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Vascular Chest Emergencies

With chest pain representing one of the most common presenting symptoms in the emergency department (ED), radiologists are frequently called upon for the noninvasive evaluation of aortic and pulmonary vascular diseases. Adequate assessment relies on the ability to understand the spectrum of the pathologic conditions and the significance of each of these entities. Thoracic Aorta Anatomy The thoracic aorta begins at the level of the aortic…

Nontraumatic, Nonvascular Chest Emergencies

Use of imaging services in the emergency department (ED) continues to outpace the growth of actual ED patient visits. This imaging surge places the emergency radiologist at the forefront of acute care. Chest imaging constitutes a large percentage of examinations generated through the ED. In the time-sensitive acute care environment, efficiency is paramount; conventional radiographs are a common triage screening tool. It is not uncommon for…

Blunt Chest Trauma

Nonmediastinal Injury Chest trauma is directly responsible for 25% of all trauma deaths and is a major contributor in another 50% of all trauma mortality. Chest trauma may be blunt (90% of cases) or penetrating. Blunt thoracic injuries are the third most common injuries in polytrauma patients, following those of the head and extremity. Although 50% of blunt chest injuries are minor, 33% will require hospital…

Nontraumatic Spine Emergencies

Infection of the vertebral column represents up to 20% of all osteomyelitis and is the most common infection of the axial skeleton. The presentation is often insidious. It is not uncommon for symptoms to be present for 6 to 8 weeks before being diagnosed. If ignored or misdiagnosed, infection of the spine can have a chronic, destructive, and significantly debilitating course. The general characteristics of spinal…

Spinal Trauma

Cervical Spine Emergencies Mark Bernstein Alexander B. Baxter F.A. Mann Each year in North America approximately 3 million patients are evaluated for spinal injury. Although the incidence of vertebral fracture and spinal cord injuries is low, the consequences of a missed injury or delayed diagnosis can be devastating. Although most cervical spine fractures are localized to a single vertebra, two or three noncontiguous injuries are often seen in high-energy…

Face and Neck Emergencies

Midfacial Trauma Ken F. Linnau Indications and Rationale for Repair The overt physical manifestation of facial trauma often causes acute psychologic distress and long-term psychologic sequelae in addition to the loss of facial organ function. The use of modern surgical repair procedures, including internal reduction, microplate fixation, and the use of bone and allograft material has led patients to expect near normal if not normal appearance and…

Nontraumatic Brain Emergencies

Intracranial Hemorrhage Arash Meshksar Wayne S. Kubal Nontraumatic Intracranial Hemorrhage Initial Diagnosis Although many cases of intracranial hemorrhage (ICH), including intra-axial and extra-axial hemorrhage, are due to trauma, this discussion will be limited to atraumatic intracranial hemorrhage. Abrupt onset of neurologic symptoms in any patient should be considered to be of vascular origin until proven otherwise. It is not possible to differentiate ischemic from hemorrhagic accidents based on…

Craniocerebral Trauma

Traumatic Brain Injury Monique Anne Meyer Wayne S. Kubal Traumatic brain injury (TBI) occurs when an external mechanical force results in tissue and cellular damage within the brain that may lead to permanent or temporary impairment of cognitive, physical, or psychosocial functions and a diminished or altered state of consciousness. There are two types of TBI: closed and penetrating. Closed TBI is an injury to the brain caused…

Image Management in Emergency Radiology

Background Imaging of Patients at Outside Facilities Before Transfer Early and timely transfer of injured patients to a trauma center capable of definitive care has been shown to decrease mortality. Although long-standing national guidelines from the American College of Surgeons Committee on Trauma recommend simple clinical parameters and radiography to identify patients who benefit from transfer to a Level I or II trauma center, these are…

Strategies for Reducing Radiation Exposure From Multidetector Computed Tomography in the Acute Care Setting

Acknowledgments All figures and much of the text in this chapter have been reprinted with permission from: Sodickson A. Strategies for reducing radiation exposure in multi-detector row CT. Radiol Clin North Am . 2012;50(1):1-14; and Sodickson A. Strategies for reducing radiation exposure from multidetector computed tomography in the acute care setting. Can Assoc Radiol J . 2013;64(2):119-129. Synopsis Many tools and strategies exist to enable reduction…

Imaging of Thoracic Trauma

▪ Introduction Thoracic injury is a common sequela of acute trauma and is the third most common injury in trauma patients, after head and extremity injuries. The overall mortality rate approaches 25%, with acute aortic, tracheobronchial, and cardiac injuries often having an even worse prognosis. Given the high mortality rate and the impact on clinical management, rapid and accurate assessment of thoracic trauma imaging is imperative.…

Thoracic Interventions

▪ Introduction Thoracic interventions are performed for the diagnosis and treatment of focal lesions in the thorax. Image-guided percutaneous biopsy is used to obtain tissue for the diagnosis of benign and malignant conditions. Drainage of fluid or air from the pleural space or mediastinum can aid both diagnosis and therapy, and ablative therapies treat primary or secondary malignancy in lungs and chest wall. ▪ Lung and…

Lung and Heart Transplantation

■ Lung Transplantation Since the first lung transplantation was performed in 1963, there have been major improvements in the surgical technique and posttransplantation management of organ recipients. Lung transplantation represents the only effective therapeutic option for many patients with advanced lung disease. Although there continue to be advancements in the understanding of the posttransplantation care of these patients, improvements in long-term survival have been limited by…

Cardiac CT for the Evaluation of Acute Coronary Syndrome in the Emergency Department

■ Introduction More than 8 million Americans each year present to the emergency department (ED) with acute chest pain. This poses a diagnostic challenge to physicians, who must distinguish patients with life-threatening conditions, including acute coronary syndrome (ACS), aortic dissection, and pulmonary embolism, from those who have chest pain related to more benign causes. Most patients with chest pain are discharged with a diagnosis of noncardiac…

Intensive Care Imaging

■ Value of a Routine Daily Chest Radiograph in the Intensive Care Unit Determining Who Needs Imaging Imaging of an intensive care unit (ICU) patient can be a difficult task that relies on cooperation and teamwork among many members of the clinical care team and technologist. The complexity of these critically ill patients, many of whom have numerous support devices, has led to the practice of…

Imaging of the Pericardium

■ Anatomy and Normal Appearance on Imaging The pericardium is a fibrous sac that surrounds the heart and is composed of two distinct layers: the visceral pericardium and parietal pericardium. The visceral pericardium is the inner serous layer that consists of a very thin (<1 mm) layer of mesothelial cells. The visceral pericardium lines the epicardial surface of the heart and is separated from the cardiac…

Cardiac Valves

■ Introduction Echocardiography is the primary imaging modality used in the evaluation of cardiac valve morphology, function, and disease. This modality is broadly available and portable, and there is widespread clinical familiarity with the performance and interpretation of this modality. However, it is operator-dependent and is sometimes limited by suboptimal acoustic windows (e.g., patients affected by obesity). In certain patients, MRI may be used in the…

Trachea and Bronchi

■ Central Airway Anatomy and Physiology: Essentials for the Radiologist Anatomy The trachea is a cartilaginous and fibromuscular conduct extending from the lower border of the larynx (2 cm below the vocal cords, at the level of spinal C6) to the carina (at the level of spinal T5), where it bifurcates into the main stem bronchi. The trachea ranges from 10 to 12 cm in length, with an…

The Pleura

▪ Pleural Anatomy The pleura is a stroma supported by the mesothelial lining of the thoracic cavity. It is composed of two layers: an inner visceral pleura and an outer parietal pleura. The visceral pleura lines the lungs and their fissures. The visceral pleura is supplied by pulmonary arterioles, with drainage via the pulmonary veins. The parietal pleura lines the chest wall, diaphragm, and mediastinum. The…

Problem Solving in the Mediastinum

▪ Mediastinal Lesions Although it may not be difficult to identify a mediastinal mass on cross-sectional imaging, it can be challenging to determine its nature. Diagnostic specificity is critical to prevent unnecessary intervention and its associated morbidity and expenditure. The aim of this chapter is to serve as a guide toward maximizing the benefit of current diagnostic imaging tools for mediastinal lesions to improve diagnostic accuracy…