窥知

Emergency_Chest_Imaging.pdf Preface xi Stuart E. Mirvis and Kathirkamanathan Shanmuganathan Chest Pain: A Clinical Assessment 165 Kenneth H. Butler and Sharon A. Swencki Chest pain is one of the most common presentations in emergency medicine. The initial evaluation should always consider life-threatening causes such as aortic dissection, pul- monary embolism, pneumothorax, pneumomediastinum, pericarditis, and esophageal perforation. Radiographic imaging is performed in tandem with the initial clinical assess- ment and stabilization of the patient. Radiologic findings are key to diagnosis and man- agement of this entity. Thoracic Vascular Injury 181 Stuart E. Mirvis This article emphasizes multirow detector CT (MDCT) technique, the spectrum of find- ings for diagnosing major thoracic vascular injuries, and the challenges and potential errors that might be encountered. In particular, the role of MDCT data after processing to enhance diagnostic accuracy and convey appropriate and required diagnostic information to the doctors who are managing these vascular injuries are discussed. Imaging of Diaphragm Injuries 199 Clint W. Sliker Diaphragm injuries are uncommon consequences of blunt and penetrating trauma. Early diagnosis and repair prevent potentially devastating complications that typically result from visceral herniation through the posttraumatic diaphragm defect. Although clinical and radiographic manifestations frequently are nonspecific, the stalwarts of trauma imaging—chest radiography and CT—typically demonstrate these injuries. To render the appropriate diagnosis, the radiologist must be familiar with the varied imag- ing manifestations of injury, and maintain a high index of suspicion within the appro- priate clinical setting. vii Contents EMERGENCY CHEST IMAGING Volume 44 • Number 2 • March 2006 Contentsviii Chest Wall, Lung, and Pleural Space Trauma 213 Lisa A. Miller Chest radiographs frequently underestimate the severity and extent of chest trauma and, in some cases, fail to detect the presence of injury. CT is more sensitive than chest radiography in the detection of pulmonary, pleural, and osseous abnormalities in the patient who has chest trauma. With the advent of multidetector CT (MDCT), high-quality multiplanar reformations are obtained easily and add to the diagnostic capabilities of MDCT. This article reviews the radiographic and CT findings of chest wall, pleural, and pulmonary injuries that are seen in the patient who has experi- enced blunt thoracic trauma. Imaging of Penetrating Chest Trauma 225 Kathirkamanathan Shanmuganathan and Junichi Matsumoto This article discusses the role of imaging in evaluating patients who are admitted with penetrating injuries to the chest. Emphasis is placed on the role of multidetector row CT, which has been introduced in the past 5 years into the arena of care for trauma victims. It is important to take full advantage of this new CT technology with its capability to pro- duce high-resolution multiplanar and volumetric images to diagnose penetrating chest injuries. This article emphasizes detection of active bleeding and assessment of the medi- astinum for penetrating injury. Thoracic Angiography and Intervention in Trauma 239 Patrick C. Malloy and Howard Marks Richard III Interventional radiologists are involved less often in the initial diagnostic evaluation of patients who have acute chest trauma today than in the past. Patients are cleared of signifi- cant injury by CT, or, when a significant injury is present, they are triaged appropriately to open surgery or endovascular intervention. Significant advances in catheter-based technol- ogy, such as stent grafts and embolization coils, allow definitive repair of thoracic aortic and branch vessel injury. The opportunity to treat these types of injury with minimally invasive techniques has reinforced a continuing need for the maintenance and continued development of skills in the performance and interpretation of thoracic angiography. This article reviews these techniques and examines the status and the future of endovascular interventions in thoracic trauma. Nonvascular Mediastinal Trauma 251 Juntima Euathrongchit, Nisa Thoongsuwan, and Eric J. Stern This article discusses the radiologic and clinical features of nonvascular mediastinal trauma, and focuses on the tracheobronchial tree, the esophagus, and the thoracic duct. Blunt chest and penetrating trauma account for most of the causes of such nonvascular injuries, but iatrogenic and inhalation injuries are other well-known causes. The injury distribution and clinical manifestations are different for each structure. In our com- bined experience at a level 1 trauma center, the overall prevalence of injury in each organ is low compared with vascular injuries. As such, and given the frequent nonspe- cific nature of clinical signs and symptoms of nonvascular mediastinal injuries, the diagnosis often is delayed and results in poor treatment outcome. Contents ix Acute Pulmonary Embolism: Imaging in the Emergency Department 259 Paul G. Kluetz and Charles S. White Acute pulmonary embolism (PE) is a life-threatening condition that requires accurate diagnostic imaging. Morbidity and mortality resulting from PE can be reduced signifi- cantly if appropriate treatment is initiated early. Historically, the gold standard for the imaging of PE has been pulmonary angiography. Rapid advances in radiology and nuclear medicine have led to this modality largely being replaced by noninvasive techniques, most frequently multidetector helical CT pulmonary angiography (CTPA). For cases in which CTPA is contraindicated, other imaging modalities include nuclear ventilation- perfusion scanning, magnetic resonance pulmonary angiography, duplex Doppler ultra- sonography for deep venous thrombosis, and echocardiography. This article reviews the literature on the role of these imaging modalities in the diagnosis of PE. Nontraumatic Thoracic Emergencies 273 Jean Jeudy, Stephen Waite, and Charles S. White Acute chest pain is one of the most common complaints of patients who present to an emergency department, and accounts for up to 5% of all visits. It also is one of the most complex issues in an emergency setting because, although clinical signs and symptoms often are nonspecific, rapid diagnosis and therapy are of great importance. The chest radiograph remains an important component of the evaluation of chest pain, and usu- ally is the first examination to be obtained. Nevertheless, cross-sectional imaging has added greatly to the ability to characterize the wide constellation of clinical findings into a distinct etiology. This article reviews how the various entities that can present as nontraumatic chest pain can manifest radiographically. Acute Lung Infections in Normal and Immunocompromised Hosts 295 Stephen Waite, Jean Jeudy, and Charles S. White Pulmonary infections are among the most common causes of morbidity and mortality worldwide, and contribute substantially to annual medical expenditures in the United States. Despite the availability of antimicrobial agents, pneumonia constitutes the sixth most common cause of death and the number one cause of death from infection. Pneumonia can be particularly life threatening in the elderly, in individuals who have pre-existing heart and lung conditions, in patients who have suppressed or weakened immunity, and in pregnant women. This article discusses some of the important causes of acute lung infections in normal and immunocompromised hosts. Because there often is considerable overlap, infections are categorized by the host immune status that is most likely to be associated with a particular pathogen. Index 317 R A D I O L O G I C C L I N I C S O F N O R T H A M E R I C A Radiol Clin N Am 44 (2006) xi–xii xiPrefaceStuart E. Mirvis, MD Kathirkamanathan Shanmuganathan, MD Guest Editors0033-8389/06/$ – see front matter © 2006 Elsevier Inc. All rights radiologic.theclinics.comStuart E. Mirvis, MD Professor Department of Radiology University of Maryland Medical Center Director Section of Trauma and Emergency Radiology University of Maryland School of Medicine Baltimore, MD, USA E-mail address: smirvis@umm.edu Kathirkamanathan Shanmuganathan, MD Professor Department of Diagnostic Radiology University of Maryland School of Medicine Baltimore, MD, USA E-mail address: kshanmuganathan@umm.eduThe advent of multidetector computed tomogra- phy (MDCT) in recent years has sparked its use as a principal screening study for polytrauma patients and is increasingly commonly obtained in non- traumatic emergency department (ED) patients. The chest radiograph continues to be performed as a screening study in the polytrauma setting and for patients presenting to the ED with complaints related to the thorax. However, CT provides a sig- nificant improvement in sensitivity for detection of both traumatic and nontraumatic acute thoracic pathologies, which has fostered its common use in these settings. A thorough knowledge of the spectrum of pathology, the common and atypical CT appearances, and the influence of CT observa- tions on management is required for contemporary imaging assessment. In the blunt trauma patient, CT is essential to directly assess the thoracic vessels, pericardial fluid, and to potentially demonstrate airway and esopha- geal injuries. CT is far more sensitive than radiog- raphy for detection of pneumothorax, pleural fluid,and lung parenchymal injury. CT can document sites of active thoracic bleeding or vascular injury to direct surgical or angiographicintervention. Also, recent studies have shown that CT can play a valuable role in delineating the trajectory of penetrating tho- racic injury and can help determine the need for further imaging investigation of mediastinal struc- tures and for surgical exploration. In most poly- trauma patients multiple CT studies are usually indicated and inclusion of the chest as part of a general survey (total body CT) is being increasingly used in trauma centers. Even when the admission chest radiograph shows no definitive injury, CT can confirm the impression of normality with a higher level of accuracy or detect subtle but important pathology not revealed on the chest film. Several articles in this issue focus on traumatic chest pathol- ogy from both blunt and penetrating mechanisms. The use of CT for patients presenting with chest pain to the ED is increasing, because this approach can diagnose or exclude a wide variety of acute thoracic pathology. In these patients, MDCT hasreserved. doi:10.1016/j.rcl.2005.12.001 ...