الرحيم الرحمن الله الرحيم بسم الرحمن الله بسم

Implementation of panic alert Implementation of panic alert mechanism for critical mechanism for critical

imaging findingsimaging findings(practical approach)(practical approach)

Dr. Khairy IbrahimDr. Khairy IbrahimRad. consultantRad. consultant

ObjectiveObjective

facilitate treating physicians in facilitate treating physicians in appropriate patient care appropriate patient care management by implementing management by implementing mechanism of timely communication mechanism of timely communication of life threating emergencies of life threating emergencies detected on radiological examinationdetected on radiological examination

POLICYPOLICY

Critical tests results will be Critical tests results will be communicated to physician in an communicated to physician in an efficient and expedient manner to efficient and expedient manner to meet patients' needsmeet patients' needs . .

Critical test resultsCritical test results

– –Those values/interpretations that indicate Those values/interpretations that indicate that the patient is in imminent danger of that the patient is in imminent danger of death, significant morbidity, or serious death, significant morbidity, or serious adverse complications unless treatment is adverse complications unless treatment is

initiated immediatelyinitiated immediately . .--The time from the time of physician order to The time from the time of physician order to

radiology reporting the result is as followsradiology reporting the result is as follows : :Critical radiology results – as determined by Critical radiology results – as determined by the hospital. This time should be within the hospital. This time should be within threethree hours hours..

Critical Radiology ResultsCritical Radiology Results

11--The radiologist will call unexpected findings, which The radiologist will call unexpected findings, which require medical intervention of an urgent nature, to require medical intervention of an urgent nature, to the nurse and/ or the physician as soon as possible the nurse and/ or the physician as soon as possible and within the time frame of the host hospital policy. and within the time frame of the host hospital policy. The radiologist will ask the nurse/physician to repeat The radiologist will ask the nurse/physician to repeat the results back to verify that they were understood the results back to verify that they were understood correctlycorrectly..

22--The nurse will contact the physician within The nurse will contact the physician within oneone hour of hour of receipt of the critical test result. If the physician was receipt of the critical test result. If the physician was notified, the nurse will ask the physician to read the notified, the nurse will ask the physician to read the results back to verify that he/she was understood results back to verify that he/she was understood correctlycorrectly..

33--The nurse will document in the medical record, the test The nurse will document in the medical record, the test results received, the time the physician was notified results received, the time the physician was notified (if applicable), and the orders received or the actions (if applicable), and the orders received or the actions takentaken..

Panic radiological findingsPanic radiological findings11--PneumothoraxPneumothorax..

22--PneumomediastinumPneumomediastinum..33--PneumoperitoneumPneumoperitoneum..44--Megacolon-volvulusMegacolon-volvulus..

55--Acute intestinal obstructionAcute intestinal obstruction..66--Fracture/dislocation cervical spineFracture/dislocation cervical spine..

77--Ectopic pregnancyEctopic pregnancy..88--Testicular torsionTesticular torsion..

99--Laryngeal/tracheal injuryLaryngeal/tracheal injury..1010--Foreign body orbit and respiratory systemForeign body orbit and respiratory system..

1111--Mesentric vascular occlusionMesentric vascular occlusion..1212--Extradural HgeExtradural Hge..

1313--Dissecting aortic aneurysmDissecting aortic aneurysm..1414--Superior sagittal sinusSuperior sagittal sinus..

1515--Vascular injuryVascular injury..1616--Pulmonary embolismPulmonary embolism . .

Erect X ray Erect X ray

PneumoperitoneumPneumoperitoneum

Describes gas within the peritoneal Describes gas within the peritoneal cavity and is often of critical illness. cavity and is often of critical illness. There are numerous causesThere are numerous causes

Erect X rayErect X ray

Lat viewLat view

Double wall signDouble wall sign

The double wall sign is another The double wall sign is another name of Rigler sign for the air name of Rigler sign for the air outlining both sides of the bowel outlining both sides of the bowel loops wall it is seen when the loops wall it is seen when the large amount of free air more large amount of free air more than 1000ml is presentthan 1000ml is present

PneumothoraxPneumothorax

Refers to the presence of gas (air) in Refers to the presence of gas (air) in the pleural space . This when the the pleural space . This when the collection of gas is constantly collection of gas is constantly enlarging resulting in compression of enlarging resulting in compression of the mediastinal structuresthe mediastinal structures

It can be lifeIt can be life--threatening and is known threatening and is known as tension pneumothoraxas tension pneumothorax

Radiographic featuresRadiographic featuresChest radiographChest radiograph

A pneumothorax is, when looked for, A pneumothorax is, when looked for, usually relatively easily appreciatedusually relatively easily appreciated. . Typically they demonstrateTypically they demonstrate::

11--Visible visceral pleural edge see as a very Visible visceral pleural edge see as a very thin, sharp white linethin, sharp white line

22--No lung markings are seen peripheral to No lung markings are seen peripheral to this linethis line

33--The peripheral space is radiolucent The peripheral space is radiolucent compared to adjacent lungcompared to adjacent lung    

44--The lung may completely collapseThe lung may completely collapse55--The mediastinum should not shift away The mediastinum should not shift away

from the pneumothorax unless a from the pneumothorax unless a tension pneumothoraxtension pneumothorax is present is present. .     

CTCT

Provided lung windows are examined, a Provided lung windows are examined, a pneumothroax is very easily identified on pneumothroax is very easily identified on

CTCT .. ..

؟؟؟؟

????????

Radiograph of the chest shows a large leftRadiograph of the chest shows a large left--sided pneumothorax sided pneumothorax ((white arrowswhite arrows) ) which is under tension as manifest as which is under tension as manifest as displacement of the heart to the right displacement of the heart to the right ((black arrowblack arrow) ) and depression of the left hemidiaphragm and depression of the left hemidiaphragm ((yellow arrowyellow arrow)) . .

Tension PneumothoraxTension Pneumothorax

؟؟؟؟؟؟

PneumopericardiumPneumopericardium

Represents air within the pericardium, thus Represents air within the pericardium, thus surrounding the heartsurrounding the heart

Radiographic featuresRadiographic features

Plain film and CTPlain film and CT::

On both plain films and CT appearances are On both plain films and CT appearances are characteristic, the heart being partially or characteristic, the heart being partially or completely surrounded by air, with the completely surrounded by air, with the pericardium sharply outlined by air density pericardium sharply outlined by air density

on either sideon either side..    

????

Foreign body of the chestForeign body of the chest

A careful review of these two previous A careful review of these two previous chest radiographs reveals a chest radiographs reveals a narrowed tracheal air column best narrowed tracheal air column best visible on lateral view, the tracheal visible on lateral view, the tracheal air column on the lateral appears to air column on the lateral appears to be bent suggesting a mass pushing be bent suggesting a mass pushing on iton it..

Metallic foreign body in a patient in right orbit on Metallic foreign body in a patient in right orbit on radiograph radiograph ((arrowarrow). ). CT scan axial section of the same CT scan axial section of the same

patient showing foreign body just posterior to the limbus patient showing foreign body just posterior to the limbus which is extra occularwhich is extra occular..

Foreign body orbitForeign body orbit

CT scans are the imaging study of choice for CT scans are the imaging study of choice for IOFB localizationIOFB localization. . A helical CT scan is the A helical CT scan is the most efficient method to establish a most efficient method to establish a diagnosisdiagnosis. . Helical CT scans have a very Helical CT scans have a very high identification ratehigh identification rate. . With conventional With conventional CT scans, cuts of 0.5 mm are advisedCT scans, cuts of 0.5 mm are advised. . With the advent of MDCT the role of With the advent of MDCT the role of radiologist has become easier in radiologist has become easier in identification and diagnosis of occular identification and diagnosis of occular foreign bodyforeign body. . Plain xPlain x--ray is useful if a ray is useful if a metallic IOFB is present and a CT scan is metallic IOFB is present and a CT scan is unavailableunavailable . .

AttentionAttention

IntraIntra--orbital metallic foreign orbital metallic foreign bodies are an absolute bodies are an absolute

contraindication against MRIcontraindication against MRI

Thank youThank you