Table Of ContentProblem Solving in
Emergency
Radiology
Stuart E. Mirvis, MD, FACR
Professor
Department of Diagnostic Radiology and Nuclear Medicine
University of Maryland School of Medicine
Baltimore, Maryland
Wayne S. Kubal, MD
Professor of Medical Imaging
Department of Medical Imaging
University of Arizona
Tucson, Arizona
Kathirkamanathan Shanmuganathan, MD
Professor of Radiology
Department of Diagnostic Radiology and Nuclear Medicine
University of Maryland School of Medicine
Baltimore, Maryland
Jorge A. Soto, MD
Professor of Radiology
Boston University School of Medicine
Vice Chairman
Department of Radiology
Boston Medical Center
Boston, Massachusetts
Joseph S. Yu, MD
Professor of Radiology and Orthopedic Surgery
Vice Chair of Academic Affairs and Education
The Ohio State University Wexner Medical Center
Columbus, Ohio
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PROBLEM SOLVING IN EMERGENCY RADIOLOGY ISBN: 978-1-4557-5417-5
Copyright © 2015 by Saunders, an imprint of Elsevier Inc.
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Library of Congress Cataloging-in-Publication Data
Problem solving in emergency radiology / section/associate editors, Stuart Mirvis, Wayne S. Kubal,
Kathirkamanathan Shanmuganathan, Jorge A. Soto, Joseph S. Yu.
p.; cm.
Includes bibliographical references and index.
ISBN 978-1-4557-5417-5 (hardcover : alk. paper)
I. Mirvis, Stuart E., editor of compilation. II. Kubal, Wayne Scott, editor of compilation.
III. S hanmuganathan, K. (Kathirkamanathan), editor of compilation. IV. Soto, Jorge A., editor of
compilation. V. Yu, Joseph, editor of compilation.
[DNLM: 1. Diagnostic Imaging. 2. Emergencies. WN 180]
RC78
616.07’57--dc23 2013046612
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To Linda, for her patience and understanding, and Zack,
who always makes me smile
Stuart Mirvis
To my parents, Fred and Lillian,
who gave me the love and support to believe that all things are possible
Wayne Kubal
To my parents and sister, Nalayini Shan, who are always available
for moral support and advice when required
Kathirkamanathan Shanmuganathan
To my wife, Ana; my daughter, Andrea; and my son, Alejandro
Jorge Soto
To Cynthia and Sarah, the two anchors of my life
Joseph Yu
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Foreword
Today’s emergency departments (EDs) are emergency Analogous to the critical role emergency medicine plays
diagnostic centers. Of the 130 million patients who cur- in delivering clinical care and coordinating diverse
rently visit an ED each year in the United States, nearly medical and surgical specialties in the ED, emergency
half will have some type of imaging performed, mak- radiology sections are postured to resolve the care frag-
ing it clear that imaging has become an indispensable mentation that typically plagues imaging services pro-
tool for diagnosing acute conditions and traumatic vided by remote silos of organ- and modality-based
injuries in this setting. But it is computed tomography radiology specialties. For better or worse, such change
(CT) imaging in particular that has thrust imaging to the in radiology practice remains mostly evolutionary rather
forefront of emergent care. The diagnostic use of CT in than revolutionary.
the ED increased 330% between 1996 and 2007, from Dedicated emergency radiology sections first emerged
3% to 14% of all patient visits. There was a widespread in a few academic medical centers during the 1980s and
increase in the use of CT for the 20 most common ED 1990s. Although this care model was initially met with
chief complaints. Within this context, the matured spe- institutional inertia, in the past decade it has been more
cialties of emergency medicine and trauma surgery, widely adopted, especially in large medical centers or
and modern health care in general, have placed great multihospital systems with sufficient ED visits and/or
emphasis on contemporaneous imaging interpretation. Level 1 trauma services. Despite the growth in adoption
Together, these forces have transformed the radiolo- of dedicated emergency radiology sections, resident
gist’s role from minor participant to major player in care and fellow interpretations remain a mainstay of “after-
delivery and in so doing have given birth to the ascen- hours” coverage for many radiology departments with
dant specialty of emergency radiology. Indeed, the need training programs. At smaller-scale institutions and in
to provide coordinated radiologic care contemporane- private practice, the growth in ED imaging, coincident
ous to the ED patient visit has never been greater. This with advances in computing technology and network
is why this book is such an important and timely contri- speeds, resulted in a different course. During the 1980s
bution to the specialty. and 1990s most community radiology practices pro-
Radiologists who provide coverage of ED imag- vided coverage of after-hours ED imaging from home
ing require a broad fund of knowledge spanning most using web-based viewers rather than sophisticated tele-
imaging modalities and organ systems. Although his- radiology solutions. As the demand for this imaging
torically such practice has been characterized as general dramatically increased during the mid to late 1990s, a
radiology, this term is now anachronistic and anath- commercial market emerged for outsourced teleradiol-
ema to practicing emergency radiologists. Instead, the ogy services. By 2007 a majority of private practice radi-
required interpretational expertise is defined by the ology groups used such services.
common conditions affecting acutely ill or traumatized Although today’s approach to coverage of ED imaging
patients. Epidural hematoma, cervical spine fracture, remains heterogeneous, it appears certain that greater
aortic injury, liver laceration, stroke, aortic dissection, emphasis will continue to be placed on the value, time-
pulmonary embolus, pneumonia, appendicitis, diver- liness, and coordination of radiologic care provided.
ticulitis, bowel obstruction, ectopic pregnancy, tubo- Advocating for optimal radiologic care of the ED patient
ovarian abscess, osteomyelitis, and the like define the has been the core mission of the American Society of
field of emergency radiology. Emergency Radiology (ASER). Founded in 1988, ASER
Equally important, the skills required for optimal has worked to advance the quality of diagnosis and
radiologic care in the ED extend well beyond interpre- treatment of acutely ill or injured patients by means of
tational expertise, particularly if that expertise is largely medical imaging and to enhance teaching and research
defined by a single organ system or imaging modal- in emergency radiology. In the quarter century since its
ity. Surely no one is convinced that optimal care for a founding, ASER has grown from its 8 founders (Drs.
severely traumatized patient transferred from an outside Gordon C. Carson, John H. Harris, Jr., Alan Klein, Jack P.
institution is achieved by seeking interpretations from Lawson, James J. McCort, Stuart E. Mirvis, Charles F.
multiple organ-based subspecialties remote from the Mueller, and Robert A. Novelline) and 16 charter mem-
ED. Contemporaneous clinical consultation, appropri- bers to more than 900 members. ASER and its members
ateness oversight, examination protocol optimization, have worked tirelessly to establish emergency radiology
resource triage, image and radiation dose management as a specialty within organized radiology. A successful
across organ systems, and using the range of imaging peer-reviewed journal (Emergency Radiology), annual
modalities are required to optimize ED patient out- society meetings, a core educational curriculum for radi-
comes; these define the role of an emergency radiologist. ology trainees, a high-quality website (www.erad.org),
When such requirements are coupled with the 24/7 and equal representation alongside other radiology spe-
operations and time-sensitive obligations inherent cialties in important professional venues (for example,
in caring for ED patients, the most common legacy the Radiological Society of North America [RSNA],
approaches to ED coverage often fall short in achieving the American Roentgen Ray Society [ARRS], and the
a consistent standard of care, let alone an optimal one. American College of Radiology [ACR]), are testaments
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viii Foreword
to the Society’s success. International members also its most lofty goal, which is to more clearly define and
have made significant contributions to ASER and have broadly disseminate the body of knowledge that defines
helped disseminate the practice of emergency radiology emergency radiology practice today. Given Dr. Mirvis’s
at the global level. New emergency radiology societies lifelong devotion to and stature within the field of
have been established outside the United States, most emergency radiology, from founding member of ASER
recently in Europe and Asia. For ASER leaders and many to leading international authority on trauma and note-
practicing emergency radiologists in the United States worthy journal editor, there is no better steward of this
and abroad, the past 2 to 3 years have symbolized a tip- worthy ambition.
ping point toward the realization of our greater ambi- This book will have broad appeal to many audiences.
tions: full recognition as a specialty within the pantheon It will prove an invaluable resource to any practicing
of radiology. radiologist providing coverage of emergency department
At this pivotal time for emergency radiology, it is imaging, regardless of whether or not the radiologist
important that a single text captures the core knowl- self-identifies as an emergency radiologist. It is required
edge that defines this modern specialty. Problem Solving reading for every diagnostic radiology resident or fellow
in Emergency Radiology represents the most up-to-date and will be of great interest to emergency medicine phy-
and comprehensive contribution from many leading sicians, trauma surgeons, and the many other physicians
authors in this field. Supported by ASER and edited by and care providers who consult on patients in the ED.
Dr. Mirvis, this text draws upon a large variety of exper- Dr. Mirvis and colleagues have assembled what is sure to
tise across the broad range of emergency imaging top- become the new reference text on emergency radiology.
ics. Using a “head-to-toe” organizational approach,
with sections based on anatomic regions and subdivi- Stephen Ledbetter, MD, MPH
sion by traumatic and nontraumatic presentations, the Chief of Radiology
text is well organized for rapid access to any relevant Brigham and Women’s Faulkner Hospital
topic and easily serves as a companion to the ASER Boston, Massachusetts
core curriculum. Most important, the book achieves
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Preface
Problem Solving in Emergency Radiology is one of a series conditions, to present recent terminology, to offer a
of texts published by Elsevier starting in 2007 that are generous quantity of up-to-date imaging with postpro-
intended to provide core reviews of major areas of diag- cessing enhancement, to show and discuss confusing
nostic imaging, focusing on what the authors believe are variants that simulate pathologic conditions and atypi-
the most relevant, up-to-date concepts in the areas of their cal presentations of common emergency pathologic
expertise, as well as to provide practical knowledge to conditions, and to expose the reader to rarely encoun-
help in negotiating complex cases and unusual imaging tered emergency imaging diagnoses.
presentations of acute pathologic conditions and in dis- One difficulty encountered in multiauthored text-
tinguishing actual from “pseudo” pathologic conditions. books is maintaining a consistent writing style and a
This text is divided into five sections representing major similar level of detail in coverage of the subject. Different
anatomic areas. Each section was prepared by a coeditor, writing styles, chapter length limitations, and multiple
including Joseph S. Yu, MD (Musculoskeletal Emergen- chapter contributors create this variation. It is our hope
cies), Stuart E. Mirvis, MD, FACR (Thoracic Emergency that readers can navigate these differences in chapter
Radiology), Wayne S. Kubal, MD (Spine Emergen cies, Cra- structure to glean the core information provided within.
niocerebral and Orbital-Maxillo-Facial Emerg encies), and The chapters review major regional imaging anatomy,
Kathirkamanathan Shanmuganathan, MD (Blunt Abdom- clinical concepts germane to the topic, and the applica-
inal and Retroperitoneal Trauma) and Jorge A. Soto, MD tion of various imaging modalities and their strengths
(Nontraumatic Abdominal Emergen cies) sharing the and limitations where appropriate. The authors attempt
work of the section on Abdominal Emergencies. The book to provide a basic foundation for imaging emergent
starts with overview chapters on strategies for computed pathologic conditions to address the needs of radiolo-
tomography radiation reduction in the acute care setting gists in training, as well as to provide advanced concepts,
by Aaron Sodickson, MD, PhD, and image management detailed information, subtle findings, and challenging
in emergency radiology by Martin L. Gunn, MBChB, cases for the more seasoned radiologist.
FRANZCR, and Jeffrey D. Robinson, MD. Both chapters In addition to imaging specialists, physicians special-
have general application in all aspects of emergency imag- izing in emergency medicine, critical care and internal
ing. There are 88 contributors to the text, offering a wide medicine, and emergent surgical conditions will find
spectrum of information covering a huge number of topics an understandable, clinically relevant, timely, and com-
in emergency radiology. prehensive text to gain new or refresh prior knowledge
The goal of this text is to bring together in one book that is essential to diagnosis and planning treatment of
both traumatic and nontraumatic imaging findings of acutely ill or injured patients.
emergency radiology. Some of our goals were to provide
an update on imaging techniques, to review the evolving Stuart E. Mirvis, MD, FACR
scoring (grading) systems for trauma and nontraumatic
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