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What to order, When

dr. Rima Zakiyah SpRad


Emergency Radiology

Important !!
What are the different Radiological
investigation to order In different
Emergency situations
Emergency Radiology
• Common Topics
- CNS Emergencies
- Face & Neck Emergencies.
- Spinal Emergencies.
- Chest Emergencies.
- Cardiovascular Emergencies.
- Abdominal Emergencies.
- Gynecological & Obstetrical emergencies.
- Male Genitourinary Emergencies.
- Pelvis
- Extremities
- Pediatric Emergencies
Emergency Radiology
1. CNS Emergencies:
- Skull Fractures
- Hemorrhage: (Traumatic-Non Traumatic)
• Extra-axial
• Parenchymal
- Cerebral infarction.
- Spinal trauma.
Emergency Radiology
CNS Emergencies:
- Skull Fractures:
- What to order:
• Plain X-ray of the skull (lateral view - AP)
• Computed tomography of the Brain (Axial -
Coronal) (bone window)
- When:
• History of trauma - evident injury of the
scalp
- Findings:
Skull Fractures (Plain X-ray)
Skull Fractures (Plain X-ray)
Skull Fractures (CT Scan)

Bone window
Skull Fractures (CT Scan)

Soft tissue window


Skull Fractures (CT Scan)
Skull Fractures (CT Scan) 3D Reconstruction
FACE (3D Reconstruction)

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Emergency Radiology
CNS Emergencies:
- Hemorrhage: Traumatic - Non Traumatic
- What to order:
• Computed tomography (CT) of the Brain
(Axial)
- When:
• Head trauma - focal neurological defect.
- Findings:
Emergency Radiology
• CNS Emergencies:
- Hemorrhage: Traumatic
- Findings in:
• Extra Dural Blood
• Subdural Blood.
• Cerebral contusion.
Traumatic Extradural Hematoma (CT Scan)
Traumatic Subdural Hematoma (CT Scan)
Traumatic Cerebral Contusion (CT Scan)
Traumatic Cerebral Contusion (CT Scan)
Emergency Radiology
• CNS Emergencies:
- Hemorrhage: Non - Traumatic
- Findings in:
• Subarachnoid Blood
• Intraparenchymal Blood.
• Intraventricular Blood
Intraparenchymal Hemorrhage (CT Scan)
ICH, SAH (CT scan) Angiografi
IVH (CT scan)
Emergency Radiology
• CNS Emergencies:
- Cerebral infarction:
- What to order:
• Computed tomography (CT) of the Brain
(Axial)
• Magnetic Resonance Imaging (MRI) : DWI
- When:
• Focal neurological defect -Stroke
- Findings:
Cerebral infarction (CT Scan)
Cerebral infarction (CTScan, Angiography)
Cerebral Infarction (CT Scan)
Cerebral Infarction (MRI, DWI)
Emergency Radiology
2. Face Emergencies:
- Facial Fractures
• Orbit - Zygoma - Maxillary - Frontal - Nasal
- Soft tissue injuries of the orbit
• FB - occular injuries
Emergency Radiology
Facial fractures:
- What to order?
• Plain X-ray of the Skull (Lateral view - PA
view)
• Computed Tomography of the facial bones
(Bone window-Axial & coronal-3D recon.)
- When?
• History of trauma to the face -disfigurement
-Severe facial contusions
- Findings
FACIAL FRACTURE (SKULL AP/LATERAL)
Fracture Maxilla (CT Scan)
Fracture Maxilla, Mandible, Zygoma (CT Scan)
Fracture Mandible (Plain X-ray, Panorama)
Emergency Radiology
Orbital Injuries:
- What to order?
• Plain X-ray of the Skull (Lateral view - PA
view)
• Computed Tomography of the Orbit (Axial &
Coronal - Bone & Soft tissue settings)
- When?
• History of trauma to the orbit - History of FB
to the eye
- Findings
Blowout fracture (CTscan)
Foreign Body of the Orbit (CT scan)
Emergency Radiology
3. Spinal Emergencies:

- Trauma
• Vertebral fracture (Varieties)
• Spinal cord injuries.
Emergency Radiology
Spinal trauma:
- What to order?
• Plain X-ray of the spine (Lateral view - AP
view)
• Computed Tomography of the Spine (Axial -
Bone & Soft tissue settings-3D recon.)
• MRI of the spine. (for cord injury)
- When?
• History of trauma - Falling from height.
- Findings
Lumbar Spine Fracture (Plain X-ray)
Cervical Spine Fracture (Plain X-ray, CT scan)
Cervical Spine Fracture (CT scan)
Cervical Spine Fracture (MRI)
Emergency Radiology
4. Chest Emergencies:
- Chest Trauma
• Rib fractures - Traumatic Hemothorax
pneumothorax - pneumomediastinum
pulmonary contusion, laceration
hematoma - Esophageal injury
diaphragmatic injury - etc.
- Airway Foreign Body.
Emergency Radiology

Chest trauma:
- What to order?
• Plain X-ray of the Chest (PA view - Lateral view)
• Computed Tomography of the Chest
• Angiography (Aortography)
- When?
• History of trauma - Difficulty of breathing.
- Findings
Multiple Ribs Fracture (Plain X-ray)
Pneumothorax (Plain X-ray)
PASIEN DENGAN SESAK SPONTAN POST TRAUMA
Pneumothorax, Lung Contusion (CT Scan)
Hemopneumothorax (Plain X-ray)
Hemopneumothorax, Lung Contusion, Fracture ribs (Plain X-ray)
Diaphragmatic Rupture (Plain X-ray - Contrast Meal)
Tracheal injury (CT scan)
Emergency Radiology
FB of the Airway:
- What to order?
• Plain X-ray of the Chest (PA view - Lateral
view)
• Computed Tomography of the Chest
- When?
• Children - Bad Habits - Unconscious
patient.
- Findings
FB of the Airways (Plain X-ray)
FB of the Airways (Plain X-ray)
FB of the Airways (Plain X-ray)
Emergency Radiology
5. Cardiovascular Emergencies:
- CHF
- Pericardial effusion
- Aortic dissection, trauma.
- Pulmonary Edema
- Pulmonary Embolism.
- Peripheral ischemia (acute)
-DVT
Emergency Radiology
CHF:
- What to order?
• Plain X-ray of the Chest (PA view - Lateral
view)
• Echocardiography
- When?
• Dyspnea - signs of low cardiac output.
- Findings
CHF (Plain X-ray)

CARDIOMEGALI
EDEMA PARU / BUTTERFLY APPEARANCE
Emergency Radiology
Pericardial effusion:
- What to order?
• Plain X-ray of the Chest (PA view - Lateral
view)
• Echocardiography
- When?
• Chest pain - friction rub - faint heart sounds
on auscultation.
- Findings
Pericardial Effusion (Plain X-ray)
Pericardial Effusion (CT scan)
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Emergency Radiology
Aortic dissection:
- What to order?
• Plain X-ray of the Chest (PA view-Lat. view)
• CT scan.
• MRI
• Aortography
- When?
• Sudden severe tearing substernal chest
pain.
- Findings
Aortic Dissection (CT scan)
Aortic Dissection (Angiography)
Emergency Radiology
Acute peripheral ischemia:
- What to order?
• Arteriography
• Color doppler Ultrasound (chronic)
- When?
• Sudden onset of severe pain, coldness,
numbness or pallor in a portion of an
extremity.
- Findings
Acute Peripheral Ischemia (Angiography)

Complete occlusion of popliteal artery


Emergency Radiology
• DVT (Deep Vein Thrombosis):
- What to order?
• Color Doppler Ultrasound.
• Venography
- When?
• Asymptomatic - pain - edema -
discoloration.
- Findings
DVT (ColorDoppler)

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Emergency Radiology
6. Abdominal Emergencies:
- Abdominal Trauma
• Hemoperitonium
• Visceral injuries (Liver, Spleen, Kidney, UB,
etc.)
- Non-Traumatic emergencies.
• Intestinal obstruction, Appendicitis, GUT
perforation
• Ascites, Jaundice, peritonitis, GI bleeding
Emergency Radiology
Abdominal trauma:
- What to order?
• Chest & Abdominal radiographs.
• Ultrasound (FAST)
• CT scan
• Arteriography.
- When?
• History of trauma to the abdomen - Motor
vehicle accidents.
- Findings
Abdominal Trauma (Plain X-ray, US)
Abdominal Trauma (CT scan)
Abdominal Trauma (CT scan, Ultrasound)
Emergency Radiology
Miscellaneous Abdominal Emergencies:
Intestinal Obstruction
- What to order?
• Abdominal radiograph.
• CT scan
- When?
• Crampy abdominal pain - nausea &
vomiting - abdominal tenderness.
- Findings
Intestinal Obstruction (Plain X-ray)
Intestinal Obstruction (Plain X-ray, CT scan)
Emergency Radiology
Miscellaneous Abdominal Emergencies:
Gut Perforation (e.g. Perforated
DU/duodenal ulcer)
- What to order?
• Abdominal radiograph (Erect).
• US
- When?
• History of peptic ulceration - signs of
peritonitis.
- Findings
Perforated Gut (Plain X-ray)
Perforated Gut (Plain X-ray)
Emergency Radiology
Miscellaneous Abdominal
Emergencies: Jaundice
- What to order?
• Ultrasound
• CT scan
• Percutaneous transhepatic cholangiography (PTHC)
• Endoscopic retrograde cholangiopancreatography
(ERCP)

- When?
• Yellowish discoloration of the skin - dark urine -pale
stools
- Findings
Obstructive Jaundice
(ERCP, PTC)

Endoscopic Retrograde
Cholangiopancreatography

Percutaneus Transhepatic
Cholangiography
Emergency Radiology
Miscellaneous Abdominal Emergencies:
Appendicitis:
- What to order?
• Abdominal radiograph.
• Ultrasound
• CT scan
- When?
• Sudden onset of epigastric pain - rebound
tenderness.
- Findings
Appendicitis (Plain X-ray)
Appendicitis (Plain X-ray, US)
Emergency Radiology
• Miscellaneous Abdominal Emergencies:
• Cholecystitis:
- What to order?
• Ultrasound
- When?
• Sudden onset of epigastric pain -
rebound tenderness.
- Findings
Cholecystitis (Plain X-ray, US)
Emergency Radiology
7. Genitourinary Emergencies:
- UT stones
- Hematuria
- Urinary tract trauma.
- Urethral Injuries, stones (male)
- Scrotal injuries, swellings, testicular
torsion, epididymitis (male)
Emergency Radiology
Ureteric Stones (Renal Colic):
- What to order?
• Plain X-ray of the urinary tract (PUT)
• Ultrasound
• Intravenous Urography (IVU)
• CT of the abdomen
- When?
• Sudden onset of loin pain radiating to the
groin.
- Findings
Ureteric Stones (Plain X-ray, IVU)
Ureteric Stones (IVU)
Emergency Radiology
Hematuria (Painful - Painless):
- What to order?
• Plain X-ray of the urinary tract (PUT)
• Ultrasound
• Intravenous Urography (IVU)
• CT of the abdomen
• Cystoscopy
- When?
• Passage of blood or blood clots with urination (either
painful or painless).
- Findings
Renal Stones (Plain X-ray, IVU)
Urinary Bladder Stones (Plain X-ray)
Renal Mass (US, CT)
VU Mass (IVU, CT, US)
Emergency Radiology
Urinary tract trauma (Renal - Urinary Bladder -
male urethra):
- What to order?
• Plain X-ray of the urinary tract (PUT)
• Ultrasound
• Intravenous Urography (IVU)
• CT of the abdomen
• Ascending urethrocystography
- When?
• History of blunt trauma to the abdomen - Falling astride.
- Findings
Renal Trauma (CT)
Renal Trauma (CT)
Extraperitoneal bladder rupture
(ASCENDING CYSTOGRAPHY)
VU Rupture (Ascending cystogram, CT)
Urethral Trauma (Ascending Urethrogram)
Emergency Radiology
• Scrotal emergencies:
- What to order?
• Ultrasound with color Doppler.
-When?
• Acute scrotal pain - trauma to testis.
- Findings
Testicular Torsion (Doppler US)
Acute Epididymo-orchitis (US)

Norma! testis

Enlarged tail of epididymis


with increased vascularity
on color doppler
Testicular Trauma (US)
Emergency Radiology
8. Gynecological & Obstetric Emergencies:
- Ovarian Torsion - P I D
- Abortion
- Ectopic pregnancy
- Placenta Previa
Emergency Radiology
Gynecological emergencies:
- What to order?
• Ultrasound (Color Doppler)
-When?
• Lower abdominal pain - fever - vaginal
discharge
- Findings
Ovarian Torsion (US)
Emergency Radiology
• Obstetric emergencies:
- What to order?
• Ultrasound (Color Doppler)
-When?
• Bleeding in early / late pregnancy.
- Findings
Viable Fetus (US)
Non Viable Fetus (US)
Incomplete Abortion (US)
Blighted Ovum (US)
Ectopic Pregnancy (US)

Fetus located superior to


uterus
Retroplacental Hematoma, Placenta Previa (US)
Emergency Radiology
9. Musculoskeletal Emergencies:
- Upper & lower extremities Fractures &
dislocations
- Pelvic Fractures.
- Joint injuries
- Ligaments and tendons injuries.
Emergency Radiology
• Musculoskeletal emergencies:
- What to order?
• Plain X-ray.
• CT scan.
• MRI
-When?
• History of trauma.
- Findings
Fracture Both bones forearm (Plain X-ray)
Fracture dislocation of the elbow (Plain X-ray)
Fracture neck humerus (Plain X- Ray)
Fracture Pelvic Bone (CT)
Emergency Radiology
10. Pediatric Emergencies:
- Neonatal emergencies (intestinal
obstruction )
- Intusussception.
- Foreign body aspiration.
- Bone injuries.
Neonatal Intestinal Obstruction
(Contrast)

Duodenal atresia dan Ileal


Atresia
Intussusception (Ultrasound)

Multilayer ring sign

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