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Instant Download Ebook of Emergency Imaging of at Risk Patients General Principles Michael N Patlas Online Full Chapter PDF
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Emergency Imaging
of At-Risk Patients
General Principles
When most people think about vulnerability, they Radiology and imaging are increasingly used, par-
typically consider the concept in the first-person emo- ticularly in acute care settings, and thus often play a
tional context of being harmed or exposed to harm by central role in health access. Like other health care
another person or entity—whether intended or not.1–3 service lines, imaging is not immune to the health dis-
For physicians, who are tasked with ensuring the best parity issues that disproportionately impact vulnerable
outcomes for some of society’s most vulnerable popu- populations.10 Screening mammography has received
lations, the concept of vulnerability (and associated considerable attention, with ample evidence linking
duty) becomes much more complex. Sadly, even the underutilization to socioeconomic status, race, ethnic-
most modern health care delivery systems leave gaps ity, age, and location. For example, less than 40% of
in care that result in significant disparities for the peo- newly immigrated women report having a mammo-
ple most in need. gram in the past 2 years, compared with over 70% of
To understand how to best approach the care of women who were born in or have long resided in the
vulnerable patients requires a nuanced understand- United States.11–13 Similar work has highlighted how
ing of what vulnerability means in the context of race and location (rural vs. urban) are often differen-
health care. This ultimately requires a deliberate will- tiators in access to imaging for lung cancer screening.
ingness to fully appreciate the situation, context, and Of note, such vulnerable patients may be addition-
environment that have placed patients in a position ally vulnerable because of prior exposure to toxins
in which they are not able to fully protect and care like asbestos, making adequate lung cancer screening
for themselves. These drivers are complex and often imaging even more critical.14–17
interconnected, and include socioeconomic status, In busy emergency department settings, radiolo-
language barriers, age, mental status, mental health, gists may be the first physicians to identify vulnera-
racial bias, and physical ability. The risks of vulner- ble patients. This is particularly important for victims
ability are both serious and real and range from falls of child abuse and intimate partner violence. Recent
to delayed diagnosis, neglect, abuse, and, in some work by Khurana et al., for example, demonstrated
cases, death.2,3 Increasingly, research and recent that an isolated ulnar fracture may be a marker for
events have highlighted links between patient vul- intimate partner violence in up to one-third of adult
nerability and health care disparities. The COVID- women with this finding.18 Such work highlights
19 pandemic, of note, caused a significant strain on the historically hidden but critical contributions that
health care delivery systems worldwide, dispropor- radiologists can make to the care of such patients.
tionately impacting Indigenous, Black, and Hispanic Recent advances in machine learning have now led
populations and catalyzing important conversations to algorithms that can leverage imaging findings to
about the vulnerability of patients due to race, socio- identify victims of intimate partner violence up to 3
economic status, and class.4 Examples of such dis- years before known victims have historically entered
parities include Indigenous and Black mothers who violence prevention programs.19 Although such work
are two to three times more likely to die from preg- is relatively new, it could be highly generalizable
nancy-related causes than White women, a number and impactful. Radiologists have long been trained
that increases to four and five times over the age of to identify healing and new fractures in children as
30 years.5,6 Similarly, rural populations that have his- potential signs of violence. They are often critical ini-
torically had inadequate access to preventative, spe- tiators of conversations of potential abuse in children
cialized, and emergent health care now increasingly (and now intimate partners) with important legal and
struggle, as a significant number of rural hospitals social implications for patients, their families, and
and health systems have closed.7–9 consulting providers.
xi
xii Foreword
As imaging leaders, radiologists have a unique role 4. Rogers TN, Rogers CR, VanSant-Webb E, Gu LY, Yan B,
Qeadan F. Racial disparities in COVID-19 mortality among
in improving the health of vulnerable populations.10,20 essential workers in the United States. World Med Health Policy.
The criticality of that role in the emergency depart- 2020; https://doi.org/10.1002/wmh3.358.
ment is highlighted for several groups of vulnerable 5. Howell EA. Reducing disparities in severe maternal morbidity
and mortality. Clin Obstet Gynecol. 2018;61(2):387–399.
populations. As the leaders in emergency imaging, 6. Heaman MI, Sword W, Elliott L, Moffatt M, Helewa ME, Morris
radiologists must recognize their role in improving H, et al. Barriers and facilitators related to use of prenatal care
imaging access for these groups. Progress within the by inner-city women: perceptions of health care providers.
BMC Pregnancy Childbirth. 2015;15:2.
radiology community will require several steps: (1) 7. Cyr ME, Etchin AG, Guthrie BJ, Benneyan JC. Access to spe-
understanding the barriers to hospital access and cialty healthcare in urban versus rural US populations: a sys-
how these can be lessened through imaging; (2) par- tematic literature review. BMC Health Serv Res. 2019;19(1):974.
8. Institute of Medicine (U.S.). Committee on Monitoring Access to
ticipating in and leading collaborative conversations Personal Health Care Services. Access to health care in America. In:
with emergency medicine colleagues to first identify Millman M, ed. Washington, DC: National Academies Press; 1993.
vulnerable patient groups and existing disparities in 9. Hartley D. Rural health disparities, population health, and
rural culture. Am J Public Health. 2004;94(10):1675–1678.
imaging, so as to close such gaps; (3) ensuring that 10. Waite S, Scott J, Colombo D. Narrowing the gap: imaging dis-
vulnerable patients receive the proper imaging, care, parities in radiology. Radiology. 2021;299(1):27–35.
and timely communication of their results; and (4) 11. Peek ME, Han JH. Disparities in screening mammography.
Current status, interventions and implications. J Gen Intern
facilitating and ensuring access to appropriate imag- Med. 2004;19(2):184–194.
ing follow-up. 12. Ahmed AT, Welch BT, Brinjikji W, Farah WH, Henrichsen
Readers of this book will gain a depth of knowl- TL, Murad MH, et al. Racial disparities in screening mammo-
graphy in the United States: a systematic review and meta-
edge regarding imaging in a breadth of vulnerable analysis. J Am Coll Radiol. 2017;14(2):157–165.e9.
populations, with a focus on the emergency depart- 13. Rauscher GH, Allgood KL, Whitman S, Conant E. Disparities in
ment, where many of these patients disproportionately screening mammography services by race/ethnicity and health
insurance. J Womens Health (Larchmt). 2012;21(2):154–160.
receive their care. Our hope is that, through reading this 14. Haddad DN, Sandler KL, Henderson LM, Rivera MP, Aldrich
text, radiologists will better identify the value of their MC. Disparities in lung cancer screening: a review. Annals of
impact in ensuring that all populations receive the care the American Thoracic Society. 2020;17(4):399–405.
15. Borondy Kitts AK. The patient perspective on lung cancer
they need, and hopefully they will then lead their radi- screening and health disparities. J Am Coll Radiol. 2019;16(4
ology practices, departments, hospitals, and commu- Pt B):601–606.
nities with a lens of health equity and a focus on lifting 16. Odahowski CL, Zahnd WE, Eberth JM. Challenges and oppor-
tunities for lung cancer screening in rural America. J Am Coll
up vulnerable populations. Engaged imaging experts Radiol. 2019;16(4 Pt B):590–595.
looking at the entire continuum of care can make a 17. Prosper A, Brown K, Schussel B, Aberle D. Lung cancer screen-
difference! ing in African Americans: the time to act is now. Radiol Imaging
Cancer. 2020;2(5):e200107.
Melissa A. Davis, MD, MBA 18. Khurana B, Sing D, Gujrathi R, Keraliya A, Bay CP, Chen
Richard Duszak, MD, FACR, FSIR, FRBMA I, et al. Recognizing isolated ulnar fracture as a poten-
tial marker for intimate partner violence. J Am Coll Radiol.
2021;18(8):1108–1117.
19. Chen IY, Alsentzer E, Park H, Thomas R, Gosangi B, Gujrathi
BIBLIOGRAPHY R, et al. Intimate partner violence and injury prediction
1. Adler NE, Rehkopf DH. U.S. disparities in health: descrip- from radiology reports. Biocomputing 2021. World Scientific.
tions, causes, and mechanisms. Annu Rev Public Health. 2020;26:55–66.
2008;29:235–252. 20. Safdar NM. An introduction to health disparities for the prac-
2. Waisel DB. Vulnerable populations in healthcare. Curr Opin ticing radiologist. J Am Coll Radiol. 2019;16(4 Pt B):542–546.
Anaesthesiol. 2013;26(2):186–192.
3. Am J. Vulnerable populations: who are they? Manag Care.
2006;12(13 Suppl):S348–S352.
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Index 227
xiii
Contributors
v
vi Contributors
The goal of Emergency Imaging of At-Risk Patients is to The book starts with an overview of social deter-
bring together in one book emergency findings in at- minants of health, which disproportionately affect
risk patient populations with unique clinical and imag- diverse, marginalized, and vulnerable populations.
ing presentations. We elected to focus on emergency We discuss health disparities that exist within acute
conditions in a diverse group of vulnerable patients. It diagnostic imaging. This overview is followed by two
is challenging to assess at-risk patients due to a myriad chapters describing neurological emergencies in geri-
of factors, including atypical clinical pictures, normal atric, cancer, and immunocompromised patients. The
physiological changes, delays in seeking medical care, following chapters cover traumatic and nontraumatic
comorbidities, and blunted inflammatory responses. chest, abdominal, and pelvic emergencies encoun-
History and physical examination can be misleading tered in pregnant patients. Then, abdominal emergen-
in at-risk patients, and imaging plays a crucial role in cies in postoperative bariatric patients and geriatric
effective triage of vulnerable patients. patients are discussed. It is unusual to have a subspe-
The emergency radiologist is expected to be com- cialty pediatric imaging emergency coverage 24/7/365
fortable with the interpretation of imaging studies outside of major children’s hospitals. Instead, imag-
covering all anatomic areas and to be at ease with ing examinations of acutely ill children admitted to
different imaging modalities, including radiography, the emergency department are typically performed by
fluoroscopy, and cross-sectional imaging. The editor emergency radiologists. Therefore, this book contains
of this book spent two decades teaching emergency two dedicated chapters describing imaging pitfalls
and trauma imaging and noted that his trainees excel in the assessment of common pediatric neurological,
in interpretation of cross-sectional examinations chest, and abdominal entities seen in the emergency
but can find it quite challenging to deal with radio- setting, including an in-depth discussion of imaging
graphs, especially with the high volume of abnormal of foreign bodies and complications related to malpo-
x-rays typical of the multitrauma patient. Therefore, sition of central lines and gastrointestinal tubes. Both
numerous adult and pediatric radiographs have pediatric chapters cover different aspects of imag-
been included. Multidetector computed tomography ing in victims of nonaccidental trauma and provide
(MDCT) is a workhorse in the emergency department. practical tips for the evaluation of imaging studies in
The book extensively discusses emergency indications this extremely vulnerable population. In the editor’s
for MDCT, with specific exploration of MDCT protocol opinion, there is one additional group of patients with
adaptation and adjustment of contrast injection tech- special imaging presentations justifying a dedicated
niques in vulnerable patients. However, emergency chapter: recreational drug users.
imagers should be cognizant of the effects of ioniz- The book draws on the vast clinical experience of
ing radiation related to computed tomography. These emergency and trauma radiologists from the largest
considerations are of paramount importance in emer- academic medical centers across North America. The
gency and trauma imaging of pediatric and pregnant authors present basic and advanced emergency imag-
patients. Hence, the role of ultrasound and magnetic ing concepts and discuss subtle imaging findings that
resonance imaging (MRI) in the emergency evaluation will be useful for radiologists in training and more sea-
of vulnerable patients is discussed. Emergency Imaging soned imagers, as well as emergency physicians, gen-
of At-Risk Patients contains multiple MRI cases with a eral, trauma and orthopedic surgeons, pediatricians,
thorough discussion of the intelligent use of MRI not obstetricians and gynecologists, and critical care phy-
only for the evaluation of brain, spine, and musculo- sicians looking for an update on this difficult topic.
skeletal emergencies but also for assessment of acute
chest, abdominal, and pelvic conditions.
ix
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1
2 Emergency Imaging of At-Risk Patients
their racial or ethnic group; religion; socioeconomic radiology, to work together to address the explicit and
status; gender; age; mental health; cognitive, sensory, implicit biases and structural issues that create barriers
or physical disability; sexual orientation or gender to care and lead to worse health outcomes for indi-
identity; geographic location; or other characteristics viduals and communities.
historically linked to discrimination or exclusion.”13
Health disparities disproportionately affect at-risk,
Geriatric Patients
vulnerable populations whose health conditions may
be exacerbated by a complex network of factors that In 2018, approximately 29 million US adults over
contribute to social determinants of health and create the age of 65 years, 16 million of whom were over
barriers to health care. the age of 75 years, sought ED care.16 Studies have
Addressing the social determinants of health is shown that older adults suffer higher rates of morbid-
essential to understanding the systemic and struc- ity and mortality in the ED despite receiving inten-
tural factors at every level of society that contribute sified resource use, including more physician time,
to health disparities. Social determinants of health more diagnostic testing, longer lengths of stay in the
comprise the material and social conditions in which ED, and higher admission rates.17 In a 2014 study,
people are born, grow, live, work, and age, as well as nearly half (49.8%) of all elderly patients presenting
the complex, interrelated economic systems and social to the ED across the United States underwent diag-
structures that fundamentally shape these condi- nostic imaging, 42.8% of whom were evaluated with
tions.14 According to the Centers for Disease Control X-ray and 12.6% with computed tomography (CT).18
and Prevention (CDC), social determinants have been There are many unique challenges to imaging elderly
found to influence health outcomes more than lifestyle patients, including limited mobility and increased falls
choices or health care. Studies have found that social risk, potential decreased cognitive abilities, inability to
determinants of health account for between 30% and hold still due to voluntary or involuntary motion, and
55% of health outcomes, with some estimates show- increased anxiety and disorientation in the ED setting.
ing that the contribution of sectors outside health to To obtain proper imaging and maintain safety, it may
population health outcomes exceeds the contribu- be necessary to use soft immobilization techniques,
tion from the health sector.14 To achieve health equity adjust patient positioning, and assist with transfers.
requires addressing obstacles to health such as pov- Elderly patients are also more vulnerable to social
erty, discrimination, lack of access to quality education isolation, socioeconomic instability, and abuse and
and housing, good jobs with fair pay, and safe envi- neglect, which increase their likelihood of presenting
ronments, as well as access to quality health care.15 to the ED.19 For example, seniors with lower incomes
Appropriately addressing social determinants of health or those who rely on Medicaid insurance may have
is therefore “fundamental for improving health and unmet health care needs, prompting them to seek out
reducing longstanding inequities in health, which emergency services to meet these needs.20 Isolation
requires action by all sectors and civil society.”14 and lack of social support have also been found to
Some of the most vulnerable and at-risk patient be significant indicators of increased frequency of ED
populations addressed in this book include geriatric visits by older adults.21 In particular, individuals with
patients, pediatric patients, pregnant patients, patients dementia have been shown to have consistently higher
with obesity, patients with cancer and compromised rates of ED visits.22 Dementia is also a well-docu-
immune systems, and patients with substance use mented risk factor for elder abuse,23 which may be
disorder. Each of these patient populations presents overlooked in the fast-paced environment of the ED.
particular challenges to care in the ED while also fac- Elder abuse is common, but unfortunately fre-
ing various barriers to care that cut across race, class, quently underrecognized and underreported. As many
gender, and socioeconomic factors that contribute to as 10% of older adults in the United States are vic-
health disparities. As many of these patients are con- tims of elder abuse each year, with fewer than 1 in
sidered high-risk both medically and socially, it is 24 cases identified and reported.24 Surprisingly, physi-
incumbent upon the entire health care team, including cians account for only 2% of all reported cases of elder
Chapter 1 Emergency Imaging of At-Risk Patients: General Principles 3
abuse.23 Because many elderly patients who present to and indirect complications related to cancer present
the ED undergo some form of diagnostic imaging, the significant challenges in the ED. Immunocompromised
radiologist is optimally positioned to identify potential patients are often sicker, present with atypical infec-
signs of abuse and communicate these concerns with tions, and have more complex medical needs com-
the health care team. pared with the general population.
Due to an overall increased risk of falls, osteopo- Many patients may also be first diagnosed with can-
rosis, and age-related brain atrophy, it can be difficult cer during an ED visit.33,34 Patients of lower socio-
to distinguish accidental from nonaccidental injury economic status are often more dependent on ED
in elderly patients.24,25 While there is substantial evi- services for health care and are therefore more likely
dence-based literature regarding radiologic findings to present emergently with undiagnosed cancer.33,35
of nonaccidental trauma in children, less literature Many studies have demonstrated significant racial and
is available on the subject of elder abuse. However, socioeconomic disparities in cancer screening imag-
imaging correlates do exist, particularly regarding frac- ing and procedures such as mammography,7 lung
ture patterns24 and “mechanism mismatch,” whereby cancer screening,9 and colorectal cancer screening.10
the fracture pattern is discordant with the mecha- For example, Black Americans have the highest inci-
nism of injury described by the patient or caregiver.25 dence and mortality rates of colorectal cancer, with
Additionally, screening tools such as the Elder Abuse many of the disparities arising from access to care and
Index and Elder Abuse Suspicion Index that incor- screening, as well as other socioeconomic factors.10,11
porate physical findings and social factors have been Emergency cancer presentations have also been asso-
developed and validated for use in the community and ciated with lower curative rates when compared with
in busy clinics or EDs to assist in detection of elder cancers diagnosed on an elective or screening basis,
abuse.23,26 even when the cancer is at the same stage.33
Elderly patients not only have more comorbidities Patients with cancer constitute a significant per-
and complex medical needs but also are more vulner- centage of ED visits in the United States, with nearly
able to socioeconomic instability, decreased access to 4 million visits per year.36 Common oncology-related
care, and abuse and neglect. As many elderly patients presentations include abdominal pain, nausea and
in the ED undergo diagnostic imaging, radiologists vomiting, fever, infection, and systemic reactions to
have the potential to play an important role in the therapeutic agents.27,37 Over 65% of patient with can-
detection of elder physical abuse and advocacy for the cer presenting to the ED undergo radiological imag-
health and safety of their patients. ing,27 highlighting the central role diagnostic imaging
plays in the diagnosis and management of acutely ill
Cancer and Immunocompromised oncology patients in the ED. Hsu et al. found that
patients with cancer were nearly twice as likely to
Patients undergo head, chest, and abdomen pelvis CT scans
Immunocompromised patients represent a growing and 30% more likely to receive X-ray imaging than
population in the United States and account for an patients without cancer presenting to the ED.36
increasing number of emergency room visits annu- Some of the most common ED presentations in
ally.27–29 Among cancer patients, more than 650,000 immunocompromised patients include acute abdomen
individuals per year receive cytotoxic chemotherapy,28 and central nervous system (CNS) infections. Acute
the side effects of which frequently require ED visits abdomen accounts for nearly 40% of ED presentations
and hospitalization for management.29,30 The num- of cancer patients.38 Patients may present with treat-
ber of patients undergoing solid organ transplants has ment-induced enteritis; complications related to a pri-
tripled over the last 30 years with advancements in mary tumor; or treatment-related complications from
immunosuppressive drugs,28,31 and currently more surgery, chemotherapy, or radiotherapy.38 Prompt radio-
than 1.2 million people in the United States are living logical diagnosis of life-threatening complications such
with human immunodeficiency virus.32 Treatment- as bowel perforation, obstruction, hemoperitoneum, or
associated toxicity, opportunistic infections, and direct graft-versus-host disease is necessary to ensure timely
4 Emergency Imaging of At-Risk Patients
and appropriate surgical and medical management. during pregnancy make physical examinations dif-
Immunocompromised patients are also at higher risk ficult, while physiological changes can complicate
of CNS infections.28 Although many image findings airway management and interpretation of vital signs.
may be nonspecific, the radiologist must be alert to These changes may result in diagnostic uncertainty and
both overt and subtle findings of a wide range of bacte- delay in care, which in turn increases the risk of com-
rial, fungal, parasitic, viral, and neoplastic pathologies. plications both for the mother and for the fetus. The
Prompt identification of meningitis, encephalopathy, radiologist, therefore, plays a crucial role in obtaining
abscesses, and mass-like lesions with or without her- timely and accurate imaging in order to make a correct
niation is key to directing appropriate emergent medi- diagnosis and direct appropriate care. The radiologist
cal and neurosurgical treatment. is also responsible for ensuring diagnostic imaging
Immunocompromised patients presenting to the quality while balancing the risks of ionizing radiation
ED for acute care represent a highly vulnerable popu- to the fetus and the mother.
lation at risk of numerous life-threatening infections, The first-line modality in imaging pregnant patients
malignancy-related complications, and treatment- is ultrasound, which avoids ionizing radiation and
related complications. Diagnostic imaging plays a allows for assessment of both the mother and the fetus.
central role in the detection and diagnosis of such When ultrasound in inconclusive, magnetic resonance
complications, as well as identifying the extent of dis- imaging (MRI) is the preferred second-line modal-
ease and its local and systemic affects. Timely clinical ity, particularly in the assessment of acute abdomi-
management requires prompt and accurate diagnosis nal pain.42,43 In the setting of trauma, or when other
in order to decrease morbidity and mortality in this modalities are nondiagnostic, CT is the modality of
at-risk population. It is incumbent upon the radiolo- choice,42,43 although the benefits need to be weighed
gist to work closely with referring clinicians to ensure against the risk of exposing the fetus to radiation. In
patients receive appropriate medical and surgical the setting of acute trauma, the American College of
management. Radiology (ACR) recommends CT of the abdomen and
pelvis with contrast, and when serious injury is sus-
pected, CT is the proven modality for full evaluation.43
Pregnant Patients The most common nonobstetric nontraumatic
Pregnant patients presenting to the ED represent a emergency presentations in pregnant patients include
highly vulnerable population. Studies have found that acute appendicitis, cholecystitis, and bowel obstruc-
30% of pregnant women in the United States present- tion.42,43 Studies have found that abdominal emer-
ing to the ED for care had one or more comorbidities gencies during pregnancy complicate approximately
(such as obesity, asthma, diabetes, and hypertension), one in 500 to 700 pregnancies, and up to 2% of cases
compared with 21% of pregnant women who did not require surgical intervention.42 The need for timely
seek ED care.39 Pregnant women seeking ED care are diagnosis is key, as delays in treatment increase the
also more likely to be at higher risk of socioeconomic risk of complication. For example, in the setting of
disparity, have delayed entry to prenatal care, be of a acute appendicitis, diagnostic delay is associated with
minority race, be on Medicaid insurance, and have a higher risk of perforation, which is associated with a
experienced domestic abuse.39,40 For example, many 20% to 35% rate of fetal loss.42
studies have shown that pregnant women of racial or Acute trauma also poses a significant risk to the
ethnic minority are at higher risk of pregnancy-related pregnant patient and the fetus and is the leading cause
morbidity and mortality due in large part to dispari- of nonobstetric maternal death in the United States,
ties in care driven by implicit racial bias.40 Pregnant affecting 5% to 8% of all pregnancies.43–45 Studies have
women are also at higher risk of domestic abuse, and found that, in cases of severe trauma, the rate of fetal
may present to the ED with a variety of complex inju- loss is as high as 50% to 90%.43,44 The most common
ries that endanger both the mother and the fetus.40,41 cause of injury is motor vehicle collisions, followed by
Managing pregnant women in the ED poses many falls, assault, accidents, and suicide.44 Blunt abdomi-
unique challenges. The anatomical changes that occur nal trauma accounts for 69% of all traumas45 and is
Chapter 1 Emergency Imaging of At-Risk Patients: General Principles 5
a leading cause of adverse fetal outcomes, including Evaluation of patients with obesity in the ED poses
preterm labor, abruption, uterine rupture, and fetal unique challenges both to the clinical care team as
demise.41,44 Radiology, therefore, plays a critical role well as to the diagnostic imaging team. Studies have
in the rapid and accurate diagnosis of potentially life- reported increased difficulty in cardiopulmonary
threatening injuries in both the mother and the fetus. auscultation, abdominal palpation, venous cannula-
Although the majority of traumas are nonviolent, tion, sedation, intubation, and patient positioning.49
pregnant women are nearly twice as likely to expe- Obesity also creates significant challenges for diagnos-
rience violent trauma as nonpregnant women.44 tic imaging. For example, limited mobility may result
Studies have shown that the reported prevalence of in suboptimal patient positioning; the aperture diam-
interpersonal violence ranges between 1% and 20% eter of CT and MRI scanners and maximum table load
of all pregnant women, although this is likely grossly limits may exclude some patients from receiving more
underestimated due to the underreporting of domes- advanced imaging; CT images may have more trun-
tic violence.45 As there is an increased risk of abuse cation artifact and photon starvation, which decrease
among pregnant patients seeking emergency care, imaging quality50; increased body mass and thickness
health care providers are in a unique position to help result in increased photon scatter and reduced con-
identify and assist patients in finding safe and accessi- trast resolution in radiography50; and the thickness of
ble resources. The radiology department in particular subcutaneous tissue and sound-attenuating properties
offers a uniquely private space away from the potential of fat limit the use of ultrasound in larger patients.51
abuser in which patients may feel safe disclosing abuse Additionally, studies performed in phantoms indicate
and requesting help. that patients with obesity receive higher radiation
Radiology plays a critical role in the timely and doses during CT and radiography than do nonobese
accurate diagnosis of nontraumatic and trauma-related patients.52
emergencies in pregnant patients in the ED. The diag- As the rates of obesity have risen, so too has the
nostic imaging team may also play an important role use of bariatric surgery, as it remains the most effec-
in assisting victims of abuse, as well as advocating for tive long-term treatment for severe obesity and associ-
all patients to have equal access to high-quality health ated comorbidities.53,54 Although bariatric surgery has
care regardless of race, ethnicity, or socioeconomic a low complication profile, studies have shown that
status. up to 10% to 12% of patients visit the ED within 30
days of surgery.53 The most common postoperative
complications include surgical site infection,55 cho-
Bariatric Patients lelithiasis,56 bowel obstruction,54,55 and anastomotic
The prevalence of obesity has steadily increased over leaks.57 As diagnostic imaging, particularly the use
the past three decades and has become a major public of abdominal CT, is central to the diagnosis of many
health issue. According to the CDC and the National postbariatric surgery complications, it is imperative
Center for Health Statistics, the prevalence of obe- that appropriate patient positioning and modified pro-
sity across the United States has risen to 42.2%, with tocols be used to optimize image quality and ensure a
severe obesity reaching highs of 9.2%.46 There are timely and accurate diagnosis.
significant health issues related to obesity, including Patients with obesity not only face obstacles to care
heart disease, stroke, type II diabetes, hypertension, based on particular physical and technological limita-
hyperlipidemia, and obstructive sleep apnea, to name tions but are also subject to pervasive stigmatization
a few. The cost of obesity-related health care is signifi- and weight bias, which has been shown to contrib-
cant, with an estimated annual cost of $147 billion46 ute (independent of weight or body mass index) to
and a 41.5% increase in per capita medical spending increased morbidity and mortality.58,59 Weight bias is
compared with nonobese adults.47 Prior studies have defined as the negative beliefs and attitudes attributed
also shown that patients with obesity have a greater to an individual based on their weight, and stems from
use of hospital services with greater hospital costs than perceptions that obesity is caused by an individual’s fail-
do nonobese patients.48 ure to control their diet and exercise. The stigmatization
6 Emergency Imaging of At-Risk Patients
of people with obesity has contributed not only to may present not only with life-threatening physiologi-
health and social inequalities but also to inequities in cal symptoms related to neurologic, pulmonary, or
obesity treatment with respect to both access and qual- cardiovascular failure but also with complications sec-
ity of care.60,61 The perceived message of shame and ondary to infection, trauma, and behavioral/psychoso-
blame perpetuated by health care professionals and cial changes, as well as altered mental status. Patients
public health officials may be at least partly responsible suffering from substance abuse and addiction also
for health care avoidance and decreased adherence to face the added burden of stigma within the medical
medical advice.60 Therefore, it is important that health community, which has been associated with a higher
care professionals and policy makers advocate for and rate of diagnostic errors and adverse effects on health
support people living with obesity, including support- outcomes.67,68
ing policy action to prevent weight bias and weight- Substance abuse results in a wide variety of medi-
based discrimination.22,28 cal complications affecting nearly every organ system
Radiology plays a key role in the management of in the body.69 Diagnostic imaging plays a critical role
patients with obesity in the ED, particularly in postbar- in the diagnosis and guidance of treatment for many
iatric surgery patients. In order to provide high-quality drug abuse–related complications, which can be asso-
care, it is important that the radiology team possess ciated with significant morbidity and mortality.70 As
a thorough understanding of the limits of imaging patients may be unconscious or otherwise unable to
equipment, how to reduce image artifacts, and how to describe their symptoms, many drug-related com-
implement specific techniques and protocols to ensure plications may only be detected by imaging, and it
high-quality imaging. The entire radiology department is incumbent upon the radiologist to provide timely
should also work to ensure their clinical environment and accurate diagnoses to help direct care. Patients
is accessible, safe, and respectful to all patients regard- presenting with altered mental status due to substance
less of their weight or size.58 abuse may also make it difficult to obtain high-quality
imaging. Patients may be unable to lie still or follow
directions related to positioning or breath-holding, or
Patients With Drug Abuse may in some cases be combative toward health care
Recreational abuse of both pharmaceutical and illicit workers. As such, patients may require physical or
drugs has risen sharply in the United States over the chemical restraints for the safety of both themselves
past two decades. According to the CDC, the number and the imaging team in order to obtain quality images
of deaths related to drug overdose increased by nearly to aid in a correct diagnosis.
5% from 2018 to 2019 and has quadrupled since For the radiologist, awareness of the imaging
1999.62 Opioid abuse in particular has risen to epi- features associated with recreational drug abuse is
demic proportions, prompting the US Department of key, as the complications from many drugs, particu-
Health and Human Services to declare a public health larly intravenous drugs, often affect multiple body
emergency in 2017.63,64 Of all the drug-related deaths systems.71 For example, CNS manifestations may
in 2019, over 70% involved an opioid, while deaths include posterior reversible encephalopathy syn-
related to synthetic opioids (excluding methadone) drome, spongiform leukoencephalopathy, infarct,
increased by over 15% in 2019.62 Drug “misuse” and hemorrhage, and vasoconstriction72; respiratory
“abuse” account for approximately 2.5 million vis- complications include pneumonitis, pulmonary
its to the ED per year, nearly half of which are due edema, pneumothorax, and alveolar hemorrhage73;
to illicit drugs.65,66 The most common drug-related cardiovascular injury may present as aortic dissec-
deaths from pharmaceuticals are due to opioids and tion, mycotic aneurisms, and septic thrombophlebi-
benzodiazepines, while the most common illicit drugs tis; gastrointestinal manifestations include decreased
encountered in the ED include cocaine, marijuana, motility and constipation resulting in pressure-asso-
methamphetamines, and hallucinogens.65,66 ciated ischemia,69 as well as body packing of drugs
Managing drug and alcohol abuse in the ED poses within the bowel, resulting in obstruction or perfo-
a number of challenges. Patients with substance abuse ration74; and musculoskeletal complications may
Chapter 1 Emergency Imaging of At-Risk Patients: General Principles 7
occur from infection, trauma, thrombosis, foreign ED environment. These factors make it difficult to
bodies, compartment syndrome, and osteomyeli- obtain diagnostic-quality imaging, especially if the
tis.69,75 However, many of these imaging features are child is unable to hold still or otherwise cooperate.81
nonspecific, and clinical history may be lacking. As Pediatric imaging also requires specific protocols
such, the radiologist should maintain a high index of across all modalities, as well as strict adherence to
suspicion, particularly in patients with unexplained the As Low As Reasonably Achievable (ALARA) prin-
symptoms or clinical presentations, and should com- ciple in order to minimize radiation. As such, it is
municate directly with referring physicians to ensure important that all radiology personnel involved work
patients receive timely and appropriate care. to gain the child’s trust and cooperation prior to and
All members of the health care team should also be throughout the entirety of the exam.81
aware of the internal bias and stigmatizing attitudes Children are also highly vulnerable to abuse,
toward patients who suffer from substance abuse. exploitation, and discrimination, and it is the duty of
Studies have found that negative attitudes of health all health care professionals to be alert to signs of mal-
professionals toward patients with addiction lead to treatment at both the domestic and the societal level.
poor communication, poor therapeutic alliance, and Radiology technologists, and the reporting radiologist
increased diagnostic errors.67,76 In addition to the eth- in particular, play an important role in the identifica-
ical implications of stigmatizing patients with addic- tion, evaluation, intervention, and prevention of child
tion, studies have also shown that patients who felt abuse by being attentive to signs of nonaccidental
discriminated against by health professionals were less trauma (NAT).82 In 2019, approximately 3.5 million
likely to complete their treatment.76 As the radiolo- children were subject to investigation due to suspi-
gist plays a key role in the detection and diagnosis of cion for NAT, with 656,000 determined to be victims
complications related to substance abuse, it is impera- of maltreatment. Additionally, there were 877 victims
tive that the diagnostic imaging team work together to of sex trafficking identified in the 29 states for which
ensure patients not only receive timely and accurate these reporting data are available.83 As radiology tech-
imaging but also feel safe, supported, and respected nologists have direct physical contact with the child,
within the health care environment. particularly during sonographic imaging, this pres-
ents a valuable opportunity to evaluate the child for
any signs of potential abuse. The radiologist in turn
Pediatric Patients is doubly responsible for being alert to signs of NAT,
Pediatric ED visits constitute nearly 20% of all ED vis- as well as communicating any concerns to the health
its. In 2018, there were approximately 29 million ED care team.
visits in the United States for children under the age of As the appropriate use of diagnostic testing in chil-
18 years, with a rate of 388.2 per 1000 population.16 dren is an essential determinant of health care qual-
Although patient presentations vary by age, some ity, it is important to understand the ways in which
of the most common conditions include wounds, health care disparities may manifest in the use of
sprains, strains, fractures, viral and respiratory infec- diagnostic imaging in the pediatric emergency set-
tions, fever, cough, nausea and vomiting, and abdomi- ting. Many studies have identified disparities in both
nal pain.77 Pediatric trauma more specifically is one of access to and quality of health care for children of dif-
the leading causes of ED presentations and a leading ferent races, ethnicities, and income levels regardless
cause of morbidity and mortality.78,79 of presenting complaint.3,79,84 For example, a 2021
Radiological imaging is commonly used for pedi- study found that ED imaging was performed in 33.5%
atric patients in the ED setting, with approximately of non-Hispanic White children compared with
one-third of all visits including at least one imag- 24.1% of non-Hispanic Black children and 26.1%
ing study.3,80 Pediatric imaging poses a number of of Hispanic children.3 A 2016 study similarly found
challenges in the ED setting. Injured and sick chil- that Black and other minority patients and patients
dren presenting to the ED are often frightened, without private insurance had lower odds of receiving
irritable, wary of strangers, and intimidated by the advanced imaging for abdominal pain compared with
8 Emergency Imaging of At-Risk Patients
White patients.84 In the trauma setting, Black patients Program Requirements for residency training pro-
with blunt abdominal trauma were 20% less likely to grams and specifically included health care disparities
receive an abdominal CT exam compared with White as a key component of quality health care.88,89 There
patients.85 are a number of resources designed to help provide
These racial disparities arise from a variety of con- basic introductions to cultural competency and social
founding factors encompassing a wide range of indi- determinants of health, all of which are applicable to
vidual, structural, and systemic issues surrounding radiology.4,89,90 A departmental and profession-wide
racial inequality. Such factors include parent/guard- commitment to education is key to developing a pro-
ian preferences, physicians’ implicit racial biases, and fessional community that is capable of discussing and
pervasive structural factors rooted in the health care addressing health disparities at all levels of society.
system.3 Implicit racial bias among clinicians in par- Improving diversity within the workforce is also
ticular has been found to be a determining factor in fundamental to improving care for diverse populations.
patient access to quality care and has been associated Despite more recent efforts to improve diversity within
with doctor-patient interactions, treatment decisions, radiology, women as well as racial and ethnic minori-
and patient health outcomes.3 ties remain significantly underrepresented in diagnos-
Such biases have also been found to play a role in the tic imaging.91,92 The ACR Commission for Women
racial disparity surrounding reporting of suspected child and General Diversity emphasizes that the benefits
abuse. For example, a 2002 study found that minority of a diverse specialty are not limited only to physi-
children aged 12 months to 3 years who sustained a cians, but that patients also receive better care in an
skull or long bone fracture were significantly more likely inclusive, diverse health care system.93 Participating in
to undergo a skeletal survey than non-Hispanic White research related to health disparities is also a valuable
children and also more likely to be reported to Child way to interrogate inequities in diagnostic imaging
Protective Services.86 However, after the implementa- while also providing a road map for actionable change.
tion of abuse-screening guidelines, other studies found Radiologists may also choose to participate in various
that racial disparities in reporting significantly decreased, forms of advocacy at the local and national level as a
resulting in no statistically significant difference by race.87 means to promote the specialty and improve access to
Radiology plays an important role in the diagno- imaging services for all patient populations. Through
sis and management of pediatric patients in the ED. education, commitment to diversity and inclusion,
The diagnostic imaging team may help identify and research, and advocacy, radiologists can work to
prevent not only child maltreatment but also potential address health care disparities and improve care for
racial disparities in access to imaging. Through clear diverse, marginalized, and vulnerable populations.
communication with the referring care team, the radi-
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Chapter 2
Neurological Emergencies in
Geriatric Patients
Maria J. Borja, Angela Guarnizo, Elizabeth S. Lustrin, Thomas Mehuron, Brian Zhu, Steven
Sapozhnikov, Nader Zakhari, and Carlos Torres
12
Chapter 2 Neurological Emergencies in Geriatric Patients 13
challenges faced with this population underscore the and motor vehicle–related trauma being the second
importance of neuroimaging in older patients. This most common mechanism of injury.7
chapter will discuss imaging findings of neurological Noncontrast computed tomography (NCCT) is the
emergencies in geriatric patients. imaging modality of choice in the acute setting due to
speed and high sensitivity for detecting ICH. NCCT
helps guide the clinician to the etiology of the hemor-
Intracranial Hemorrhage rhage, assesses ICH evolution, evaluates for the pres-
Intracranial hemorrhage (ICH) is a growing cause of ence of mass effect and shift of midline structures and
death and disability worldwide due to the increasing hydrocephalus, and assesses bony integrity. Computed
population of elderly people in the developed world. tomography (CT) angiography (CTA) and CT venog-
The incidence of intracerebral hemorrhage is 5.9 per raphy may be useful in the acute setting for the evalu-
100,000 in ages 35 to 54 years, 37.2 per 100,000 in ation of arterial and venous vasculature when vascular
ages 55 to 74 years, and 176.3 per 100,000 in ages lesions or vascular injury are suspected.
75 to 94 years.4 Risk factors include falls, amyloid Although typically not the first imaging modality,
angiopathy, hypertension, and greater use of antico- magnetic resonance imaging (MRI) can also be used in
agulant or antiplatelet therapy, with mortality rates as the evaluation of ICH and has high sensitivity for intra-
high as 50%.5,6 parenchymal microbleeds. The presence of microbleeds
ICH can be subdivided by location, either within may be a marker for underlying pathologies, including
the brain parenchyma or in the surrounding com- hypertension, amyloid angiopathy, vascular malforma-
partments, including the subdural, epidural, sub- tions, posttreatment changes, and diffuse axonal injury,
arachnoid, and intraventricular spaces. ICH most and can help predict the risk of future bleeding events.8
commonly occurs in the setting of trauma in the The appearance of blood on CT and MRI varies
elderly population, with falls accounting for 84% of depending on the staging of blood products and the
trauma incidents in patients aged 65 years or older, chemical state of hemoglobin (Table 2.1 and Fig. 2.1).
TABLE 2.1 Hemorrhage Phases and Appearance on Computed Tomography and Magnetic
Resonance Imaging
Magnetic Resonance Imaging Signala
Hemorrhage Computed
Phase Time Tomography Densitya Hemoglobin T1 T2
Hyperacute <12 hours Isodense <1 hour, Oxyhemo- Isointense Iso- to hyperintense
then hyperdense globin
A B C
D E F
G H I
J K L
Fig. 2.1 Magnetic resonance imaging and noncontrast computed tomography (NCCT) images of hemorrhages at different stages. The first row (A–C)
shows acute intraparenchymal hemorrhage in the right frontal lobe (arrows). Note isointense signal on T1-weighted imaging (WI) (A), hypointense
signal on T2WI (B), and corresponding hyperdensity on NCCT (C). The second row (D–F) shows early subacute hemorrhage. Note hyperintense signal
on T1WI (D) and hypointense signal on T2WI (E) in the left parietal lobe (white arrows), consistent with early subacute hemorrhage, with associated
cavernous malformation (star). NCCT (F) on a different patient shows isodense attenuation along the left frontoparietal convexity, consistent with
early subacute subdural hematoma (black arrow). The third row (G–I) shows late subacute hemorrhage. Note hyperintense signal on both T1WI (G)
and T2WI (H) in the right occipital lobe (white arrows) consistent with late subacute intraparenchymal hemorrhage. Iso- to hypodense attenuation
along the left convexity on NCCT (I) of a different patient is consistent with late subacute subdural hematoma (black arrow). There is associated
midline shift (arrowhead). Fourth row (J–L) shows chronic subdural hematoma along the right frontoparietal convexity (arrows). Note hypointense
signal on T1WI (J), hyperintense signal on T2WI following the signal of cerebrospinal fluid (K), and corresponding hypodensity on NCCT (L).
Chapter 2 Neurological Emergencies in Geriatric Patients 15
A B C
Fig. 2.2 Different locations of acute subdural hematomas. Coronal noncontrast computed tomography (NCCT) (A) shows acute subdural hematoma
along the left tentorial leaflet (long arrow) and left convexity (short arrow). Axial NCCT (B) shows subdural hematoma along the bilateral tentorial
leaflets (long arrows) and the left temporo-occipital convexity (short arrow). Axial NCCT through the high frontal and parietal lobes (C) shows acute
subdural hematoma along the falx bilaterally (arrows).
A B
Fig. 2.3 Epidural hematoma. Coronal (A) and axial (B) noncontrast computed tomography of the brain in a 77-year-old male after a fall demonstrate
a biconvex hyperdense lesion centered along the right parietal convexity (arrows in A and B), consistent with epidural hematoma.
16 Emergency Imaging of At-Risk Patients
do not typically cross suture lines, unless there is a superior to CT in detecting acute SAH. Acute traumatic
concomitant sutural diastasis. Compression of the SAH is identified by hyperintense signal abnormal-
adjacent brain parenchyma is often present. ity within the cerebral sulci on FLAIR sequences and
hypointense blooming on SWI12 (Fig. 2.4).
SUBARACHNOID HEMORRHAGE Some 80% to 85% of spontaneous (i.e., nontrau-
Subarachnoid hemorrhage (SAH) is the most encoun- matic) SAHs are caused by rupture of saccular aneu-
tered type of traumatic ICH,11 and is typically seen in rysms. Most saccular aneurysms occur at the circle of
the cerebral sulci along the convexities and vertex of Willis and bifurcation of the middle cerebral arteries
the head. Although MRI is less commonly used for ini- (MCAs); thus, most aneurysmal hemorrhages involve
tial evaluation of head trauma, the combination of fluid the basal cisterns and sylvian fissures (Fig. 2.5). Once
attenuation inversion recovery (FLAIR) and suscepti- an acute SAH with a basal aneurysmal pattern is identi-
bility-weighted imaging (SWI) sequences has excellent fied on initial NCCT, CTA is the indicated next step for
sensitivity for acute ICH and has been shown to be identification of aneurysms. Aneurysmal hemorrhages
A B C
Fig. 2.4 Acute subarachnoid hemorrhage (SAH). Hyperdensity along the left frontal sulci on noncontrast computed tomography (A), with correspond-
ing hyperintense signal on fluid attenuation inversion recovery (B) and susceptibility on susceptibility-weighted imaging (SWI) (C), is consistent with
acute SAH (long arrows). Siderosis from chronic SAH (short arrow) is seen in the right frontal sulci on SWI (C).
A B C
Fig. 2.5 Aneurysmal subarachnoid hemorrhage. (SAH) Axial (A and B) and sagittal (C) noncontrast computed tomography in a 67-year-old male with
acute “worst headache of life” from ruptured anterior communicating artery aneurysm. Extensive SAH centered at the basal cisterns and adjacent
sulci (long arrow). Note intraventricular hemorrhage with mild hydrocephalus (short arrow).
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