MISSED FINDINGS IN EMERGENCY RADIOLOGY: CASE BASE SESSION 5 th Nordic Trauma Radiology Course Oslo, Norway
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1 MISSED FINDINGS IN EMERGENCY RADIOLOGY: CASE BASE SESSION 5 th Nordic Trauma Radiology Course Oslo, Norway K.SHANMUGANATHAN M.D. EASILY MISSED FINDINGS IN EMERGENCY RADIOLOGY OBJECTIVES Commonly missed injuries How to avoid these errors Impact on management
2 Question 1: Blunt Trauma Which of the following MDCT image set(s) do you routinely use to evaluate trauma cases (choose one)? 1. Transverse (axial) images only. 2. Sagittal and coronal MPR images only & 2 in all cases & 2 in cases with injuries only. 5. 1, 2, and 3D images in cases with injuries. Question 1: Blunt Trauma Who performs the MPR & 3D images? 1. Radiologist. 2. Radiographer (Technologist)
3 CASE 1 27-Years old man admitted with abdominal pain following a MVC. CASE 1
4 Question 3 Case 1 The best management option is: 1. The radiological and clinical abnormalities with the trauma surgeon to plan management. 2. Repeat CT in 4-6 hours 3. Diagnostic peritoneal lavage. 4. Repeat abdominal and pelvic ultrasound examination 5. Serial clinical examination for 3 days. CASE 1 Abdominal pain was getting better
5 Question 4: Case 1 Based on clinical and MDCT findings, the best option (choose one)? 1. Discharge the patient from hospital. 2. Observe the patient for another 24 hours. 3. Observe the patient for another 3 5 days. 4. Perform a diagnostic peritoneal lavage. 5. Perform a laparotomy. CASE 1
6 CASE 1 Error - why? Uncommon presentation Nonspecific abnormalities MDCT - characterizes the lesion Injury evolved over a period BOWEL INJURY SPECIFIC CT SIGNS FREE EXTRA INTESTINAL AIR ORAL CONTRAST EXTRAVASATION EXTRAVASATION OF INTESTINAL CONTENT DISCONTINUITY OF BOWEL WALL AIR WITHIN BOWEL WALL
7 BOWEL INJURY NONSPECIFIC CT SIGNS BOWEL WALL THICKENING FREE INTRAPERITONEAL FLUID WITH NO SOURCE BOWEL INJURY NONSPECIFIC CT SIGNS OPTIONS Serial clinical Examination Follow-up MDCT DPL Laparoscopy Laparotomy
8 BOWEL INJURY SPIRAL CT (SURGICAL) SEN SPE ACC NPV PPV FREE AIR 30 76% 98% 91% 89% 95% % FF 76% 39% 51% 76% 39% BWT 44% 47% 46% 62% 30% OCE 8% 100% 69% 68% 100% KLK, KS, SEM, ET AL. J TRAUMA 2001;51:1-11 COLONIC INJURY
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11 21 Admission Follow-up 48 hours
12 SMALL BOWEL INJURY
13 12 hours
14 CASE 2 35-Year old male admitted following blunt force trauma with chest, abdominal, and pelvic pain
15 Question 5: Case 2 Based on the CXR & MDCT findings, the best diagnosis? 1. Surgical Diaphragm injury. 2. Surgical injury to Stomach. 3. Blunt cardiac contusion. 4. Lung injury. 5. Aortic injury. Question 5: Case 2 Why did you diagnose a surgical diaphragm injury? 1. Only positive cases are shown in the 5 th Nordic Trauma Course. 2. Dependent viscera sign. 3. Large defect in the diaphragm. 4. Collar sign. 5. Thickening of the diaphragm
16 Admission Day 10
17 CASE 2 Error - why? Nonspecific signs - only No specific sign of diaphragm injury Intubation prevented herniation MDCT OF DIAPHRAGM INJURY SPECIFIC SIGNS HERNIATION OF ABDOMINAL VISCERA INTO THORAX FOCAL CONSTRICTION - CT COLLAR SIGN DEPENDENT VISCERA SIGN
18 MDCT OF DIAPHRAGM INJURY RIGHT HEMIDIAPHARGM (n = 12) HUMP SIGN 83% (10/12) ROUNDED PORTION OF LIVER PARENCHYMA BAND SIGN 33% (4/12) LINEAR LUCENCY ACROSS LIVER OR, SEM, KS. Clinic Radiol 2005;60: MDCT OF DIAPHRAGM INJURY NONSPECIFIC SIGNS DISCONTINUITY OF CRUS THICKENING OF DIAPHRAGM HIGH HEMIDIAPHRAGM
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23 Yes No
24 CASE 3 61-year old man involved in an industrial accident. A heavy weight fell over patients upper chest. C A S E 3
25 Question 6: Case 3 Based on the MDCT findings, the best diagnosis? 1. Pneumothorax and pneumomediastinum. 2. Pneumothorax and tracheal injury. 3. Tracheal and aortic injury. 4. Tracheal and subclavian artery injury. 5. Aortic injury and pneumothorax C A S E 3
26 CASE 3 CASE 3 Error - why? Two uncommon injuries No reformations subclavian artery IV Contrast material side of pathology Proximal injury - SVC
27 VASCULAR INJURIES SPECIFIC Contour abnormalities Intramural thrombus Wall hematoma Intimal flap VASCULAR INJURIES SPECIFIC Cut-off of a vessel Pseudoaneurysm or A-V fistulas Active bleeding
28 VASCULAR INJURIES NONSPECIFIC Perivascular hematoma Concentric contour abnormalities Perivascular gas Proximity injury - WT
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