Emergency Radiology:

The Basics
Rathachai Kaewlai, MD

www.RadiologyInThai.com

Created: November 2006

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 Study Objectives

After studying, the readers should be knowledgeable of

Basic physics of different imaging modality, especially plain
radiography, US and CT.
Advantages and limitations of each modality.
Basic rules in requesting radiology examinations.
Basic principle of picture archiving communication systems
(PACS).
Current and future trends in radiology.

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Basics: Plain Film Radiography

Plain film radiography uses x-ray as a source to create an

image on the screen, and projected as a hard-copy image or
into a computer.
It is a 2D image of a 3D object (human organs), this should
be kept in mind and there is extensive overlapping structures
in plain film radiographs. This issue is resolved by
Do at least 2 views perpendicular to each other; for example,
chest x-ray in PA and lateral views.
Do a cross-sectional imaging such as CT, MRI or ultrasound
to overcome the overlapping.

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Basics: Plain Film Radiography

There are 5 relative different radiodensities in medical x-ray. This

is presented from the least dense to the most dense particles (Dark
to bright)

Density Appearance
Air least dark
Fat less dark, but still dark
Soft tissue medium
Bone bright
Metal most brightest

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Basics: Plain Film Radiograph
Projections (views) of radiograph
determined by
Location of the x-ray tube and the
x-ray film in relation to the patients
anatomy.
For example, Postero-anterior (PA)
view means the x-ray beam travels
from back to front of the patients
and hit the film in the front of the
patients.
Chest x-ray (PA)

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The difference between PA and AP, is
the organ (or part of the body) that is
closer to the film, will be better
visualized. For example, in PA skull
radiograph, the lesion in frontal bone
will be better visualized than in
occipital bone. In chest radiograph,
different magnification causes the
cardiac silhouette to be larger in AP
projection. The rule is put the film on
the side of interest.

Chest x-rays of the same patient

performed in the same day, in two
different projections (above; PA,
below; AP).

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Basics: Plain Film Radiograph

Projections (views) of radiograph determined by

Position of the patient: this will define the heaviness of
movable substances in our body. Air goes up against the
gravity, free fluid follows the gravity.
Right/left decubitus: Right lateral decubitus is putting the right
side of the patient down. This is still a frontal (AP or PA)
radiograph.
Lateral cross-table: A lateral projection that is taken across the side
of the patient when he/she is on the bed.

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Basics: Plain Film Radiograph

Portable radiograph:
The only indication is when the patient is too sick to leave the
bed. Example - ICU patients, injured patients on the trauma
board or in the operating rooms.
Cons: Different magnification (distortion of the size of organs),
decreased quality of the images.
Usually it is done in AP projection, which is still different from AP
projection performed in the radiography room.

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Basics: Plain Film Radiograph
Stress radiograph:
Put a stress (either patients
own weight, force or extra
weights to carry) on specific
organs, usually joints. For
example, acromioclavicular
joints radiograph, standing
knee radiograph, flexion/
extension views of the
cervical spine.

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Basics: Computed Tomography

There is no superimposition in CT.

CT gives more information on different tissue density.

CT works by
Passing a thin x-ray beam through the body of the patient in the axial
plane, as the x-ray tube moves in a continuous arc around the patient.
The opposite side of the x-ray tube are electronic detectors. The detectors
converted the exit beam into electronic signals.
The signals are sent to the computer, which calculates the x-ray
absorption values and arrange the image.

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Basics: Computed Tomography

Hounsfield unit (HU) = the absorption value of x-ray beam

in the tissue.
Water is assigned the value of zero.
Approximate HU for fluid 0-20 HU, acute blood 40-60 HU.
Denser value (white) ranges upward to bone, and metal.
Less dense value (darker) ranges downward through fat to air.
The picture is produced equivalent to a radiograph of that
cross-sectional slice of the patient.

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Basics: Computed Tomography

CT window
Different windowing in CT allows optimal evaluation of
each organs; e.g. subdural window (for subdural blood), brain
window (for brain parenchyma), bone window (for bone), etc.

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Basics: Computed Tomography

CT protocol
Almost all CT scans were performed in axial plane. These axial
scans can be processed into sagittal, coronal reformations or
others.
What is useful to find out, as a clinician?
Scanner type (conventional, helical, multidetector),
Slice thickness (ranges from submillimeter to 10
mm),
Location of first and last slices (to see the extent of study; will it
include the organ of interest?),
Type of contrast usage (what kind of contrast will radiologists give to
the patients?)

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Basics: Computed Tomography
View the CT scan as though you
were looking up at it from the
patients feet.

CT protocol
Different radiology departments have
different CT protocols. It is best to
know your own hospitals radiology
department scanners and protocols,
in order to adjust it with your own Right
Left
practice.

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Basics: Computed Tomography
Reformatted CT images
The CT scanner computer or a separate
computer can stack a series of CT slices
on top of one another, so the stack can be
sliced in other planes such as coronal,
sagittal or oblique planes.
The techniques are especially useful to
see pathology of the spine, long bone,
joint. Coronal images are easier to
understand by clinicians.

Reformatted CT images and 3DCT can be performed with multidetector CT scanners.

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Basics: Computed Tomography
Three-dimensional CT (3DCT)
As explained in previous page,
computer can also stack multiple
slices into 3D image of the soft
tissues, bones or blood vessels.
Useful to provide a surgeon with
the most realistic display of the
pathology; especially complex
orthopedic injuries.

Reformatted CT images and 3DCT can be performed with multidetector CT scanners.

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 Basics: CT Angiography

Scanning when the IV contrast bolus reaches its peak in the

vascular structures being studied (either arterial or venous).

Similarity with conventional angiography

Give same information in a much less invasive way.
Use of x-ray and IV contrast material.

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 Basics: CT Angiography
Technical difference from CT
Need faster scanner (helical, multidetector).
Need faster IV contrast injection rate (means
larger size of the needle).

Technical difference from conventional

angiography
No placement of angiographic catheter (non-
invasive).
Unable to provide treatment such as angioplasty,
stent placement, etc.

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 Basics: CT Angiography
Head-to-toe applications
Head and neck: aneurysm, AVM,
carotid atherosclerosis, venous sinus
thrombosis, etc.
Body: aortic dissection, pulmonary
embolism, coronary artery, renal artery
stenosis, deep vein thrombosis, etc.
Extremity: brachial, femoral
arteriogram.

Preparation
No oral contrast or rectal contrast
used.

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 Basics: MRI

MRI uses very powerful magnets, ranging from 0.3 to 3

Tesla (in clinical practice).

The patient is placed in the magnet bore, radio waves are

passed through the body in particular sequences. The body
tissues respond by emitting the pulses, which are then
recorded by a detector, sent to computer.

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 Basics: MRI
Various body tissues emit
characteristic MR signals, which
determine whether they will appear
white, gray or black on the images. T2-WI
In general: Water is black on T1-WI
(T1 weighted image), white on T2-
WI. Most tumors and inflammatory
masses appear white on T2-WI.
Compact bone appears black in all
sequences. T1-WI

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 Basics: MRI
T1-WI
Advantages
Greater differentiation of soft tissue
structures.
Can be acquired in any planes.
Can provide vascular study without use of
IV contrast.

Disadvantages
Longer time of scanning.
Motion artifacts from respiration, cardiac
pulsation (for scanning of the chest and
abdomen).
T1-WI + IV contrast
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 Basics: Ultrasound

Use of high-frequency sound waves and its reflection to create the

cross-sectional images of the body.

Advantages
No ionizing radiation, no biological injury.
Can be acquired in any planes.
Less expensive machine and exam cost.
Can be performed at the bedside of the very sick patients.
Provide moving images of the heart, fetus, and other structures.

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 Basics: Ultrasound
Disadvantages
Less sharp and clear images,
Take more time than CT,
Quality and accuracy
depending on operators skills.
Some structures such as bone
and lung cannot be examined.
Normal Doppler US of the
lower extremity veins

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 Basics: PACS

Picture Archiving Communication Systems (PACS) are computers or

networks dedicated to the storage, retrieval, distribution and presentation of
images.

It replaces hard-copy medical images (such as plain film radiographs,

ultrasound, CT and MRI). Radiologists use PACS to see the images and
interpret them.

Advantages:
Image manipulation: brightness, contrast, rotate, zoom, measurements, etc. Better
diagnostic accuracy, e.g. see through bone in chest x-ray.
Less storage space for hard-copy images, less risky for wrong patients identification.
Teleradiology.

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With PACS, radiologists can play
with the images in multiple way. For
example: we can look at lung, ribs and
spine in one chest radiograph without
difficulty.

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 Prepare Your Patients for
Imaging

Rule #1: select the right imaging technique to answer the specific clinical
question.
Know the indications.
Know what to expect from each imaging modality (its limitation and
usefulness).
Know your hospital capability (scanners, radiologists preference and ability).

Rule #2: check the contraindication.

Rule #3: discuss with the radiologist(s).

Rule #4: prepare the patients.

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 Rule #1

The American College of Radiology (ACR) has published

Appropriateness Criteria for imaging investigation in various
clinical settings in its website, http://www.acr.org/s_acr/sec.asp?
CID=1845&DID=16050 for several years.

This criteria has been proposed to be used by referring physicians

for a better and efficient way of choosing the right imaging
modality to answer the specific clinical question.

They will be presented separately in the upcoming lectures in each

topic.

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 Rule #2

CT: contraindications
There is no absolute contraindication if benefits weigh risks.
X-ray related: in pregnant patients and children
Contrast related:
Hypersensitivity to iodinated contrast medium.
History of seafood allergy is NOT a contraindication to iodinated
contrast medium administration. Although, if other allergic disorders
coexist, this will increase the chance of having contrast
hypersensitivity.
Asthma, allergic disorders increase risk of hypersensitivity.
Renal failure, diabetes, current use of metformin contribute to
increased risk of contrast-related renal failure.

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 Rule #2
CT: contraindications - What To Do?
Pregnancy, children Other modalities (MRI, US)
Risk of hypersensitivity
Premedication with oral/IV
Steroids (consult your radiologist)
Use non-ionic contrast medium reduces the risk of minor reaction.
High serum creatinine (usually defined as Cr > 1.5 in healthy
adults, lower in older individuals. Treatment protocol varies
(consult your nephrologist)

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 Rule #2

MRI: contraindications
Generally, MRI is very safe and adverse reactions to contrast
agents are extremely rare.
Absolute contraindications
Cardiac pacemakers,implanted cardiac defibrillators, otic/inner ear/
cochlear implants, metal fragments in the eye.
Others
Heart valve, aneurysm clip (depending on the models), passive
implants (depending on its ferromagnetic status).
Pregnancy: No known risks, however, late effects on fetus may be
unrealized since MR has been widely available for only 15 years.
Gadolinium is not FDA-approved during pregnancy.

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 Rule #3
Know your radiologist
Communication is the key. Two-way communication between
clinicians and radiologists is encouraged for a better patient
care.
Having radiologists in the emergency department will make a
difference.
There is a different nature of emergency radiology from other
radiology subspecialties.
Safe, fast, effective radiology protocols
Supervision of the technical performance of imaging.
Performing bedside procedures.
Timely interpretation of the images.
Better communication with the emergency physicians.
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 Rule #4

Prepare the patients

Plain film radiography and CT
All sexually-active women must be checked for potential pregnancy.
If IV contrast will be used:
Serum creatinine is mandatory in patients of old age, history of kidney
disease, diabetes, hypertension.
History of previous hypersensitivity reaction or allergy disease. For
diabetics, metformin use need to be checked.
If oral contrast will be used:
If bowel perforation is suspected; use water-soluble contrast.
If rectal contrast will be used:
If bowel perforation is suspected; use water-soluble contrast.

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 Rule #4

Prepare the patients

Ultrasound
Depending on the type of exams: fasting, full bladder may be
needed.
Make sure there is no obstructing object at the area of interest
(such as bandage).
MRI
Complete MRI request checklist.
There might be a need for sedation in children and claustrophobic
patients.

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 What to Expect

Increased volume of patients through the emergency department.

Increased volume of radiologic procedures in the emergency

department.

Increased use of advanced imaging technique for noninvasive

diagnosis and treatment.

Modern ED incorporates emergency radiology (plain film

radiography, ultrasound and CT) as a subsection. The ultra-
modern ED will have MRI.

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 Current Trends in ED
Radiology

Total body CT scan for multiply injured patient: Scanning from

head down to pelvis in one pass, allowing rapid and accurate
diagnosis of multiple organ injuries ranging from brain, chest,
abdomen/pelvis, spine from cervical down to thoracolumbar
region.
Stroke protocol: optimized protocol for rapid stroke diagnosis,
diagnosis of salvageable brain for potential anticoagulation
treatment or interventions.

Cervical spine CT for trauma: More accurate and faster than

plain film radiography.

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 Current Trends in ED
Radiology

Chest CT to rule out PE: Historically difficult diagnosis becomes

easier in seconds of MDCT scanning.

Stone protocol abdomen CT: More accurate than plain film

radiograph, faster than IVP and most importantly, MDCT detects
alternative diagnosis such as appendicitis, gynecologic conditions,
etc.

Bone CT with 3D reformation for complex fractures: Help in

orthopedic treatment planning such as fractures of the
acetabulum, tibial plateau.

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 New Trends in Radiology

CT colonography (Virtual colonoscopy)

CT bronchography (Virtual bronchoscopy)

Coronary calcium scoring

Coronary CT angiography

Fusion PET-CT (Positron emission tomography-computed tomograph)

Functional MRI

Molecular imaging

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How Radiology Effects Patient
Care

Pros
Help in clinical decision making, surgical VS. medical issue.
Triage patients toward proper areas (discharge, observation unit, surgery or
admission).
Fast, accurate, noninvasive diagnosis.
This could lead to faster treatment, better outcome and an overall better patient
care.

Cons
Higher cost?
Non-important incidental findings from CT may lead to multiple unnecessary
follow ups.

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 Suggested reading:
Basics in radiology
Novelline RA. Squires Fundamentals of Radiology, 6th edition
(2004).
American College of Radiology Appropriateness Criteria
http://www.acr.org/s_acr/sec.asp?CID=1845&DID=16050

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 The information provided in this presentation
Is intended to be used as educational purposes only.
Is designed to assist emergency practitioners in providing
appropriate radiologic care for patients.
Is flexible and not intended, nor should they be used to
establish a legal standard of care.

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