ABC of Emergency Radiology

Otto Chan

• Publisher: BMJ Books
• Year: 2012
• Print ISBN: 9780470670934
• eBook ISBN: 9781118495179
• Edition: 3
• Topic: Medicine
• Subtopic: Radiology, Radiotherapy & Nuclear Medicine

Rapid acquisition and interpretation of radiographs, portable ultrasound (US) and computed tomography (CT) are now the mainstay of initial successful management of sick and traumatized patients presenting to Accident and Emergency Departments.

The ABC of Emergency Radiology is a simple and logical step-by-step guide on how to interpret radiographs, US and CT. It incorporates all the latest technological advances, including replacing plain radiographs with digital radiographs, changes in imaging protocols and the role of portable US and multidetector CT.

With over 400 illustrations and annotated radiographs, this thoroughly revised third edition provides more images, new illustrations, and new chapters on emergency US and CT that reflect current practice. Each chapter starts with radiological anatomy, standard and then additional views, a systematic approach to interpretation (ABC approach) and followed by a review of common abnormalities.

The ABC of Emergency Radiology is an invaluable resource for accident and emergency staff, trainee radiologists, medical students, nurses, radiographers and all medical personnel involved in the immediate care of trauma patients.

This title is also available as a mobile App from MedHand Mobile Libraries. Buy it now from https://itunes.apple.com/us/app/abc-emergency-radiology-3rd/id1055348839?ls=1&mt=8, https://www.medhand.com/products/abc-of-emergency-radiology or the https://www.medhand.com/products/abc-of-emergency-radiology.

Chapter 1

Introduction: ABCs and Rules of Two

Otto Chan

The London Independent Hospital, London, UK

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Overview

• Request the correct investigation
• Use a systematic approach to interpretation—ABCs
• Fundamental principles to avoid errors—Rules of two
• Always ASK for help—if in doubt!

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Emergency medicine often brings together critically ill patients and inexperienced and tired doctors—a dangerous combination at the best of times with potentially serious clinical and medicolegal consequences. Virtually any medical condition can present in the emergency department (ED) and so the volume of medical knowledge needed to manage these patients satisfactorily is enormous.

There have been major technological advances in the past decade which have had a major impact on the management of patients in the ED, not least picture archiving and communication systems (PACS), digital radiography (replacing conventional plain to X rays), portable ultrasound (US; which is now readily available and often, but not often enough, performed by clinicians in the ED) and multidetector computed tomography (MDCT) in the ED. Despite all these advances, plain to X rays (whether conventional or digital) remain the mainstay of initial and successful management of most sick and traumatised patients in the ED.

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Radiological investigations

• Plain to X rays (conventional or digital)
• Portable US
• MDCT
• MRI

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The correct selection of imaging modality, rapid acquisition and the accurate interpretation of these investigations is often the key to quick and successful management of patients in the ED. Unfortunately these investigations are often done and interpreted by medical staff who have little, if any, training in radiology and the usual safety net of a specialist radiological service is not available at the time of presentation, when it is most needed. This leads to delays and invariably results in increased morbidity and mortality! The selection of the correct imaging modality on admission saves time and saving time, saves lives! Ideally there should be a seamless 24/7 service.

MDCT—initial imaging modality of choice in the ED

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Head injuries/headaches or epilepsy	Skull X-ray (SXR) no longer done. CT head ± contrast
Facial injuries	MDCT with multiplanar reconstructions (MPR) and 3D are essential
Chest pain (suspected aortic aneurysm (AA), myocardial infarction (MI), pulmonary embolus (PE) or pneumothorax (Px))	Triple rule out CT scan
Severe abdominal pain (obstruction)	CT has replaced abdominal X-ray (AXR)
Renal/ureteric colic	CT kidneys, ureters and bladder (KUB) has replaced Intravenous urogram (IVU) in ED
Suspected leaking abdominal aortic aneurysm (AAA)	CT has replaced US and AXR
Suspected gastrointestinal (GI) bleeding	Initially CT angiography instead of angiography
Major trauma (adults)	Whole body CT instead of chest X-ray (CXR), AXR and US

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Figure 1.1 (a) Anteroposterior shows minimal overlap of proximal interphalangeal joint (PIPJ) of little finger; (b) lateral shows obvious dislocation of PIPJ.

The Rules of Two (Ro2) is a helpful, simple set of guidelines, which relate to who, what, when and how to radiograph and how to get help or get out of trouble and therefore minimise the chances and the consequences of errors.

The ABCs systematic assessment is a simple systematic approach, which starts with basic essential normal radiographic anatomy, common normal variants, which may mimic pathology and in particular how to interpret imaging using a systematic approach, which is logical and easy to remember and therefore hopefully helps to minimise interpretive errors.

Rules of Two

These rules represent a simple set of guidelines, most are obvious, some relate to specific clinical problems, but most are common sense useful general principles which should help in avoiding errors in interpretation and management of patients in the ED.

Figure 1.2 (a) Anteroposterior shows no obvious abnormality; (b) lateral shows oblique fracture of fibula.

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Rules of Twos

• Two views—one view is always one view too few
• Two abnormalities—if you see one abnormality, always look for a second
• Two joints—image the joint above
• Two sides—if not sure or difficult X ray, compare with other side
• Two views too many—CT (and rarely US) has replaced plain X rays in many clinical situations
• Two occasions—always compare with old films IF available
• Two visits—bring patient back for repeat examination
• Two opinions and two records—always ask a colleague if not sure and record findings
• Two specialists—always get your ED specialist and also a radiologist's opinion
• Two investigations—always consider whether US, CT or MRI would help in diagnosis

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Rule 1—two views (‘One view is always one view too few’)

Tw...

Table of contents

• Cover
• Series Page
• Title Page
• Copyright
• Dedication
• Contributors
• Preface
• Chapter 1: Introduction: ABCs and Rules of Two
• Chapter 2: Hand and Wrist
• Chapter 3: Elbow
• Chapter 4: Shoulder
• Chapter 5: Pelvis and Hip
• Chapter 6: Knee
• Chapter 7: Ankle and Foot
• Chapter 8: Head
• Chapter 9: Face
• Chapter 10: Cervical Spine
• Chapter 11: Thoracic and Lumbar Spine
• Chapter 12: Chest
• Chapter 13: Abdomen
• Chapter 14: Computed Tomography in Emergency Radiology
• Chapter 15: Emergency Ultrasound
• Chapter 16: Emergency Paediatric Radiology
• Chapter 17: Major Trauma
• Index
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