16 - DR Rosy Emergency Radiology

CHOOSING NECESSARY
RADIOLOGIC TEST
IN EMERGENCY
Rosy Setiawati
Radiology Department
Faculty of Medicine, Airlangga University
Dr. Soetomo Airlangga University Hospital, Surabaya, Indonesia
29 Januari 2017
Different radiological investigation to
order in different emergency situations
Topics
CNS Emergencies.
Gynecological & Obstetrical
Face & Neck Emergencies.
Emergencies.
Spinal Emergencies. Male Genitourinary Emergencies.

Chest Emergencies.
Musculoskeletal Emergencies.
Cardiovascular Emergencies.
Pediatric Emergencies
Abdominal Emergencies.
CNS Emergencies
Skull fracture
Hemorrage (traumatic non-

traumatic)
Cerebral infarction
Spinal trauma
CNS Emergencies
SKULL FRACTURES
What to order ?
Plain X-ray of the skull (AP-lateral view)

Computed tomography of the Brain (Axial
- Coronal) (bone window)
WHEN ?
History of trauma evident injury of the scalp

Case 1 . Skull fracture
CNS Emergencies
Skull fracture

traumatic)
Cerebral infarction
Spinal trauma
CNS Emergencies
HEMORRAGE : TRAUMA NON TRAUMA
What to order ? WHEN ?
Head trauma
CT of the brain plain
focal neurological
CNS Emergencies
HEMORRAGE : TRAUMA NON TRAUMA
Trauma Non Trauma
Epidural hem. Subarachnoid hem.

Subdural hem. Intracerebral hem.
Cerebral contusion Intraventricular hem.
SAH & EDH
Case 4 . Stroke Hemorrhage
ICH & IVH
Case 5 . Contusional
Hemorrhage
Case 6 . Subdural
hematome
CNS Emergencies
Skull fracture

traumatic)
Cerebral infarction
Spinal trauma
CNS Emergencies
CEREBRAL INFARCTION
CT of the brain
What to MRI : DWI
order
Focal neurological defect -

When stroke
Case 1. Stroke infarction (CT Scan )
Case 2. Acute Thromboembolic infarction (MRI-DWI + MRA)
Summary of CNS Emergencies
Type of CNS What to order When
Emergencies
Skull Fracture Plain X-ray of the History of trauma
skull (AP lateral evident Injury of the
view) scalp
CT of the brain
(axial-coronal)
(bone window)
Hemorrhage CT of the brain Head trauma focal

plain neurological
Cerebral infarction CT of the brain Focal neurological

MRI : DWI defect - stroke
Topics
CNS Emergencies
Face and Neck Emergencies.
Emergencies.
Chest Emergencies.
Extremities Emergencies.
Facial Emergencies
Plain X-ray of the Skull (Lateral
What view PA view)
to Computed Tomography of the
order facial bones
Bone windowAxial & coronal3D
recon.)
History of trauma to the face

disfigurement When
Severe facial contusions
Case 1. Skull and Maxillofacial fracture (3D CT Scan )
Case 2. Maxillofacial fracture
(CT Scan )
Orbital Injuries
Plain X-ray of the Skull (Lateral view PA
view)
What to Computed Tomography of the Orbit (Axial
order? Coronal - Bone & Soft tissue settings)
History of trauma to the orbit

History of Foreign Body to the eye
When ?
Topics
CNS Emergencies. Gynecological & Obstetrical
Emergencies.
Male Genitourinary Emergencies.
Spinal Emergencies.
Chest Emergencies. Pelvic Emergencies.
Abdominal Emergencies. Pediatric Emergencies

Spinal Emergencies
SPINAL TRAUMA
What to order
? Plain X-ray of the spine (lateral view AP
view)
CT of the spine (bone & soft tissue setting
3D recon)
MRI of the spine (for cord injury)
When ? History of trauma Falling from height

Case 1. Extension Tear drop fracture of C3
Case 2. Dislocation fracture
Case 3. Dislocation fracture
Topics
CNS Emergencies.
Emergencies.
Chest Emergencies.
Chest Emergencies
Chest trauma
Airway foreign body

Chest Emergencies
Chest Trauma
What to
order ?
Plain X-ray of the chest (PA view lateral
view)
CT of the chest
Angiography (Aotography)
When ?
History of trauma Difficulty of breathing
Chest Emergencies
Chest trauma
Airway foreign body

Case 1. Pneumothoraks
Case 2. Contusional pulmonum + multiple rt rib fractures
Chest Emergencies
FB of the Airways
What to Plain X-ray of the chest (PA

view lateral view)
order ? CT of the chest
When ? Children difficulty in breathing

unconscious patient
Case 1. FB of the esophagus (penny)
Case 2 . FB (fish bone ) in the esophagus
Case 3 . FB (fish bone ) in the duodenum
Summary of Chest
emergencies
What to order When
Chest trauma Plain X-ray of the chest History of trauma
(PA view lateral view) Difficulty of breathing
CT of the chest
Angiography
(Aotography)
FB of the Plain X-ray of the chest Children difficulty

airways (PA view lateral view) in breathing
CT of the chest unconscious patient
Topics
CNS Emergencies.
Emergencies.
Chest Emergencies.
Cardiovascular Emergencies
CHF
Pericardial effusion
Aortic dissection
Peripheral ischemia (acute)
DVT
Pulmonary edema
Pulmonary embolism
Congestive Heart Failure (CHF)
What Plain X-ray of the chest (PA
to view lateral view)
Order? Echocardiography
Dyspnea Signs of low cardiac

When?
output
CHF
Aortic dissection
DVT
Pulmonary edema
Pulmonary embolism
Pericardial Effusion
What to Plain X-ray of the chest (PA view

lateral view)
order? Echocardiography
When? Chest pain Fiction rub Faint

heart sounds on auscultation
CHF
Aortic dissection
DVT
Pulmonary edema
Pulmonary embolism
Aortic Dissection
Plain X-ray of the chest (PA
What view lateral view)
to CT Scan
order? MRI
Aortography
Sudden severe tearing

When? substernal chest pain
CHF
Aortic dissection
DVT
Pulmonary edema
Pulmonary embolism
Acute peripheral ischemia
What
to When
CT Sudden
order?
Arteriography onset of
severe pain,
Arteriography coldness,
numbness
or pallor in a
Color doppler portion of
Ultrasound an extremity
(chronic)
CHF
Aortic dissection
DVT
Pulmonary edema
Pulmonary embolism
Deep Vein Thrombosis (DVT)
What to order? When ?
Color doppler Asymptomatic

ultrasound pain edema
CT Venography skin
discoloration
Venography
CHF
Aortic dissection
DVT
Pulmonary edema
Pulmonary embolism
Pulmonal embolism / thrombus
Summary of
What to order When
CHF Plain X-ray of the chest (PA view Dyspnea Sihns of low cardiac
lateral view) output
Echocardiography
Pericardial Plain X-ray of the chest (PA view Chest pain Fiction rub Faint
effusion lateral view) heart sounds on auscultation
Echocardiography
Aortic Plain X-ray of the chest (PA view Sudden severe tearing
dissection lateral view) substernal chest pain
CT Scan
MRI
Aortography
Avute Arteriography Sudden onset of severe pain,
peripheral Color doppler Ultrasound coldness, numbness or pallor in
ischemia (chronic) a portion of an extremity
DVT Color doppler ultrasound Asymptomatic pain edema

Venography skin discoloration
Topics
CNS Emergencies.
Emergencies.
Chest Emergencies.
Abdominal Emergencies
Abdominal trauma Abdominal Non-

Trauma
Hemoperitonium Intestinal
Visceral injuries obstruction,
(Liver, spleen, appendicitis, GIT
kidney, UB, etc.) perforation
Ascites, jaundice,
peritonitis, GI
bleeding
Abdominal trauma
What When?
Chest & abdominal
to History of
radiographs
order? trauma to
Ultrasound (FAST) the
abdomen
CT Scan - motor
vehicle
Arteriography accidents
Hepatic CT injury grading scale
Grade I Laceration(s) < 1 cm deep
Subcapsular hematoma < 1 cm diameter
Grade II Laceration(s) 1 3 cm deep
Subcapsular or central hematoma 1 3 cm
diameter
Grade III Laceration(s) 3 10 cm deep
Subcapsular or central hematoma 3 10
diameter
Grade IV Laceration(s) > 10 cm deep
Subcapsular or central hematoma > 10 cm
diameter
Lobar maceration or devascularization
Grade V Bilobar tissue maceration or
devascularization
US FAST
Liver laceration
Intestinal obstruction
Abdominal radiograph
What to CT Scan
order?
Crampy abdominal pain

nausea & vomiting abdominal
When? tenderness
Ileus Obstruction
GIT perforation
Abdominal radiograph (Erect.)

USG
What to
order? CT Scan
History of peptic ulceration signs of

peritonitis
When?
Pneumoperitoneum
Jaundice
What to order? When?
US Yellowish
CT Scan discoloration of the
ERCP skin dark urine
MRCP pale stools
US - IHBD dilatation
ERCP - Multiple CBD Stone
Emergency Radiology
MRCP - CBD Stone
Appendicitis
Abdominal radiograph
US
What to
CT Scan
order?
Sudden onset or RLQ pain rebound

tenderness
When?
Cholecystitis
What to US (Gold standard)

order?
Sudden onset of epigastric pain -

When? rebound tenderness
Summary of
Intestinal Abdominal radiograph Crampy abdominal pain nausea
obstruction CT Scan & vomiting abdominal
tenderness
Gut Abdominal radiograph History of peptic ulceration signs
perforation (Erect.) of peritonitis
USG
CT Scan
Jaundice US Yellowish discoloration of the skin
CT Scan dark urine pale stools
ERCP
MRCP
Appendicitis Abdominal radiograph Sudden onset or RLQ pain
US rebound tenderness
CT Scan
Cholecystitis US (Gold standard) Sudden onset of epigastric pain -
rebound tenderness
Topics
CNS Emergencies.
Face & Neck Emergencies. Emergencies.
Chest Emergencies.
Cardiovascular Emergencies. Pediatric Emergencies
Gynecological & obstetrical
Emergencies
Gynecological emergencies
What to Ultrasound (Color doppler)

order?
Lower abdominal pain fever

When? vaginal discharge
Tuboovarian abscess
PID
Gynecological & obstetrical
Emergencies
Obstetrical emergencies
What to Ultrasound (Color doppler)

order?
Bleeding in early /late pregnancy

When?
Incomplete abortus
Ectopic pregnancy
Ectopic pregnancy
Topics
CNS Emergencies.
Emergencies.
Chest Emergencies.
Genitourinary Emergencies
UT stones
Hematuria
Urinary tract trauma
Scrotal injury, swellings, testicular torsion,

epididymitis (male)
Uretral injuries, stones (male)

Genitorinary Emergencies
Ureteric stones (Renal colic)
What to
When?
order?
* Plain X-ray of the urinary tract
Sudden
(PUT)
onset of loin
* US pain radiating
* Itravenous urography (IVU) to the groin
* CT of the abdomen
UT stones
Hematuria

epididymitis (male)

Hematuria (Painfull-painless)
Plain x-ray of the Passage of blood or
urinary tract (PUT) blood clots with
US urination (either
Intravenous urography painful or painless)
Cystogram
CT of the abdomen
Grawitz tumor
Grawitz tumor
Bladder mass -IVU
Bladder mass
Bladder mass
UT stones
Hematuria

epididymitis (male)

Genitourinary Emergecies
Urinary tract and Urethral trauma
Plain X-ray of the History of blunt

urinary tract (PUT) trauma to the
US abdomen falling
Intravenous astride
urography
CT of the abdomen
Ascending
urethrocystography
Bladder rupture
Rt. Kidney laceration
Lt. Kidney laceration
Posterior urethral rupture
Urethral stone and stricture
UT stones
Hematuria

epididymitis (male)
Urethral injuries, stones (male)

Scrotal emergencies
What to Ultrasound with color doppler

order?
Acute scrotal pain trauma to

When? testis
Orchitis
Torsion Testis
Complete Torsion testis
Summary of
Ureteric stones Plain X-ray of the urinary tract Sudden onset of loin pain
(Renal colic) (PUT) radiating to the groin
US
Itravenous urography (IVU)
CT of the abdomen
Hematuria Plain X-ray of the urinary tract Passage of blood or blood
(Painfull-painless) (PUT) clots with urination (either
US painful or painless)
Intravenous urography
CT of the abdomen
Cystogram
Urinary tract Plain X-ray of the urinary tract History of blunt trauma to
trauma (PUT) the abdomen falling
US astride
Intravenous urography
CT of the abdomen
Ascending urethrocystography
Scrotal Ultrasound with color doppler Acute scrotal pain trauma
emergencies to testis
Topics
CNS Emergencies.
Emergencies.
Chest Emergencies.
Musculoskeletal Emergencies
Plain X-ray
CT Scan
What to
order? MRI
History of trauma
When?
Upper & lower extremities fracture & dislocations
Pelvic fractures
Joint injuries
Ligaments and tendons injuries

Extremities and Pelvic Fractures
What to order ?
Plain X-ray (AP-lateral / oblique view)

Computed tomography of the Brain (Axial
- Coronal) (bone window)
WHEN ?
History of trauma evident injury of the

extremity / flank
Case 1
Right Humeral head dislocation to the inferior site
Suspicious of upper labrum glenoid fracture
Case 2
Colles Fracture
Pelvic fractures
Joint injuries

Pelvic fractures
Joint injuries

Topics
CNS Emergencies.
Emergencies.
Chest Emergencies.
Neonatal emergencies (intestinal obstruction
intussception)
Foreign body aspiration
Bone injuries
Case 1. Intususception
Case 1. Intususception
intussception)
Bone injuries
intussception)
Bone injuries
Thank you
Case 1 Intesusepsi
Case 2 intesusepsi
Case 3
intesusepsi

16 - DR Rosy Emergency Radiology

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16 - DR Rosy Emergency Radiology

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CHOOSING NECESSARY

Spinal Emergencies. Male Genitourinary Emergencies.

Hemorrage (traumatic non-

Plain X-ray of the skull (AP-lateral view)

History of trauma evident injury of the scalp

Hemorrage (traumatic non-

What to order ? WHEN ?

Trauma Non Trauma

Epidural hem. Subarachnoid hem.

Hemorrage (traumatic non-

Focal neurological defect -

Hemorrhage CT of the brain Head trauma focal

Cerebral infarction CT of the brain Focal neurological

History of trauma to the face

History of trauma to the orbit

Chest Emergencies. Pelvic Emergencies.

Abdominal Emergencies. Pediatric Emergencies

When ? History of trauma Falling from height

Airway foreign body

Airway foreign body

What to Plain X-ray of the chest (PA

When ? Children difficulty in breathing

FB of the Plain X-ray of the chest Children difficulty

Dyspnea Signs of low cardiac

What to Plain X-ray of the chest (PA view

When? Chest pain Fiction rub Faint

Sudden severe tearing

What to order? When ?

Color doppler Asymptomatic

DVT Color doppler ultrasound Asymptomatic pain edema

Abdominal trauma Abdominal Non-

Crampy abdominal pain

Abdominal radiograph (Erect.)

History of peptic ulceration signs of

Sudden onset or RLQ pain rebound

What to US (Gold standard)

Sudden onset of epigastric pain -

Spinal Emergencies. Male Genitourinary Emergencies.

Cardiovascular Emergencies. Pediatric Emergencies

What to Ultrasound (Color doppler)

Lower abdominal pain fever

What to Ultrasound (Color doppler)

Bleeding in early /late pregnancy

Urinary tract trauma

Scrotal injury, swellings, testicular torsion,

Uretral injuries, stones (male)

Urinary tract trauma

Scrotal injury, swellings, testicular torsion,

Uretral injuries, stones (male)

Urinary tract trauma

Scrotal injury, swellings, testicular torsion,

Uretral injuries, stones (male)

What to order? When?

Plain X-ray of the History of blunt

Urinary tract trauma

Scrotal injury, swellings, testicular torsion,

Urethral injuries, stones (male)

What to Ultrasound with color doppler

Acute scrotal pain trauma to

Ligaments and tendons injuries

Plain X-ray (AP-lateral / oblique view)

History of trauma evident injury of the