Professional Documents
Culture Documents
EBMEDICINE.NET
AN EVIDENCE-BASED APPROACH TO EMERGENCY MEDICINE
Peer Reviewers
Bret Nelson, MD
Department of Emergency Medicine, Mount Sinai
School of Medicine, New York, NY
Keith A Marrill, MD
Instructor, Department of Emergency Medicine,
Massachusetts General Hospital, Harvard Medical
School, Boston, MA
CME Objectives
Pneumothorax or Pneumomediastinum
The primary modality currently used for detection of
pneumothorax or pneumomediastinum is the CXR
(Figure 7). Inspiratory and expiratory views probably
do not improve the detection of pneumothoraces above
83,84,85
the standard CXR. A prospective, randomized
review of 178 patients paired inspiratory and expiratory
chest radiographs with and without pneumothoraces;
inspiratory and expiratory upright films were found to
be equally sensitive for pneumothorax detection.84
Films must be perused carefully since small
pneumothoraces can easily be missed and overlying mediastinal hemorrhage, but, in a study comparing
skin folds can simulate pneumothoraces. Ultrasound is radiograph interpretation in normal patients and
more sensitive than AP CXR for the detection of patients with mediastinal hemorrhage, Woodring found
88
pneumothorax and demonstrates good agreement with only five signs to be helpful; see Table 5. The aortic
CT scan.69 contour is considered to be abnormal when the aortic
knob is enlarged, irregular, or indistinct. The
Pneumopericardium mediastinum is considered to be widened on the supine
Pneumopericardium may result from blunt chest AP CXR when the width is 8 cm or greater when
trauma, pneumothorax, pneumoperitoneum, measured just above the aortic knob. An apical cap is
pneumomediastinum, tracheobronchial tears, or formed when blood dissects above the lung on either
esophageal tears. It may be seen on CXR (Figure 10), side; but a left apical cap is more indicative of
but is best diagnosed using CT scan of the thorax and mediastinal bleeding than one on the right.
abdomen (Figure 11) which allows for the additional Displacement of a nasogastric tube to the right at the
detection of concomitant injuries.86,87 level of T4 is also suggestive of a mediastinal
hematoma. The right paratracheal stripe is a space
Figure 10. CXR Showing Streaks Of Air In The between the right tracheal wall and the adjacent lung
Mediastinum; Suspicious For Pneumopericardium
and pleura. With hemorrhage into the mediastinum,
this potential space can fill with blood and become
distended. Based on a study of 102 consecutive
patients using thoracic arteriograms as the gold
standard, widening to greater than 5 mm is suggestive
of mediastinal hemorrhage; a paratracheal stripe was
reported to be associated with major arterial injury in
23% of cases.89
CT of the chest is 100% sensitive and 99.7%
specific for mediastinal hemorrhage. The positive
predictive value is 89% while the negative predictive
value is
Figure 11. CT Of The Thorax Showing
Pneumomediastinum & Pneumopericardium
Table 5. Radiographic Manifestations Of
Mediastinal Hemorrhage
? Abnormal aortic contour (aortic knob enlarged,
irregular, or indistinct)
? Abnormal mediastinal width (greater than 8
cm at a level just above the aortic knob)
? Widening of the right paratracheal
stripe (greater than 5 mm)
? Apical cap (either side, but the left side
is more indicative than right)
? Deviation of nasogastric tube (to the
Right at Level of T4 spinous process)
Mediastinal Hemorrhage
Hemorrhage into the mediastinum is suspected when
Based on Woodring JH, Loh FK, Kryscio RJ:
the supine AP CXR shows abnormal mediastinal
Mediastinal hemorrhage. Radiology
contours (Figure 12). A number of radiographic
1984;151(1):15-21.
findings have been promulgated as indicative of
Dyspnea
ACR's Appropriateness Criteria rates CXR as highly
appropriate (8/9) for most patients with a complaint of
dyspnea regardless of physical findings, other
symptoms, or risk factors for cardiopulmonary disease.3
CXR may demonstrate pulmonary infiltrates, vascular
congestion, pneumothorax, pleural effusions, or
neoplastic disease. Indirect evidence of With 16-slice multidetector-row CT scanners now
thromboembolic disease may also be seen. For those commonly available, the entire chest can be imaged
under the age of 40 with a negative physical with excellent resolution, requiring a breath-hold of less
examination, the appropriateness is described as being than 10 seconds. These scanners can reliably diagnose
influenced by severity and duration of dyspnea and the tiny emboli in sub-segmental vessels.106 The clinical
presence of other symptoms or risk factors for significance of sub-segmental emboli is unclear. In a
cardiovascular, pulmonary, and neoplastic diseases.3 study that included 67 patients with isolated
While CT is not recommended for the initial evaluation subsegmental pulmonary emboli, Eyer et al reported
of patients with dyspnea, except for patients with that 37% did not receive anticoagulation and that there
suspected pulmonary embolism, the ACR rates CT as was no evidence of recurrent thromboembolism on
appropriate (8/9) at any age when clinical evaluation, follow up.107 Further study to confirm these findings is
plain films, and laboratory studies are non-diagnostic.3 needed.
Plain CT is useful for detecting many diseases that may A positive CT result is an intraluminal filling
present with dyspnea, such as emphysema, sarcoidosis, defect or vascular occlusion24 (Figure 15). Reported
and lung cancer. sensitivities vary widely, being affected significantly by
the generation of scanner used. While large series
Pulmonary Embolism using specific generations of scanners are yet to be
Ventilation/perfusion (V/Q) lung scanning has been the published, Russo et al published a meta-analysis of the
primary tool for imaging pulmonary embolism in the relevant literature from 1995 to 2004. This review
past. In the Prospective Investigation of Pulmonary showed the sensitivity and specificity to have increased
Embolism Diagnosis (PIOPED) study, the sensitivity of from 37 to 94% and from 81 to 100% respectively,
a normal or near-normal V/Q scan was shown to be primarily due to the possibility of depicting
Acute Asthma
ACR’s Appropriateness Criteria for CXR in Pulmonary Infections
uncomplicated asthma is only 4/9.4 A CXR is often The CXR gets a relatively low ACR appropriateness
recommended for the first episode of wheezing. Based rating (4/9) for adults less than 40 years of age with
on a retrospective review of 90 episodes of acute acute respiratory symptoms, negative physical
asthma in adults, Findley et al reported that the chest examination, and no other signs, symptoms, or risk
radiograph findings were most commonly normal factors for pulmonary disease. The appropriateness
(55%), hyperinflated (37%), or showed interstitial rating goes up to 8 when the patient is greater than 40
changes previously identified on radiographs (7%). years of age or has dementia, hemoptysis, leukocytosis,
Only one new alveolar infiltrate was found in this series hypoxemia, or cardio-respiratory disease.4
(1%). They concluded that, in the setting of acute The 2001 American Thoracic Society Guidelines
asthma, the chest radiograph is indicated only when lists the indications for CXR as newly acquired
pneumonia or pneumothorax is suspected.16 Abnormal respiratory symptoms, such as cough, sputum
CXR findings are more common in children with first production, dyspnea, associated fever, or auscultatory
episodes of wheezing (6 to 16%), but, in the absence of findings.9 For patients with advanced age113 or
clinical variables, these findings rarely affect the acute inadequate immune response, additional indications
management of the patient.17-19 include confusion, failure to thrive, worsening of
underlying illness, falls, and tachypnea114.
Acute Exacerbation Of Chronic Obstructive The CXR may help to determine which patients
Pulmonary Disease should be hospitalized. Admission is indicated when
Approximately one-fourth of radiographic the CXR shows bilateral involvement (Figure 17),
abnormalities seen in patients with apparent multilobar involvement, cavitation, rapid progression,
exacerbations of chronic obstructive pulmonary disease or pleural effusion (Figure 18). In addition, the CXR
are not predictable on the basis of high-risk criteria. may help in differentiating pneumonia from other
Consequently, routine chest radiography should be conditions, may suggest specific etiologies, and may
considered.20 ACR’s Appropriateness Criteria for detect coexisting conditions, such as lung abscess or
uncomplicated COPD is 7/9; the appropriateness rating bronchial obstruction.
increases to 9/9 in the presence of leukocytosis,
5. Using chest x-rays to decide whether a 10. Using chest radiography to rule out
patient's pneumonia needs antibiotics. dissection. Chest radiographic findings are
Chest radiograph cannot, by itself, be used to often abnormal in the presence of aortic
differentiate between viral and bacterial dissection and CXR has a reported sensitivity
disease. of 90%. However, the presence of a normal
aorta and mediastinum only decreases the
probability of dissection; it does not exclude
it.
1. Mediastinal widening is present when the 12. With advanced generation scanners, it now
mediastinum measures greater than 8 cm at the aortic appears feasible to use clinical risk stratification, D-
arch or the mediastinum:chest width ratio is greater dimer measurement, and multi-detector CT scanning
than 0.25. to reliably and safely diagnose or exclude clinically
significant pulmonary emboli.
2. In the setting of trauma, serial CXR's may be
indicated when suspicion is high and initial screening 13. Chest radiography has been recommended for
radiographs are negative. febrile children (temperature greater than 380C or
100.40F) younger than three months with evidence of
3. The American College of Radiology rates acute respiratory illness. However, the chance of a
specialized rib views as having a low level of positive chest radiograph in a febrile infant less than
appropriateness for adults less than 65 years of age three months of age with no pulmonary signs or
who have sustained chest trauma and possible rib symptoms is only approximately 1%.
fracture(s). However, the chest radiograph is
appropriate at any age when the diagnosis of rib 14. The typical radiological presentation of post-
fracture is under consideration, primarily to rule out primary tuberculosis in adults is with infiltration
associated pulmonary injury. nodules in the upper zones, with or without
cavitation.
4. Ultrasonography has been shown to have greater
sensitivity in detecting chest wall fractures than either 15. CT may be better at defining the cause of
clinical acumen or radiography. hemoptysis than bronchoscopy and the two
modalities are equally effective at determining the
5.Ultrasonography can detect hemothoraces not site of bleeding.
evident on CXR, and is rapid and accurate.
17. Non-contrast CT is easy, fast, and 100% sensitive
6.As follow up for an abnormal CXR, computed for upper esophageal foreign bodies. It should be the
tomography of the chest has a sensitivity of 100% first choice for diagnostic imaging of suspected upper
and specificity of 99.7%. esophageal foreign bodies not expected to be visible
on plain radiographs.
7. Myocardial contusion is best diagnosed by
transesophageal echocardiography. There are no 18. In the acute or exudative phase of acute
complications related to the procedure and high respiratory distress syndrome (ARDS), CXR findings
quality images are generally obtained. include bilateral, patchy, asymmetrical pulmonary
infiltrates. There may be associated pleural effusions.
8. In the setting of penetrating trauma to the heart or The pattern is indistinguishable from cardiogenic
lung, evaluation for pericardial hemorrhage is best pulmonary edema.
carried out by echocardiography. The best view is
the subcostal view in which blood will appear as an 19. High-resolution images obtained rapidly by
anechoic area surrounding the heart. multi-detector computed tomography have recently
improved image quality to the point where it is
9. CT has been shown to have sensitivity and possible to consider non-invasive coronary
specificity of 100% after suspected esophageal angiography as a routine clinical tool.
perforation.
20. Echocardiography performed by emergency
10. On CT, the combination of discontinuity, physicians has been shown to be a reliable
thickening, and segmental non-recognition is technique for evaluating for pericardial effusion.
reported to be 100% sensitive for diaphragmatic
injury. 22. The CT scan has become a standard test for aortic
dissection. In fact, multi-slice CT scanning now
11. With 16-slice multidetector-row CT scanners, appears to be the modality of choice for complete
now commonly available, the entire chest can be examination of the entire aorta.
imaged with excellent resolution, requiring a breath-
hold of less than 10 seconds. These scanners can
reliably diagnose tiny emboli in sub-segmental
vessels, although the clinical significance of sub-
segmental emboli is still in question.
CME Questions
69. In which of the following clinical situations
65. In assessing a postero-anterior chest radiograph, would rib views be most appropriate?
the thoracic width is measured at which of the
following sites? a. 50-year-old male with right rib tenderness after a
fall.
a. Apices b. 50-year-old female with right rib tenderness after a
b. Aortic arch fall.
c. Aorticopulmonary window c. 70-year-old female with right rib tenderness after
d. Lung base a fall.
e. Right hilum d. 50-year-old patient with left lower rib tenderness
after a fall.
e. 10-year-old child with left rib tenderness after a
66. In which of the following presentations would a fall.
routine chest radiograph be most appropriately
indicated?
74. Sonographic criteria for the diagnosis of 78. Which of the following statements regarding
cardiac tamponade include which of the imaging in the diagnosis of acute coronary
following? syndromes is true?
Coming In Future Issues Target Audience: This enduring material is designed for emergency
medicine physicians.
Pediatric Toxicology Update Needs Assessment: The need for this educational activity was
determined by a survey of medical staff, including the editorial board of
Acutely Decompensated Heart Failure Update this publication; review of morbidity and mortality data from the CDC,
Delirium & Agitation AHA, NCHS, and ACEP; and evaluation of prior activities for emergency
physicians.
Class Of Evidence Definitions Date of Original Release: This issue of Emergency Medicine Practice
was published November 1, 2006. This activity is eligible for CME
credit through November 1, 2009. The latest review of this material was
October 13, 2006.
Accreditation: This activity has been planned and implemented in AOA Accreditation: Emergency Medicine Practice has been approved
accordance with the Essentials and Standards of the Accreditation for 48 Category 2B credit hours per year by the American Osteopathic
Council for Continuing Medical Education (ACCME) through the joint Association.
sponsorship of Mount Sinai School of Medicine and Emergency
Medicine Practice. The Mount Sinai School of Medicine is accredited
by the ACCME to provide continuing medical education for
physicians.
Emergency Medicine Practice is not affiliated with any pharmaceutical firm or medical device manufacturer.
Emergency Medicine Practice (ISSN Print: 1524-1971, ISSN Online: 1559-3708) is published monthly (12 times per year) by EB Practice, LLC, 305 Windlake Court, Alpharetta, GA 30022. Opinions
expressed are not necessarily those of this publication. Mention of products or services does not constitute endorsement. This publication is intended as a general guide and is intended to
supplement, rather than substitute, professional judgment. It covers a highly technical and complex subject and should not be used for making specific medical decisions. The materials contained
herein are not intended to establish policy, procedure, or standard of care. Emergency Medicine Practice is a trademark of EB Practice, LLC. Copyright © 2006 EB Practice, LLC. All rights reserved.
No part of this publication may be reproduced in any format without written consent of EB Practice, LLC. Subscription price: $299, U.S. funds. (Call for international shipping prices.)