EMERGENCY RADIOLOGY :

THE BASICS

Sianny Suryawati, dr., Sp.Rad

Radiology Department, Faculty of Medicine

Wijaya Kusuma University
Surabaya
2016
 STUDY OBJECTIVES

• Basic physics of different modality, especially plain

radiography, US and CT
• Advantages and limitation of each modality
• Basic rules in requesting radiology examinations
• Basic principle of picture archiving communication
systems (PACS)
• Current and future trends in radiology
• Standards of practice and guidance for trauma in
radiology in severely injured patients
 BASICS : PLAIN FILM RADIOGRAPHY

• Plain film radiography uses x-ray as a source to create

an image on the scressn, and projected as a hard-copy
image or into a computer.
• It is a 2D image of a 3D object (human organs), this
should be kept in mind and there is extensive
overlapping structures in plain film radiographs.
• This issue is resolved by …
 Do at least 2 views perpendicular to each other; for example,
chest x-ray in PA and lateral views
 Do a cross-sectional imaging such as CT, MRI or ultrasound to
overcome the overlapping.
 BASICS : PLAIN FILM RADIOGRAPHY

There are 5 relative different radiodensities in medical x-

ray. This is presented from the least dense to the most
dense particles (dark to bright)

Density Appearance
Air least Dark
Fat Less dark, but still dark
Soft tissue Medium
Bone Bright
Metal most Brightest
 BASICS : PLAIN FILM RADIOGRAPHY

• Projections (views) of
radiograph determined by
 location of the x-ray tube
and the x-ray film in
relation to the patient’s
anatomy.

For example, Postero-anterior (PA) view

means the x-ray beam travels from back
to front of the patient and hit the film in
the front of the patient.
The difference between PA and AP, is
the organ (or part of the body) that is
closer to the film, will be better
visualized.
For example, in PA skull radiograph,
the lesion in frontal bone will better
visulaized than in occipital bone.
In chest radiograph, different
magnification causes the cardiac
silhoutte to be larger in AP projection.
The rule is ‘put the film on the side of
interest’.
Chest x-rays of the same patient
performed in the same day, in two
different projections (above; PA, below;
AP).
 BASICS : PLAIN FILM RADIOGRAPHY

• Projections (views) of radiographs determined by

 Position of the patient : this will define the heaviness of
movable substances in our body. Air goes up against the
gravity, free fluid follows the gravity.
 Right/left decubitus : Right lateral decubitus is putting the
right side of the patient down. This is still a frontal (AP or
PA) radiograph.
 Lateral crosss-table : A lateral projection that is taken across
the side of the patient when he/she is on the bed.
 BASICS : PLAIN FILM RADIOGRAPHY

• Protable radiograph :
 The only indication is when the patient is
“too sick to leave the bed”. Example – ICU
patients, injured patients on the trauma
board or in the operating rooms.
 Cons : Different magnificantion (distortion of the size of
organs), decreased quality of the images.
 Usually it is done in AP projection, which is still different
from AP projection performed in the radiography room.
 BASICS : PLAIN FILM RADIOGRAPHY

• Stress radiograph :
 Put a stress (either patient’s
own weight, force or extra
weights to carry) on specific
organs, usually joints.
 For example,
acromioclavicular joints
radiograph, standing knee
radiograph, flexion/extension
views of the cervical spine.
 BASICS : COMPUTED TOMOGRAPHY

• There is no superimposition in CT.

• CT gives more information on different tissue density.
• CT works by :
 Passing a thin x-ray beam through the body of the patient in
the axial plane, as the x-ray tube moves in a continous arc
around the patient.
 The opposite side of the x-ray tube are electronic detectors.
The detectors converted the exit beam into electronic signals.
 The signals are sent to the computer, which calculates the x-
ray absorption values and arrange the image.
 BASICS : COMPUTED TOMOGRAPHY

• Hounsfield unit (HU) = the absorption value of x-ray

beam in the tissue.
 Water is assigned the value of zero.
 Approximate HU for fluid 0-20 HU, acute blood 40-60 HU
 Denser value (white) ranges upward to bone, and metal.
 Less dense value (darker) ranges downward through fat to air.
 The picture is produced equivalent to a radiograph of that
cross-sectional slice of patient.
 BASICS : COMPUTED TOMOGRAPHY

• CT ‘window’
 Different windowing in CT allows optimal evaluation of each
organs; e.g. subdural window (for subdural blood), brain
window (for brain parenchyma), bone window (for bone), etc
 BASICS : COMPUTED TOMOGRAPHY

• CT protocol
 Almost all CT scans were performed
in axial plane.
 These axial scans can be processed
into sagittal, coronal reformations or
others.
 View the CT scan as though you
were looking up at it from the
patient’s feet.
 BASICS : COMPUTED TOMOGRAPHY

• Reformatted CT images
 The CT scanner computer or a
separate computer can stack a
series of CT slices on top of one
another, so the stack can be sliced
in other planes such as coronal,
sagittal, or oblique planes.
 The techniques are especially
useful to see pathology of the
spine, long bone,and joint.
 Coronal image are easier to
understand by clinicians.
 BASICS : COMPUTED TOMOGRAPHY

• Three-dimensional CT (3D CT)

 As explained in previous page, computer can also stack
multiple slices into 3D image of the soft tissues, bones or
blood vessels.
 Useful to provide a surgeon with the most realistic display of
the pathology, especially complex ortopedic injuries.
 BASICS : CT ANGIOGRAPHY

• Scanning when the i.v contrast bolus reaches its peak

in the vascular structures being studied (either arterial
or venous)
• Similarity with conventional angiography
 Give same information in a much less invasive way.
 Use of x-ray and i.v contrast material.
 BASICS : CT ANGIOGRAPHY

• Technical difference from CT

 Need faster scanner (helical,
multidetector)
 Need faster i.v contrast injection rate
(means larger size of the needle).
• Technical difference from
conventional angiography
 No placement of angiographic catheter
(non-invasive).
 Unable to provide treatment such as
angioplasty, stent placement, etc.
 BASICS : CT ANGIOGRAPHY
• Head-to-toe applications
 Head and neck : aneurysm, AVM,
carotid atherosclerosis, venous
sinus thrombosis, etc.
 Body : aortic dissection, pulmonary
embolism, coronary artery, renal
artery stenosis, deep vein
thrombosis, etc.
 Extremity : brachial, femoral
arteriogram.
• Preparation
 No oral contrast or rectal contrast
used.
 BASICS : MRI

MRI uses very powerful

magnets, ranging from 0.3 to 3
Tesla (in clinical practice)
The patient is placed in the
magnet bore, radio waves are
passed through the body in
particular sequences. The
body tissues respond by
emitting pulses, which are the
recorde by a detector, send to
computer.
 BASICS : MRI

Various body tissues emit characteristic MR signals,

which determine whether they will appear white, gray or
black on the images.
In general : Water is black on T1-WI (T1 weighted image),
white on T2-WI. Most tumors and inflammatory masses
appear white on T2-WI. Compact bone appears black in all
sequences.
 BASICS : MRI

• Advantages
 Greater differention of soft tissue structures.
 Can be acquired in any places.
 Can provide vascular study without use of i.v
contrast.
• Disadvantages
 Longer time of scanning
 Motion artifacts from respiration, cardiac pulsation
(for scanning of the chest and abdomen)
 BASICS : ULTRASOUND

• Use of high-frequency sound waves and its reflection to

create the cross-sectional images of the body
• Advantages :
 No ionizing radiation, no biological injury
 Can be acquired in any planes
 Less expensive machine and exam cost
 Can be performed at the bedside of the very sick
patients
 Provide moving images of the heart, fetus, and other
structures.
 BASICS : ULTRASOUND

• Disadvantages
 Less sharp and clear
images
 Take more time than CT
 Quality and accuracy
depending on operator’s
skills.
 Some structures such as
bone and lung cannot be
examined.
 BASICS : PACS

• Picture Archiving Communication Systems (PACS) are

computers or networks dedicated to the storage, retrieval,
dstribution and presentarion of images.
• It replaces hard-copy medical images (such as plain film
radiographs, ultrasound, CT and MRI). Radiologists use PACS to
see the images and interpret them.
• Advantages :
 Image manipulation : brightness, contrast, rotate, zoom,
measurement, etc. Better diagnostic accuracy, e.g. see through
bone in chest x-ray.
 Less storage space for hard-copy images, less risky for wrong
patient identification.
 Teleradiology.
With PACS, radiologists can ‘play’
with the images in multiple way.
For example : we can look at lung,
ribs, and spine in one chest
radiograph without difficulty.
 PREPARE YOUR PATIENTS FOR IMAGING

• Rule #1 : select the right imaging technique to answer

the specific clinical question.
 Know the indications.
 Know what to expect from each imaging modality (its limitation
and usefulness).
 Know your hospital capability (scanners, radiologist’s
preference and ability)
• Rule #2 : check the contraindication.
• Rule #3 : discuss with the radiologist(s)
• Rule #4 : prepare the patients.
 RULE #1

• The American College of Radiology (ACR) has

published ‘Appropriateness Criteria’ for imaging
investigation in various clinical settings in its websita,
http://www.acr.org/s_acr/sec.ascp?CID=1845&DID=160
50 for several years.
• This criteria has been proposed to be used by referring
physicians for a better and efficient way of choosing
the right imaging modality to answer the specific
clinical question.
 RULE #2

• CT : Contraindications
 There is no absolute contraindication if benefits weigh risks.
 X-ray related : in pregnant patients and children.
 Contrast related :
 Hypersensitivity to iodinated contrast medium.
 History of seafood allergy is NOT a contraindication to
iodinated contrast medium administration. Altough, if other
allergic disorders coexist, this will increase the chanceof
having contrast hypersensitivity.
 Asthma, allergic disoders increase risk of hypersensitivity.
 Renal failure, diabetes, current use of metformin contribute to
increased risk of contrast-related renal failure.
 RULE #2

• CT : Contraindications – What To Do ?
 Pregnancy, children other modalities (MRI, US)
 Risk of hypersensitivity
 Premedication with oral/i.v steroids
 Use non-ionic contrast medium reduces the risk of minor
reaction.
 High serum creatinine (usually defined as Cr > 1.5 in
healthy adults, lower in older individuals. Treatment protocol
varies).
 RULE #2

• MRI : contraindications
 Generally, MRI is very save and adverse reaction to contrast
agents are extremely rare.
 Absolute contraindications :
 Cardiac pacemakers, impanted cardiac defibrillators,
otic/inner ear/cochlear implants (depending on its
ferromagnetic status).
 Pregnancy : No known risks, however, late effects on fetus
may be unrealized since MR has been widely available for
only 15 years. Gadolinium is not FDA-approved during
pregnancy.
 RULE #3

• Know your radiologist

• Communication is the key. Two-way communication between
clinicians and radiologist is encouraged for a better patient care.
• Having radiologist in the emergency department will make a
difference.
 There is a different nature of ‘emergency radiology’ from other
radiology subspecialities.
 Safe, fast, effective radiology protocols.
 Supervision of the technical performace of imaging.
Performing bedside procedures.
 Timely interpretation of the images.
 Better communication with the emergency physician.
 RULE #4

• Prepare the patients

• Plain radiography and CT
 All sexually-active women must be checked for potential
pregnancy.
 If i.v contrast will be used :
 Serum creatinin is mandatory in patients of old age, history
of kidney disease, diabetes, hypertension.
 History of previous hypersensitivity reaction or allergy
disease. For diabetics, metformin use must be checked.
 If oral or rectal contrast will be used :
 If bowel perforation is suspected, use water-soluble
contrast.
 RULE #4

• Prepare the patients

 Ultrasound
 Depending on the type of exams : fasting, full bladder may
be needed.
 Make sure there is no obstructing object at the area of
interest (such as bandage)
 MRI
 Complete MRI request checklist
 There might be a need for sedation in children and
claustrophobic patients.
 WHAT TO EXPECT

• Increased volume of patients through emergency

department.
• Increased volume of radiologic procedures in the
emergency department.
• Increased use of advanced imaging technique for
noninvasive diagnosis and treatment.
• Modern ED incorporates emergency radiology (plain
film radiography, ultrasound and CT) as a subsection.
The ultramodern ED will have MRI.
 EMERGENCY IMAGING

• Radiographs of the chest, pelvis, C-spine, and FAST are

adjuncts to the primary survey.
• Imaging is considered helpful but should be used judiciously
and should not interrupt or delay the resuscitation process.
When appropriate, radiography may be postponed until the
secondary survey.
• CXR-Chest radiograph must be obtained to document the
position of tubes and lines and to evaluate for pneumothorax
or hemothorax and mediastinal abnormalities
• AXR or pelvic X Ray are usually irrelevant if patient is going
in for CT.
 EMERGENCY IMAGING

• CT, contrast studies, and radiographs of the thoracic

spine, lumbar spine, and extremities are also adjuncts
to the secondary survey.
• The British Orthopaedic Association and British Society
of Spine Surgeons do not recommend plain films of the
C-spine in a severely injured patients and their
standard of practice is CT.
• Cervical spinal injury precautions and pelvic binders
should remain in place until the MDCT has been fully
assessed
 BLUNT TRAUMA : THORAX

• A chest radiograph must be obtained to document the position of

tubes and lines and to evaluate for pneumothorax or hemothorax
and mediastinal abnormalities.
• When not obtained in the primary survey, it should be done in the
secondary survey.
• A CT of the chest is considered an accurate screening method for
traumatic aortic injury. If a contrast enhanced helical CT is
negative for mediastinal hemorrhage and aortic injury, no
additional diagnostic imaging is necessary.
• Although it is recognized that the severity of pulmonary contusions
does not correlate very well with the chest radiograph, a CT for the
evaluation of pulmonary contusion is not mentioned.
• The superiority of CT in the detection of pneumothoraces and
evaluation of the position of chest tubes is not stated
 BLUNT TRAUMA :
ABDOMEN

• FAST is used in hemodynamic abnormal patients as a rapid, non-

invasive, bedside, repeatable method to document fluid in the
pericardial sac, hepato-renal fossa, spleno-renal fossa, and pelvis
or pouch of Douglas.
• An abdominal CT is the most sensitive and specific investigation
for the diagnosis of visceral and vascular injury.
• According to the ATLS® manual, an upper GI contrast study is the
imaging method of choice in suspected diaphragm rupture. CT is
not mentioned as an option. On the contrary, MDCT has the
advantage that it is much easier and quicker to perform in trauma
patients
 FOCUSED ABDOMINAL SONOGRAPHY IN
TRAUMA (FAST)

FAST is used to demonstrate :

• Intra-abdominal
hemorrhage
• Solid organ injuries -
spleen, liver, kidney
• Pericardial effusion
 BLUNT TRAUMA : PELVIS

• It is recommended that a pelvic radiograph should be

performed when the mechanism of injury or the physical
examination indicates the possibility of a pelvic fracture.
• Compared to conventional radiography, CT has a higher
sensitivity and specificity for the diagnosis of pelvic
fractures, and MPRs can be used to delineate the full
extend of the fracture
• In a hemodynamically abnormal patient with a pelvic
fracture and no indication for intra-abdominal hemorrhage
on FAST or DPL, angiography with embolization is advised
preceding surgical pelvic fixation.
 BLUNT TRAUMA : PELVIS

• In patients with an unstable pelvic fracture, inability to void, blood

at the meatus, a scrotal hematoma, perineal ecchymoses, or a
high-riding prostate, there is a suspicion of a urethral tear, and in
these patients, a retrograde urethrogram should be performed
before inserting a urinary catheter.
• To exclude an intraperitoneal or extraperitoneal bladder rupture in
patients with hematuria, a conventional or a CT cystogram can be
performed
 BLUNT TRAUMA : CERVICAL SPINE

• Cervical spine radiographs are not indicated in patients who are

awake, alert, sober, neurologically normal, have no neck pain or
midline tenderness, can voluntary move their neck from side to
side, and flex and extend without pain.
• In all other patients, a lateral, AP, and open-mouth odontoid view
should be obtained.
• On the lateral view of the cervical spine film, the base of the skull
to the first thoracic vertebra must be assessed
• All suspicious areas and all not adequately visualized areas, an
axial CT with 3-mm intervals should be obtained.
 BLUNT TRAUMA : CERVICAL SPINE

• To detect occult instability in patients without an altered

level of consciousness, or those who complain of neck
pain, flexion-extension radiographs of the C-spine may
be obtained.
• Performing a CT first to exclude osseous injury or a
magnetic resonance imaging (MRI) for the detection of
ligamentous injury should be recommended today
• MRI is recommended in patients with neurological
deficits to detect an epidural hematoma or a traumatic
herniated disc.
 BLUNT TRAUMA : HEAD

• A cranial CT should be considered in all head-injured

patients with:
 focal neurologic deficit of which the cause can be
localized in the brain,
 Glasgow coma scale less than 15,
 amnesia,
 loss of consciousness of more than 5 min,
 or severe headaches.
 PENETRATING TRAUMA : CHEST

• Pneumothorax and hemothorax can be diagnosed with

a chest radiograph.
• Even in patients with a normal chest radiograph, a CT
is advocated for the evaluation of heart, pericardium,
and great vessels in patients with a suspicion of
mediastinum transversing injury.
• For the heart and pericardial sac, a CT can be replaced
by ultrasound, and for the major vessels, an
angiography can be performed.
 PENETRATING TRAUMA : CHEST

• For the evaluation of oesophageal injury,

esophagography using a water-soluble contrast agent
and complementary esophagoscopy should be
performed.
• The trachea and bronchial tree can be evaluated by
bronchoscopy.
• Patients with penetrating injury of the lower chest
below the transnipple line anterior and the inferior tip of
the scapula posterior are considered to have
abdominal trauma as well until proven otherwise
 PENETRATING TRAUMA : ABDOMEN

• A hemodynamically abnormal patient with a penetrating

abdominal wound does not need diagnostic imaging
but should undergo laparotomy immediately.
• In a hemodynamically normal patient, an upright chest
radiograph can document intraperitoneal air and is
useful to exclude hemothorax or pneumothorax.
• An abdominal radiograph (supine, upright, or lateral
decubitus) may be useful in hemodynamically normal
patients to detect extra-luminal air in the
retroperitoneum or free air under the diaphragm.
 PENETRATING TRAUMA : ABDOMEN

• In all patients with penetrating abdominal injury, an

emergency laparotomy is a reasonable option,
especially in patients with gunshot wounds.
• In initially asymptomatic patients with a lower chest
wound or injuries to the back or flank, the ATLS®
considers double or triple contrast CT, DPL, and serial
physical examination less invasive diagnostic options,
equivalent to each other.
 CURRENT TRENDS IN ED RADIOLOGY

• Total body CT scan for multiply injured patients : Scanning

from head down to pelvis in one pass, allowing rapid and accurate
diagnosis of multiple organ injuries ranging from brain, chest,
abdomen/pelvis, spine from cervical down to thoracolumbar
region.
• Polytrauma protocol MDCT is indicated when :
 There is hemodynamic instability
 The mechanism of injury or representation suggests that there
may be occult severe injuries that cannot be excluded by
clinical examination or plain films
 If plain films suggest significant injury, such as pneumothorax,
pelvic fractures
 Obvious severe injury on clinical assessment
 CURRENT TRENDS IN ED RADIOLOGY

• Stroke protocol : optimized protocol for rapid stroke

diagnosis, diagnosis of ‘salvageable’ brain for potential
anticoagulation treatment or interventions.
• Cervical spine CT for trauma : more accurate and
faster than plain film radiography.
• Chest CT to rule out PE : Historically difficult
diagnosis becomes easier in seconds of MDCT
scanning.
 CURRENT TRENDS IN ED RADIOLOGY

• Stone protocol abdomen CT : More accurate than

plain film radiograph, faster than IVP and most
importantly, MDCT detects alternative diagnosis such
as appendicitis, gynecologic conditions, etc.
• Bone CT with 3D reformation for complex fractures
: Help in orthopedic treatment planning such as
fractures of the acetabulum or tibial plateau.
 CURRENT TRENDS IN ED RADIOLOGY

• Interventional radiology :
• The role of IR in the severely injured patient is to stop
hemorrhage as quickly as possible
• The decision on whether a patient with traumatic
hemorrhage undergoes endovascular treatment, open
surgery, a combination of the two or non-operative
management is typically a decision made by both the trauma
team leader and interventional radiologist after consultation.
• Interventional treatment modalities include Balloon
occlusion, transarterial embolization to stop hemorrhage.
 NO IMAGING !

There may be circumstances where imaging is

inappropriate; for example, where a severely injured
patient is admitted with profound shock, is not responding
to intravenous fluids and the site of bleeding is clear from
the mechanism of injury and rapid assessment.
Such patients may be best taken straight to theatre.
 NEW TRENDS IN RADIOLOGY

• CT colonography (Virtual colonoscopy)

• CT bronchography (Virtual bronchoscopy)
• Coronary calcium scoring
• Coronary CT angiography
• Fusion PET-CT (Positron emission tomography-
computed tomograph)
• Functional MRI
• Molecular imaging
 HOW RADIOLOGY EFFECTS PATIENT CARE

• Pros :
 Help in clinical decision making, ‘ surgical vs medical’ issue
 Triage patients toward proper areas (discharge, observation
unit, surgery or admission)
 Fast, accurate, noninvasive diagnosis
 This could lead to faster treatment, better outcome and an
overall better patient care.
• Cons :
 Higher cost ?
 Non-important incidental findings from CT may lead to multiple
unnecessary follow ups.
NON-ACCIDENTAL INJURY

Note massive
edema, minimally
hyperdense
subdural
hemorrhage, and
extreme mass effect
and herniation.
THANK YOU