopedic discussion or consultation.
                                                                                                                           Extremity
                     Interval evaluation in adults in <7 days with appropriate specialist                                 Examination
                                                                                                                                                                                    3. Angiography
                     (e.g., orthopedist, maxillofacial, neurosurgical, or otolaryngologist).


           Div. of Emergency Medicine, UCSF                                                              Div. of Emergency Medicine, UCSF




                         Trauma: Universal Diagnostic Strategy
                                                                                                        References
                                             Catastrophic
                                               Findings
                                                                                                              1. Kernberg ME, Polevoi SK, Lewin M, and Murphy C,
                                                                                                              Catastrophic errors: algorithmic solutions, 3rd
                                                                                                              Mediterranean Emergency Medicine Conference, Nice,
          Clinical Information
                                               Standard                  Advanced Imaging                     France, September 4, 2005 (Catastrophic errors
                                           Diagnostic Testing                 Options                         evaluated in a consecutive case series of 125,000
                                                                                                              emergency room patients).
                                                                                                              2. P Jaye, ME Kernberg, and T Green, Trauma
                             Vital Signs                    1. Laboratory                     1. US           Radiology, The Lancet, in press, 2007.
                                                                                                              3. Scott A. Hoffinger, Pediatric Emergency Radiology,
                                                                                                              Topics in Emergency Medicine, (ME. Kernberg, MD,
                                                                                                              Editor), 2004
                                 History                        2. ECG                      2. CT/CTA
                                                                                                              4. Radiation Risks and Pediatric Computed Tomography
                                                                                                              (CT): A Guide for Health Care Providers, National Cancer
                                                                                                              Institute (USA) and Society for Pediatric Radiology, 2002
                             Physical                                                                         (modified for Table 1).
                                                                                                              5. Weissleder R, Rieumont MJ, and Wittenberg J, Primer
                                                                3. XR                        3. MRI
                            Examination
                                                                                                              of Diagnostic Imaging, MGH, 1997
           Div. of Emergency Medicine, UCSF                                                              Div. of Emergency Medicine, UCSF




Emergency Chest Radiology
                               Discussion Slides                        After a closed head injury, with transient loss of
                                                                        consciousness, a 2 year old female infant has
                                                                        persistent nausea and vomiting. Imaging should
                                                                        include:
               1. Craniofacial                2. Appendicular           1.     None
                     Nexus rules              skeleton
                     Canadian c-spine rules     Ottawa rules            2.     Skull films
                     Head CT scanning              Ankle
                                                                        3.     Head CT scan
                                                   Knee
                                                   Hip                  4.     Head MRI
                                                   Pelvis
                                                   Shoulder
                                                   Other lumbo-sacral
                                                   spine


           Div. of Emergency Medicine, UCSF                             Div. of Emergency Medicine, UCSF




Emergency Chest Radiology

				
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