Imagingin

Friday, 14 April 2017 4:10 PM

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Abdominal XR
Friday, 14 April 2017 11:30 AM

Abdominal Xr is of more limited value than CXR

Supine position, AP with the patient lying down on their back
Can also be taken in lateral decubitus or upright position to visualise air fluid levels
Most often used in acute abdomin

Densities
Therea re 5 main densities
Black - gas
Slightly darker gray - fat (absorbs slightly fewer xrays)
Grey - soft tissue
White - calcified structures e.g. bone
Intense, bright white - metallic objects

Things to look for in AXR - anatomy

Ribs
Vertebrae
Kidney
Spleen
Small bowel
Pelvis - wing
Sacro-pelvic joint
Sacrum
Head of the humerous
ASIS
Large bowel

The systematic approach

The right film for the right person
Right person
Name
DOB
Hispital number
Right film
Date and time of XR
ABCS approach
Technical details
Interventions
Systemic search for pathology
Abnormal opacities
A
Adequacy
Adequate penetration
Alignment
rotation
Apparatus
Sugical clips/wires or tubes
B
Bones
Head and neck of fumor
#
Pelvic ring
Pelvic wing
Paget's
C
Cartilage and joints
OA
S
Soft tissue
Work intraperitoneally to retroperitoneally to evaluate outlines of the major
abdominal organs
Gas in the stomach
Gas in the bowel
Size and ocation of livera and spleen
Bladder outline
Size and position of kidneys - T12-L2
Psoas shadow
Check the following for calcification
Rib cartilage
Blood vessel
Pancreas
Kidney
RUQ for gallbladder calculi
Common pathology

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Common pathology
Small bowel obstruction
Small bowel of loos >3cm
Valvulae conniventes
Loops of bowel are centrally located
Large bowel obstuction
Haustra
Peripheral location
Diameter of colon >5cm
Caecum >9cm

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Head CT
Friday, 14 April 2017 3:50 PM

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Head trauma
Friday, 14 April 2017 3:26 PM

This is the leading cause of death in children and young adults. Peak age 15-24 and then >50
More common in males and often caused by MVA, falls, assult, violence and sports/recreation

CT is the msot important step in evaluation for head and contiguous spine injuries
3 main windows
- Brain window
- Intermediate window to assess subdural or epdural haematoma
- Bone window to determine #

MRI

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CT Abdo
Friday, 14 April 2017 4:10 PM

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Riglers sign - double wall sign
Friday, 14 April 2017 4:23 PM

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229 AXR - diarrhoea, weight loss, lethargy and abdominal
cramps
Friday, 14 April 2017 1:57 PM

229 "This is an abdominal x-ray taken of a 40 year old lady who has been admitted through ED with a
2 week history of diarrhoea, weight loss, lethargy and abdominal cramps. Please look at this image.
Please tell me what the significant features are, whether they are normal or abnormal.

This is possibly due to colitis. Causes incl (I3NR)

Infection
Inflammation
Ischaemia
Neoplasm e.g. lymphoma
Radiation

Infectious causes
C. Difficile, campylobacter, shigella, Yersinia, E. Coli,
Fungal
Viral
Parasitic
Findings
Ascites
Inflammation of periicolonic fat
Air fluid levels

Inflammatory
UC
This can lead to toxic megacolon
AXR
Mural thickening
Thumbprinting sign - large bowel wall thickening, usually due to oedema
Note that barium enema (replaced by colonscopy) should not be performed in acute
severe colitis due to risk of perforation.
Findings - colonic mucosa
If chronic
Loss of haustral markings and luminal narrowing (lead pipe sign)
CT allows visualisation of the mucosa, colonic wall, fat halo sign and extra-colonic sx
Perforation
Abscess
MRI shows colonic wall thickening
Crohns
Thumbprinting sign
Stranding of perirectal fat
Mesenteric creeping fat
Abscess
Fistula
Rosethorn sign, coomb sign, thread of pearl sign, target sign (aph ulcer), nodular appearace
(submucosal oedema)
Toxic megacolon
Typically the transverse colon becomes dilated, at least 6cm
Loss of haustral markings
Pseudopolyps extending into the lumen
Thumbprinting sign from mucosal pedema
Pneumoperitonium if perf

Ischaemic cause

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Ischaemic cause
Causes
Arterial occusion
Atheroscleosis
Vasculitis
Emboli
Venous
Hypercoaguable state
Decreaesd cardiac output
Hypotension
CHF
MI
Arrhthymias
Others
Sickle cell
Radiation
Often presents with abdominal pain, bloody diarrhoea, tenderness, peritonitis (if necrosis or
perforation)
Distribution
SMA
IMA
watershed areas
Areeas fo the body that receive dual blood supply from the most distal branches
If systemic hypoperfusion, these areas are vlnerable to ischaemia
e.g. splenic flexture
Rectosigmoid junction
Radio
AXR
Dilatation due to ileus
Thumbprinting sign - mucosal oedema/haemorrhage leading to ischaemia
Intramural gas if necrotic
Intraperitoneal gas if perforated
CT
Segmental region of abnormality
Thickening of bowel wall
Narrowing of lumen
Submucosal oedema
Intramural or portal venous gas
Mesenteric oedema
CTA
Mesenteric artery occlusion

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 crohn
Friday, 14 April 2017 2:28 PM

eatures on barium small bowel follow-through include:

mucosal ulcers
aphthous ulcers initially
deep ulcers (more than 3mm depth)
longitudinal fissures
transverse stripes
when severe leads to cobblestone appearance
may lead to sinus tracts and fistulae
widely separated loops of bowel due to fibro-fatty proliferation (creeping fat) 2
thickened folds due to oedema
pseudodiverticula formation: due to contraction at the site of ulcer with ballooning of
the opposite site
string sign: tubular narrowing due to spasm or stricture depending on chronicity
partial obstruction
on control films presence of gall stones, renal oxalate stones, and sacroiliac joint or
lumbosacral spine changes should be sought
CT
CT examination can be carried out with both intravenous and intraluminal contrast
(positive or negative) 5:
fat halo sign
comb sign
bowel wall enhancement
bowel wall thickening (1-2 cm) which is most frequently seen in the terminal ileum
(present in up to 83% of patients) 8.
strictures and fistulae
mesenteric/intra-abdominal abscess or phlegmon formation 8
abscesses are eventually seen in 15-20% of patients 8
CT is also able to give valuable information on:
perianal disease
hepatobiliary disease
MRI
MRI enterography has no ionising radiation and an ability to evaluate both mural and
extramural involvement. It has become an increasingly important part of
management of patients with Crohn disease. MRI enteroclysis may be attempted in
select patients.
MRI enterography (MRE)
MR enterography can be a useful technique for evaluation of the bowel. Inflamed
loops of bowel demonstrate thickening and contrast enhancement.
Extramural disease is where MRI excels:
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 loops of bowel demonstrate thickening and contrast enhancement.
Extramural disease is where MRI excels:
fibrofatty proliferation:
thickening of extramural fat, which separates bowel loops
equivalent to the fat halo sign on CT
vascular engorgement: comb sign
stenoses and strictures
Coronal cine sequences (bSSFP) can also be useful in diagnosis. Inflamed loops of
bowel frequently demonstrate decreased peristalsis.
MRI enteroclysis
MRI enteroclysis requires the placement of a nasojejunal catheter through which
1.5-2 L of contrast solution (e.g. water with polyethylene glycol and electrolytes) are
injected 2.
Spatial resolution is not as good as with conventional fluoroscopic enteroclysis, and
thus minor mucosal changes are not apparent. When disease is transmural, with
cobblestone appearance, the abnormalities are evident as high T2 signal linear
regions, provided adequate distension is achieved 2.
Routine MRI
Routine MRI can also give valuable information:
perianal disease
liver disease
sacroiliac joints and spine
Ultrasound
Ultrasound has a limited role, but due to it being cheap and available and not
involving ionizing radiation, it has been evaluated as an initial screening tool for
active disease and also for follow-up and to assess complications 4,20. Typically
examination is limited to the small bowel and wall thickness assessed:
bowel wall thickness should be <3 mm
The usefulness of this finding needs to be interpreted in the context of pretest
probability (i.e. thickness of less than 3 mm helps exclude the disease in a low risk
patient, and a thickness of greater than 4 mm helps establish the diagnosis in a high
risk patient) 4. As it has difficulty examining the whole bowel, it is not appropriate as
a true diagnostic test.
On Doppler evaluation, increased SMA flow volume and decreased SMA resistive
index (SMA RI) also correlate with disease activity. Successful treatment may result in
normalization of these imaging parameters 12.
Other features on ultrasound20:
non compressible, rigid, fixed bowel wall
perienteric fluid
creeping fat - echogenic area (representing proliferation of adipose tissue that
extends around active inflammation) separating bowel loops
gut signature - lost or preserved
strictures - fibrotic (maintains gut signature) or inflammatory (loss of gut signature)
abscess
fistula
Ultrasound does of course have a significant role to play in the assessment of:
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 Ultrasound does of course have a significant role to play in the assessment of:
perianal disease: rectal ultrasound
hepatobiliary disease

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US
Friday, 14 April 2017 2:29 PM

Plain radiograph
Non-specific findings, but may show evidence of mural thickening (more common),
with thumbprinting also seen in more severe cases.
Fluoroscopy
Double contrast barium enema allows for exquisite detail of the colonic mucosa and
also allows the bowel proximal to strictures to be assessed. It is however
contraindicated if acute severe colitis is present due to the risk of perforation.
Mucosal inflammation leads a granular appearance to the surface of the bowel. As
inflammation increases, the bowel wall and haustra thicken.
Mucosal ulcers are undermined (button-shaped ulcers). When most of the mucosa
has been lost, islands of mucosa remain giving it a pseudopolyp appearance.
In chronic cases, the bowel becomes featureless with the loss of normal haustral
markings, luminal narrowing and bowel shortening (lead pipe sign).
Small islands of residual mucosa can grow into thin worm-like structures (so-
called filiform polyps)
Colorectal carcinoma in the setting of ulcerative colitis is more frequently sessile and
may appear to be a simple stricture.
CT
CT will reflect the same changes that are seen with a barium enema, with the
additional advantage of being able to directly visualise the colonic wall, the terminal
ileum and identify extra-colonic complications, such as perforation or abscess
formation. It is important to note however that CT is insensitive to early mucosal
disease 2.
Inflammatory pseudopolyps may be seen if large enough, in well distended bowel. In
areas of mucosal denudation, abnormal thinning of the bowel may also be evident 2.
A cross section of the inflamed and thickened bowel has a target appearance due
concentric rings of varying attenuation, also known as mural stratification 1-2.
In chronic cases, fat submucosal deposition is seen particularly in the rectum (fat halo
sign). Also in this region, extramural deposition of fat, leads to thickening of the
perirectal fat, and widening of the presacral space 1,2.
Strictures are also common and are not all malignant. These are predominantly due
to marked muscularis mucosa hypertrophy, which is also in part responsible for
the lead pipe sign.
Colorectal carcinoma is often sessile. Focal loss of mural stratification or excessive
mural thickness (1.5 cm) should prompt endoscopic evaluation 2.
MRI
The current status of MRI in ulcerative colitis is that of a promising, noninvasive
technique for imaging extent of more severe disease.
The most striking abnormalities in ulcerative colitis are wall thickening and increased
enhancement.
The median wall thickness in ulcerative colitis ranges from 4.7 to 9.8 mm. In general,
the more severe the inflammation, the thicker the colonic wall. A colonic wall
thickness <3 mm is usually considered as normal, 3-4 mm as a "gray zone," and >4
mm as pathological.
Enhancement of the mucosa with no or less enhancement of the submucosa
producing a low SI stripe the so-called submucosal stripe.
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producing a low SI stripe the so-called submucosal stripe.
Other features are the loss of haustral markings, backwash ileitis, mild enhancement
and no wall thickening, and there is increased SI of the pericolonic fat noted.

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230 AXR - abdominal cramps, distension and vomiting
Friday, 14 April 2017 2:29 PM

230) This is an X ray of a 71 year old man, previous laparotomy 10 years ago. Now has 24 hours of
abdominal cramps, distension and vomiting. Please look at this image. Please tell me what the
significant features are, whether they are normal or abnormal (ignore the zipper)

I suspect that this patient has a small bowel obstruction due to the presence of the imaging. The
most common cause would be fibrous adhesions due to past laparotomy, but I would also consider
other intraluminal, intramural and extramural causes.

SBO
AXR
Dilated loops of small bowel proximal to the obstruction
Central dilation of loops
Rule of 3s
3 dilations/air fluid levels
>3cm or 3mm thick
Fluid levels present if taken erect
String of beads sign - small pockets of gas within fluid filled small bowel
Presence of plicae circularis
CT
More sensitive
Whirl sign indicates volulus - there is twisting of the mesentary and superior mesenteric
vein around the SMA
If closed loop obstruction (type of SBO)
Marked distension of segments of small bowel
U or C shaped small bowel loops
Beak sign - tapering bowel loops at the point of obstrction
Whirl sign - twisting of the mesentery
Signs of ischaemia if strangulation

LBO
AXR
Transition point
Colonic distension proximal to obstruction (>6cm in colon, 9 in caecum) due to gas
producing organisms in faeces
Collapse colon distally to obstruction
May have small bowel distension depending on duration of obstruction and competence
of the ileocaecal valve
May see stigmata of ischaemic colon
Intramural gas (pneumatosis coli)
Portal venous gas
Pneumoperitoneum
CT
More accurate than AXR
Can determine transitional zone and can help determine the cause

Bowel loop
Rule of 3-6-9
3cm small bowel
6cm in colon
9cm in caecum

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231-232. CT
Friday, 14 April 2017 2:46 PM

231) What are the advantages of CT as an investigation?

High structural resolution compared to MRI/XR

Good to see bones
Relatively fast to perform (satellite CT near ED)
Can be used for intervention
Increasingly widespread access across australia
Cheaper than MRI
Can be used to 3D reconstrction
Variable slices in different planes
Sensitive for repeat assessment in emergency (e.g. trauma)
CTA less invasive than XRA
Better detail compared to US
Most systems can be scanned

232) What are the disadvantages of CT as an investigation?

Ionising radiation exposure of patient

Avoid in children and pregnancy
Risk of anaphylaxis with exposure to contrast CT
Risk of renal injury due to contrast dye
Poor soft tissue differentiation compared to MRI
More expensive than XR
Higher radiation dose compared to XR
Takes longer to complete compared to XR
Claustrophobia
Not portable
Donut of death
Requires breath holding - may not be possible with patent
Artefact is common
Can be affected by bone near by - brain CT

NOTE
Non contrast
Used for trauma, stroke, kidney stones, lung nodules, interstitial lung disease
Contrast
Used for mass evaluation, infection, angiogram, LN, CTPA, appendix, diverticulitis,
pancreatitis, triple phase for liver masses

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233. CTBrain post assault
Friday, 14 April 2017 3:47 PM

This is a CT of a young person's head, taken after an assault. Please look at this image. Please tell me
what the significant features are and whether they are normal or abnormal.

--

Things to look at in a CT ehad

Blood can be very bad
Blood
Cisterns
Brain
Ventricle
Bone

Patient details
Date performed
Orientation
Contast vs non-contrast - contast does not cross the BBB and is used if there is a suspicion of
tumour, infectio/abcess, vascular abnormalities
Blood
Look for the presence of blood - clues to the origin, duration and cuase may be indicated by
position and spread
Acute haemorrhage
White on CT (hyperdense) as it absorbs XR
As the clot retracts, it becomes more hyperdense over the first few hours up to 7
days then isodense and eventuall hypodense
Blood becomes isodense with brain over 1-4 weeks and then hypodense with
brain after 4-6 weeks
Extracerebral haemorrhage (within the skull, out of the brain)
Extradural - biconvex lesions that does not cross the suture lines. Due to arterial injury
Subdural - cresent shaped blood that can cross the suture lines due to venous disruption
of bridging vessels
Subarachnoid - haemorrhage into the CSF and cisterns due to aneurysms, trauma, AV
malformations
Intracerebral haemorrhage
Intracerebral haemorrhage due to trauma, HTN, haemorrhagic stroke
Intraventricular haemorrhage due to trauma

Cisterns
These contain CSF which surrounds and protects the brain
Examine each for effacement, asymmetry and presence of blood
Circum mesencephalic - surrounds the midbrain
Suprasella - around the circle of willis
Quadrigeminal - located at the top of the midbrain
Sylvian - between the temporal and frontal lobes

Brain
Compare the sulcal and gyri pattern fro evidence of effacement and asymmetry
Trace the falx cerebri through the series of scans looking for midline shifts secondary to
compartmental mass effect
Look for inconsistencies in the grey-white matter differentiation

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 Look for inconsistencies in the grey-white matter differentiation
Envolving embolic stroke
Those with CVA may present with normal CT on presentation
subtle oedema at 6-12 hrs
Hypoattentuation at 24hrs
Maximal oedema at 3-5 days
Look for hyperdense regions
Blood
IV contrast
Calcification
Look for hyodense regions
Air
Ischaemia
Fat
Tumour

Ventricles
Examine the lateral ventricles, 3rd and 4th ventricles for asymmetry, dilatation
(hydrocephalus), effacement and haemorrhage

Bone
Cortical bone has the highest density and best viewed on separate bony window when looking
for evidence of fractures or tumours

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244. CT Abdo Swelling and distension
Friday, 14 April 2017 4:10 PM

234 This is a CT abdomen of a 19 year old woman who has presented with a history of full
abdomen, and swelling up which has happened over several weeks. "Please look at this image.
Please tell me what the significant features are, whether they are normal or abnormal.
"

Possible diagnosis
Ascities
Budd chiari syndrome
Liver cirrhosis
Cystic fibrosis

Transudative (low protein content and cell count)

Cirrhosis
Hepatic failure
Hepatic venous occlusion
Constrictive pericarditis
Kwashiorkor
Cardiac failure
EtOH hepatitis
Liver mets

Exudative (high protein, due to inflammation)

Malignancy
Infection 0 bacterial, fungal, TB
Pancreatitis
Nephrotic syndrome
Bowel obstruction ir infarction
Bile leak

Axial - is the typical view of CTs - looking from toes to head

Sagittal - side on
Coronal - front on

Pulmonary
Each lung
Effusion
Consolidation
Congestion
Small nodules

Heart
Pericardial Effusion
Size

Solid viscera
Liver
Axial
Homogenaeity
Focal nodules/lesions
Contours
Nodular (cirrhosis) vs smooth

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 Nodular (cirrhosis) vs smooth
Lobes
Focal lesion e.g. abscess
Coronal
Liver size
CBD dilation
Portal hepatitis
Portal vein
Hepatic artery

Gallbladder
Axial
Enlarged
Fluid around it - cholecystitis
Stones
Hydropic
Dilatations
Cirrhosis or lesions
Spleen
Axial
Focla lesions
Size
Pancreas
Local lesions
Fluid - pancreatitis
Adrenal
Nodules
Renal
Hydronephrosis
Focal lesions
Cysts
Masses
Should be the same contrast phase on both sides
Ureter - follow down through axial images looking for stones, dilatations
Bladder
Lesion
Thickening of wall
Prostate, seminal vesicles

Hollow viscera
Anus, rectum, sigmoid, colon
Masses
Thickening
Colitis
Inflammation around colon
Terminal ilium, appendix
Coronal view
Stomach
Small bowel
Wall thickening
Dilatation
Mesentery - nodes >1cm short diameter

Other
Free fluid or air
Pelvis for fluid
Free air outside intraluminal space

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 Free air outside intraluminal space
Rigler's sign (double wall)
Vascular
Follow the aorta down to the external and internal iliac
Arterial - aneurysm, occlusion, calcification
Venous - thrombosis
Coeliac trunk, SMA and IMA
Abdominal wall
Internal and external oblique
Transverse abdominus
Rectus abdominus
Look for hernias or wall thinning
Bones
Ribs - fracture or lesions
Vertebrae 0 compression, lesions or aliognment
Pelvis
Head of femur
Soft tissue

Overall appearance
Impression

https://youtu.be/8b_ohOtb-KM

Pulmonary

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235. CT legs/ MVA
Friday, 14 April 2017 4:32 PM

235 This is a CT of the legs of the font seat passenger of a car involved in a high speed
accident. "Please look at this image. Please tell me what the significant features are,
whether they are normal or abnormal.

--

Dx
Tibial and both femoral bones are fractured

Things to look at on CT legs

Blood
Bone
Vasculature
Soft tissue

Anatomy
Pelvis
Hip
Femur
Tibia
Fibula
Metatarsal
Calcaneus
Tarsal bone

Types of fractures
Transverse
Linear
Oblique, non-displaced
Oblique and displaced
Spiral
Greenstick
Comminuted

Femoral neck fracture

This is common in the elderly due to falls, osteoporosis, osteomalacia etc
If in the young, suspect violent, high energy injury
The pain is usually in the hip/groin and can be referred to the knee
The leg is adducted and externally rotated if the fracture is extracapsular
Classification
Intracaspular
Subcapital or transcervical
Assessed via the garden system of scorring
This is a grade from 1-4 assessing where the fracture line is with 1
being trabecular being angulated/impacted and partial fracture and 4
being gross and complete displacement of the femoral head
Extracapsular fractures
Intertrochanteric or pertrochanteric
There is less risk of AVN
Managed by
Garden I or II - internal fixation
Garden III or IV - haemiarthroplasty due to risk of AVN
Tital hip replacement if younger patients or active >70 year olds with displaced
fracture

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fracture

Femoral shaft fracture

These are caused by a high energy injury e..g VMA or fall from a height unless
suspecting pathological fracture with osteoporisis
Can be either open or closed
Need to monitor peripheral sensation and pulses
Assess pulse
Cap refil
Temp
Colour
Sensation
Motor
Classification - Hansen Winquist
Type 1 - minmal
No or minimal comminution
Type II - <50%
Comminution. <50% cortical circumferential contact of 2 major fracture lost
Type III - >50%
Type IV - 100%
All cortical contact lost as cortex is circumferentially comminuted
Others
Segmental
Spiral

Mx
Initial
ABC, O2, IVC
Fluid replacement - aggressive with Xmatch
XR of femur, hip and knees
IV analgesia
Femoral nerve/iliaca block
Reduce and immobilise - thomas splint and skin traction, Donway splint
Gallows traction in infants
Surg
Adults - intramedullary nail for types I and II; nail and screws for III and
difficult for IV
Early mobilisation and treatement reduces risk of complications
Complication
Haemorrhage
Fat embolism
DVT/PE
Infection
Shortening
Angulation
Non-union

Subtrochanteric

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Subtrochanteric
Proximal femoral shaft at or just distal to the trochanters
Due to high energy multi-truma in younger patients or minor trauma in odlerly
Manage the same as femoral shaft
Analgesia
Splint
Ortho review

Ipsilateral fracture of femur and tibia

These are called floating knee injuries and may include combination of diaphyseal,
metaphyseal and intra-articular fractures
Risks of
Compartment syndrome
Fat embolism
Tachycardia
Tachypneoa
confusion
Loss of motion
Other injuries e..g mensici
Many are open fractures with associated vascular injuries
Needs surgical management of the fracturs with early mobilisation
Assess for ligament and meniscal injuries
Mx
Initial

Resus and haemodynamic stabilisation

Splinting of the affected limb - Thomas splint
Secondary survey to identify other injuries
Radiograph chest, abdo and pelvis and other areas of suspcision
Initial wound toilet, tetnaus immunisation and antibiotics were given for
open fractures
Plan for internal fixation if can be done without tension otherwise leave
open for secondary intention or place skin graft

Femoral neck fracture

This is common in the elderly due to falls, osteoporosis, osteomalacia etc

fract

The three most frequent sources of injury for drivers in frontal crashes were the steering
wheel, instrument panel, and seat belts. The most common severe injury/source contacts for
drivers in frontal crashes were the chest with the steering wheel, lower legs with the floor,
head with the steering wheel, thigh or knee with the instrument panel, and chest with the
belt.

For front left passengers, the instrument panel, seat belts, and the windscreen or header
were primarily involved in their injuries. For these passengers, the most frequent severe
injury and source contacts included the upper limbs with the instrument panel, the chest with
the seat belt, the thigh or knee with the instrument panel, and lower leg with the floor.

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--

1 tibia and both femors are fractured

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236. CT Abdo MVA
Friday, 14 April 2017 5:59 PM

236 This is a CT of the abdomen of the driver of a car involved in a high speed accident. "Please look
at this image. Please tell me what the significant features are, whether they are normal or abnormal.

Blunt abdominal trauma can occur from a MVA leading to multiple internal injuries

CT imaging is diagnostic tool of choice for the evaluation of abdominal injury due to blunt trauma in
haemodynamically stable patients. Blunt injuries may be masked by other injuries and as such, CT
abdomen can evaluate multiple problems at once. It can provide a rapid and accurate appraisal of
the abdominal viscera, retroperitoneum and abdominal wall. It has been reported to be valuavle for
the diangosis f solid organ injuries and for the detection of active bleeding

Haemoperitoneum and active bleeding

CT has a high sensitivity and specificity for blood in the peritoneal cavity
Haemoperitoneum starts near the site of injury and spreads along the anatomic pathway
In supine
Blood in the liver collects in Morison's pouch and passes down the right paracolic gutter
to the pelvis
Blood in the spleed passes via the phrenocolic ligament to the left paracolic gutter and
the pelvis
Blood from spleen also goes to the RUQ
The sentinel clot sign indicates adjacenmt, focal higher attenuation clotted blood as a
marker for the organ that is the cause of haemorrhage
Active haemorrhage can appear as a region of extravasated contrast material and is indicated
on a CT scan by an area of high attenuation

Splenic injury
This is the most frequently injured organ during blunt trauma
CT post power injection of IV contrast is accurate
Injuries include
Laceration
Irregular, linear region of low attenuation
Non perfused region
Intraparenchymal haematoma
Shattered spleen
Multiple hypodense areas that connect to the visceral surface
Subcapsular haematoma
It is a region of low attenuation that compresses normal splenic parenchyma
Contousion
A region of injuried tissue where blood capiliary have been ruptured
Nausea
Dizziness
Turning pale
Fast heart rate
Pain and tenderness in the left upper abdomen
Pain that moves up to your left shoulder
asymptomatic
"there are multiple poorly defined areas of decreased attenuation, they are not linear, ruling
out lacerations. This is the classic presentation of contusions
There are also rib fractures and subcutaneous emphysema due to pneumothorax

Liver injury
This is the 2nd most common injuried viscus
Elevated transaminase

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 Elevated transaminase
Injuries
Subcapsular haematoma
hypodense collection, compressing on the underlying liver parenchyma
Liver laceration
non-enhancing irregular, linear low attenuation area
associated intraparenchymal haematoma
region of decrease attenuation compared to the rest of the enhanced liver
parenchyma
Urinary injuries
Renal
Laceration
Haematoma
Subcapsular haematoma of the right kidney (arrows) appears on CT as a
superficial, crescentic, low attnuation area that compresses the adjacent renal
parenchyma
Perinephric collections
Bladder
CT cystography with retrograde bladder filling
Ruptures
extravasation of contrast in the perivesical fat indicating an extraperitoneal
bladder rupture.
extravasation of contrast from a urinary bladder injury, which outline the bowel
loops (arrows). This indicates an intraperitoneal bladder rupture
Fracture of pelvis

Pancreas
More common in younger adults/children
Initially may be normal due to elastic pancreatic parenchyma but a repeat at 24-48hrs can help
reveal evolving injuries
Can lead to pancreatitis, pseudocyst, fistula or abscess
Injury
Transections

Bowel and mesentery

Focal bowel wall thickening
Mesenteric infiltration
Free airintraperitoneal fluids without solid organ injuries
Extravasated contrast
Perforated bowel
extraluminal air with focal bowel wall thickening
air pockets in the urinary bladder suggesting bladder perforation
Small bowel perforation
focal small bowel thickening

Retroperitoneum, spine and abdominal wall, lower chest

anterior displacement of the right kidney by a retroperitoneal haemorrhage
Soft tissue injury
Haematoma
Thickening of the abdominal wall
Lung contusions and laceration

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238-239 MRI
Saturday, 15 April 2017 12:41 AM

238) What are the advantages of MRI as an investigation?

Good soft tissue differentiation compared to the CT esp in the brain, spinal cord, joints
Excellent detail esp neural tissue
No radiation
High resolution, like CT
Variable slices can be made in different planes
3D construction
Angiography is not invasive
The contrast (gadolinium) is less allergenic than iodine based in CT. also not nephrotoxic and
safe for childrens
Special tests e.g. for Parkinsons
Some angiographic material can be obtained without contrast
Advanced techniques such as diffusion, spectroscopy and perfusion allow for precise tissue
characterisation rather than merely 'macroscopic' imaging
Functional MRI allows visualisation of both active parts of the brain during certain activities
and understanding of the underlying networks
Painless
Non-invasive
Can help diagnose and guide treatment for a wide range of conditions

239) What are the disadvantages of MRI as an investigation?

Poor for gas filled organs and for bones (bone and air not good)
Takes longer to perform than CT
Less useful in emergencies, young people, elderly, confused or disabled
Contracindications
Cardiac pacemakers
Cochler implants
Shrapnel injuries
Metallic FB in orbit
Prosthesis
Relative contraindications
Stents
Mechanical valves
Aneurysmal clips
Should only be used in pregnancy if essential
Risk of fetus not known
May cause teratogenesis and acoustic damange
Claustrophobia, tight, noist
Limited access if the patient deteriorates and need a non-metallic resuscitation equipment
expensive
Not available at all hospitals
May not be available out of hours
Expensive
Images subject to unique artefact that must be recognised and abated
Anaesthesia
Sslight movement can ruin the image, requiring redo
Contrast medium may be needed - renal problems, allergic

Note
The risks posed to fetus are unknown
Gadolinium based contrasts cross the placenta and thus not recommended for use
MRI to be done if risks vs benefits

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 MRI to be done if risks vs benefits
Explain to mother that safety not proven but no demonstrated adverse effects

MRI uses a magnetic property called spin. Atomic nuclei that contain an odd number of protons or
neutrons possess a magnetic moment, which describes the strength and direction of a microscopic
magnetic field surrounding the nucleus. The presence of a strong, constant external magnetic field,
such as that produced in an MRI, causes the nuclei to align themselves in the magnetic field,
producing a measurable magnetic moment. The hydrongen proton is used because of its high
abundance in the body. The fraction of protons aligned with the magnetic field can be controlled by
application of radiofrequency to induce the protons in the tissue of interest to spin at the Larmor
(resonant) frequency.The density of protons and the rate at which the magnetization returns to
equilibrium (relaxation) can then be measured to produce an image.

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240-241. US
Saturday, 15 April 2017 12:33 AM

240) What are the advantages of ultrasound as an investigation?

Can be performed on the bedside e.g. FAST scan

Allows real time assessment and dynamic imaging e.g. heart wall in echo
No radiation so safe to use in children and pregnant females
Safe in pregnancy
Can be used for screening purposes
Can be used for guiding interventions
Determines cysts vs solid lesions
Fast, easy, cheap and readily available
Disposable
Can have internal imaging - transvaginal, transoesophageal
Used quite freely for antenatal scanning and children
Safe for repeated examinations
No evidence that it breaks chromosomes, damages tissue or predisposes to malignancy
Not invasive
Painless
Cheaper - compared to MRI
More portable
Best imaging modality for soft tissue
Can be used for therapeutic use - soft tissue injury
Usually non-invasive, safe and relatively painless
Does not require injection of contrast
Can aid diagnosis of a range of conditions around the body
Abdo
Pelvis
Blood vessel
Breast
Kidney
Muscle
Bones
Joints
Can be used to check health of fetus

241) What are the disadvantages of ultrasound as an investigation?

Heavily operator dependent
The sensitivity of investigations varies widely depending on the skill of the
ultrasonographer
Quality and interpretation skills
Acoustic shadowing preventing visibility beyond bone e.g. calculi, ribs
Presence of air and calcified areas in the body (e.g. bones, plaques and hardened arteries), and
a person's body size all affect quality
Cannot penetrate gas
Depth of penetration affected by obesity
Can only see a small field
Low quality images
Can't see deep structures
The relies on reflextion of very high freqency sound waves by tissue interfaces
Increase of frequency increases resolution but decreases penetration
Normally 2.5-10MHz
May require special prep e.g. fasting or full bladder

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 237 - CXR MVA
Saturday, 15 April 2017 1:22 AM

237) This is the chest of a motorbike rider involved in a high speed accident. Please look at this
image. Please tell me what the significant features are, whether they are normal or abnormal.

Specifically looking for:

Tension pneumothorax
Lung haematoma
Rib fractures
Air under diaphragm
Immediately life-threatening injuries Potentially life-threatening injuries[23]
Airway obstruction Simple pneumo/haemothorax
Tension pneumothorax Aortic rupture
Open pneumothorax Tracheobronchial rupture
Massive haemothorax Pulmonary contusion
Flail chest Blunt cardiac injury
Cardiac tamponade Diaphragmatic rupture

Ortho
Rib fracture
These are the most common type of blunt chest injury
Can be either single or compound
Single - single break in a rib
Compound- skin is damaged and an open wound extends all the way down to fracture
site
Can risk pneumothorax if puncture lung
Managed with analgesia, surg is rarely needed
Fail chest
There are multiple fractures of the ribs or sternum resulting in a free floating unstable
segment of the chest wall
Paradoxical movement of the chest wall - in insipiration the affected area will sink while the
rest of the chest rises ditto for exhalation
Intubation may be necessary if V/Q mismatch
Regional analgesia
Calvicle fracture
Fall on an outstretched arm
Tender, crepitus, oedema, deformity
Can damage the lungs, jugular vein and subclavian
Sternum fracture

Pulmonary
Contusions
blow disrupts the microvasculature in the lung parenchyma, and blood and other
inflammatory mediators invade the tissue
Usually asymptomatic initially and as it progresses, there are crackles, dyspnoea, tachycardia
and tachypnoea
XR - opacity in the peripheral lung near the injured chest wal
May not show until 12-24hrs after the injury
Most common injury
Consolidation of the CXR
If minor, nasal prong O2; if severe, mechanical ventilation
Pneumothorax
(usually due to hitting steering wheel in MVA, leading to increased intrathoracic pressure,
while the person gasps --> no pressure relief so alveoli ruptures)
Can be either simple or tension
Simple - not life theatening and occurs when alveolar tear allows air to enter the pleural space
The air does not build up under pressure
Mild SOB
Pleuritic chest pain
Tension pneumothorax - air escapes into the pleural space under pressure resulting in lung
collapse
Trachea shift
Puts pressur on the heart -> decrease stroke volume leading to hypotension and
hypoperfusion
cyanosis, tachypnea, tachycardia (usually greater than 135 beats per minute),
paradoxical pulse (pulse that markedly decreases during inspiration), markedly
diminished lung sounds on the affected side, and hyperresonance or tympany on
percussion.
Mediastinal shift
Tracheal tug
Deviation of trachea
Mx
immediate needle decompression with a large gauge needle (ideally, 12 14
gauge) placed in the intercostal space in the midclavicular line, followed by chest
tube insertion

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 tube insertion
Cardiac
Myocardial contusions
Accumulation of blood and infalmmatory mediators in the myocardium
Risk of dysrhythmia
Need ECG
More likely to affect RV more than LV
Pericardial tamponade/aka cardiac tamponade
Occurs when blood +/- other fluids fills the pericardial sac and compresse the heart
The heart then doesn't refill sufficienty and the cardiac output rapidly drops
Beck's triad
Marked hypotension
Diminished heart sounds
Distended jugular veins
Sinus tachycardia with low voltage QRS complex
Mx
O2
IV crystalloids or bloods
Pericardiocentesis to aspirate fluids
Aortic tear
The heart is tethered by the ligamentum arteriosum to the aorta, but the rapid change on
momentum can tear it
If complete tear, exsanguination and death
skin color and temperature may differ above and below the nipple line, depending on where
the tear occurs
skin below the nipple line will generally be pale and cool or clammy; above the nipple
line, it will remain normal if the tear occurs beyond the subclavian artery
Radial and carotid pulses stronger than femoral
XR - widened mediastinum
Myocardial rupture
RV
Commotio cordis
sudden, unexpected death that occurs when a projectile, such as a baseball, strikes the
precordium during the vulnerable period of the cardiac cycle 10 to 30 milliseconds before
the peak of the T wave

CXR interpretation:
Patient Details: name, age, DOB
When was the film done? Ensure correct date, time
PA or AP film
PA film scapulae barely visible in lung fields, AP film - scapulae more visible in lung fields

Alignment look at clavicles, spinous processes of vertebrae (midline?)

Adequate exposure? Can see vertebral bodies? Need to see at least 5 ant. ribs

DRSABCD
D - details
Patient name, age, sex
Type of film - AP vs PA; erect or supine; markers; inspiratory vs expiratory
Date and time of film
R - RIPE assessment
Rotation - medial clavicle ends equidistant from spinous process
Inspiration 0 5-6 anterior ribs in MCL or 810 posterior ribs above the diaphragm
Poor or hyperexpanded
Picture - straight or oblique
Scapulae outside lung filds
Entire lung fields
Exposure - IV disc spaces, spinous process to T4
S - soft tissue and bone
Ribs, sternum, spine, clavicles symmetry, fractures, dislocations, lytic lesions, density
Soft tissues looking for symmetry, swelling, loss of tissue planes, subcutaneous air, masses
Breast shadows
Calcification great vessels, carotids

A = Airways
Trachea (deviated?), obstructions, bronchi
Deformities
Paratracheal masses
Trachea central or slightly to right lung as crosses aortic arch
Paratracheal/mediastinal masses or adenopathy
Carina & RMB/LMB
Mediastinal width <8cm on PA film
Aortic knob
Hilum T6-7 IV disc level, left hilum is usually higher (2cm) and squarer than the V -shaped
right hilum.
Check vessels, calcification.

B = Bones, Breathing (lungs)

Trace bones (including spine)
Lung fields

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 Lung fields
Consolidation? Effusion? Infiltrate? Increased markings, pneumothorax, atelectasis, pulmonary
vessels, hilar lymphadenopathy
Hyperinflation (count ribs, flattening of diaphragm)
Lung fields
Vascularity to ~2cm of pleural surface (~3cm in apices), vessels in bases > apices
Pneumothorax dont forget apices
Lung field outlines abnormal opacity/lucency, atelectasis, collapse, consolidation,
bullae
Horizontal fissure on Right Lung
Pulmonary infiltrates interstitial vs alveolar pattern
Coin lesions
Cavitary lesions
Pleura
Pleural reflections
Pleural thickening

C = Cardiac
Look at cardiac outline (obliterated by effusion? Elongated indicating hyperinflation?)
Broad mediastinum (pneumomediastinum, thymus, aortic dissection)
Cardiothoracic ratio (normal is 60% in AP view, <50% in PA)
Heart position to left, to right
Heart size measure cardiothoracic ratio on PA film (normal <0.5)
Heart borders R) border is R) atrium, L) border is L) ventricle & atrium
Heart shape
Aortic stripe

D = Diaphragm
Costophrenic angles for effusion, flattening (hyperinflation)?
Hemidiaphragm levels Right Lung higher than Left Lung (~2.5cm / 1 intercostal
space)
Diaphragm shape/contour
Cardiophrenic and costophrenic angles clear and sharp
Gastric bubble / colonic air
Subdiaphragmatic air (pneumoperitoneum)

E = Extra
Stomach bubble, equipment (ECG leads, NG tube , endotracheal tube)

Mediastinal widening
Traumatic aortic injury
Vasculature
Unfolded aorta
Double SVC
Aberrant right subclavian artery
Azygous continuation of IVC
Pneumomediastinum (gas within the mediastinum)
Lung
Atelectasis
Pulmonary masses abutting the mediastinum
LAD
Enlarged pulmonary arteries
Mediastinal lipomatosis
Mass
Anterior middle or posterior mediastinal mass
Thymus
Diaphragmatic hernia
Technical factors on CXR e.g. AP or rotaiton
Mass
Hidgkin lymphoma
Thoracic aortic aneurysm

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 Tracheal shift
Deviated towards diseased side
Atelectasis
Agenesis of lung
Pneumonectomy
Pleural fibrosis
Deviated away from diseased side
Pneumothorax
Pleural effusion
Large mass
Mediastinal masses
Tracheal masses
Kyphoscoliosis

Displacement towards the lesion Displacement away from the lesion Other displacem ent
Lobar collapse Large pleural effusion Mediastinal masses
Pneumonectomy Tension pneumothorax
Pulmonary fibrosis

In real life, there is little to no deviation of the trachea in

spontaneous pneumothorax...but for the purposes of the exam let's just go with FA. This
discussion is really technical but from what I know it has to do with intrapleural pressure
vs atmospheric pressure. Tension pneumo has a higher intrapleural pressure so that
pushes the mediastinum to the opposite side. Spontaneous has a lower intrapleural
pressure so that in theory would cause the mediastinum to shift towards the affected
side.
FA says trachea deviates to Same side of pathology in spontaneous pneumothorax whilst it
deviates to opposite side in tension pneumothorax why?

in spontaneous pneumothorax there is a rupture of the pleura > pressure equilibrates between
atmosphere and lung > the trachea deviates to the ipsilateral side

in tension pneumothorax there is a tear of the pleura forming a 1 way valve > pressure builds up in
the intrapleural space and exceeds 1 atm > the trachea deviates to the contralateral side. this can
cause compression of the other lung and lead to respiratory failure.

radiology Page 34