4A true life-threatening emergency. Memorizing these conditions may help. Call immediately for help. Try to remain calm and quickly assess ABC. Once the problem has been dealt with remember to reassess: other prob- lems may have been forgotten or missed in the heat of the moment. 3These imaging tests are urgent and need to be performed as soon as the patient is stabilized and can be brought to the department. Elective and non-urgent imaging should be delayed to make time for these patients to be imaged. Alternatively, portable imaging may need to be performed in the emergency department or on the ward as rapidly as possible. 2Imaging is required rapidly and should be performed out of hours at the next available opportunity. 1Imaging is non-urgent and can wait until the next day. This scale is intended for guidance only and each case will need to be considered in light of the clinical features on presentation. Some condi- tions may fall into one or more categories depending on the severity of symptoms and where appropriate this has been indicated. Oxford Handbook of Emergencies in Clinical Radiology Published and forthcoming titles in the Emergencies in… series: Emergencies in Anaesthesia Edited by Keith Allman, Andrew McIndoe, and Iain H. Wilson Emergencies in Cardiology Edited by Saul G. Myerson, Robin P. Choudhury, and Andrew Mitchell Emergencies in Clinical Surgery Edited by Chris Callaghan, J. Andrew Bradley, and Christopher Watson Emergencies in Critical Care Edited by Martin Beed, Richard Sherman, and Ravi Mahajan Emergencies in Nursing Edited by Philip Downing Emergencies in Obstetrics and Gynaecology Edited by S. Arulkumaran Emergencies in Oncology Edited by Martin Scott-Brown, Roy A.J. Spence, and Patrick G. Johnston Emergencies in Paediatrics and Neonatology Edited by Stuart Crisp and Jo Rainbow Emergencies in Palliative and Supportive Care Edited by David Currow and Katherine Clark Emergencies in Primary Care Chantal Simon, Karen O’Reilly, John Buckmaster, and Robin Proctor Emergencies in Psychiatry Basant K. Puri and Ian H. Treasaden Emergencies in Radiology Edited by Richard Graham and Ferdia Gallagher Emergencies in Respiratory Medicine Edited by Robert Parker, Catherine Thomas, and Lesley Bennett Head, Neck and Dental Emergencies Edited by Mike Perry Medical Emergencies in Dentistry Nigel Robb and Jason Leitch Oxford Handbook of Emergencies in Clinical Radiology Edited by Richard Graham MA FRCR Specialist Registrar in Radiology, John Radcliffe and Churchill Hospitals, Oxford, UK Lecturer in Medicine, Hertford College, University of Oxford, Oxford, UK and Ferdia Gallagher MA MRCP FRCR Cancer Research UK and Royal College of Radiologists Clinical Research Training Fellow, University of Cambridge and CRUK Cambridge Research Institute, Cambridge, UK Honorary Specialist Registrar, Addenbrooke’s Hospital, Cambridge, UK 1 1 Great Clarendon Street, Oxford OX2 6DP Oxford University Press is a department of the University of Oxford. It furthers the University’s objective of excellence in research, scholarship, and education by publishing worldwide in Oxford New York Auckland Cape Town Dar es Salaam Hong Kong Karachi Kuala Lumpur Madrid Melbourne Mexico City Nairobi New Delhi Shanghai Taipei Toronto With offi ces in Argentina Austria Brazil Chile Czech Republic France Greece Guatemala Hungary Italy Japan Poland Portugal Singapore South Korea Switzerland Thailand Turkey Ukraine Vietnam Oxford is a registered trade mark of Oxford University Press in the UK and in certain other countries Published in the United States by Oxford University Press Inc., New York © Oxford University Press 2009 The moral rights of the author have been asserted Database right Oxford University Press (maker) First published 2009 All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted, in any form or by any means, without the prior permission in writing of Oxford University Press, or as expressly permitted by law, or under terms agreed with the appropriate reprographics rights organization. Enquiries concerning reproduction outside the scope of the above should be sent to the Rights Department, Oxford University Press, at the address above You must not circulate this book in any other binding or cover and you must impose this same condition on any acquirer British Library Cataloguing in Publication Data Data available Library of Congress Cataloging in Publication Data Data available. Typeset by Cepha Imaging Private Ltd., Bangalore, India Printed in China on acid-free paper by Asia Pacifi c Offset Limited ISBN 978–0–19–923843–9 10 9 8 7 6 5 4 3 2 1 Oxford University Press makes no representation, express or implied, that the drug dosages in this book are correct. Readers must therefore always check the product information and clinical procedures with the most up-to-date published product information and data sheets provided by the manufacturers and the most recent codes of conduct and safety regulations. The authors and the publishers do not accept responsibility or legal liability for any errors in the text or for the misuse or misapplication of material in this work. 2 Except where otherwise stated, drug doses and recommendations are for the non- pregnant adult who is not breast-feeding. v Dedication To Bessie, Anita and Ciara. vi Foreword This is a very valuable contribution to the literature and will become a standard reference book for radiologists young and old. Indeed all imaging departments should have several copies close to hand in case of emergen- cies. The market was crying out for just such a book, especially as Saxton and Strickland’s ‘Procedures’ and Ansell’s ‘Complication’ books have now become obsolete. Of course, with the rapid changes in technology and guidelines, even this book will age quite quickly too. But it was good to see the authors anticipate the future by considering CT as the initial investigation for chest pain (the triple rule out – myocardial infarction, aortic dissection and pulmonary embolism). This young and energetic cast of editors and authors has assembled an extraordinary amount of useful facts within a short space. By judicious use of lists and a minimum of free text, they make it an ideal cramming book before FRCR and other ‘board type’ examination. It may also prove popular amongst medical students and allied health professionals (radiographers, technicians, etc). As an editor with relatively fi xed views on style, there are very few terms that jar on the eyes. Just occasionally the reader may get confused by which type of ‘scan’ is being referred to! And I am never quite sure what a ‘modality’ is. But these are minor quibbles from an ageing dinosaur. This is a modern book with a modern feel. All in all, this team has done a marvellous job. I wish the book (and its subsequent revised editions) well. Adrian K Dixon Cambridge vii Preface This book has arisen out of our own experiences as radiology trainees and those of our colleagues. Trainees are often daunted by the breadth of knowledge required to successfully manage an emergency radiology service, particularly when on-call; radiology has equivalent subspecialties for almost every branch of medicine and emergency radiology is an essen- tial component of each. A very high proportion of patients who enter the emergency department will undergo some form of imaging before leaving hospital and these tests will often be central in determining their manage- ment. It is unusual for a patient to undergo emergency surgery without prior imaging and cranial CT is now crucial to clinical decision-making fol- lowing head trauma. Consequently, there has been a steady increase in demand for emer- gency imaging, which can put huge pressure on radiology departments. This pressure is also experienced by trainees who are frequently on the front line of emergency radiology on-call and while there are many excel- lent radiology textbooks there has been no single, easily assessable text that provides guidance on how to successfully manage radiology on-calls. It is from these observations made by ourselves, friends and colleagues that the idea of this handbook was born. The emergency radiologist faces two questions with each emergency case: what is the correct imaging modality to answer the clinical question and how should this be performed to optimize the imaging information obtained? The answers to these questions are often not straightforward and in the pressure of the emergency setting, when time is crucial, incor- rect imaging may result leading to suboptimal patient management. This book is a guide for the emergency radiologist as to which imaging is most appropriate in what circumstance, how best to perform it, and how to interpret the results. In all cases, discussion with an experienced clinician will help to optimize the diagnostic power of the investigation. Emergencies in Clinical Radiology is intended as a readily accessible refer- ence for specialist trainees in clinical radiology as well as radiographers. In addition, it will be of use to other hospital specialists involved in the emergency care of patients as it provides advice on which radiological investigation to request in a particular clinical setting. The text lists imaging strategies for frequently presenting complaints and common conditions, including the relative merits of each modality and advice on how they may be optimized. It also discusses the expected radiological fi ndings to aid interpretation of these tests. We hope the use of this book will help all those involved in emergency imaging and will ultimately enhance patient care. We would value any feedback to improve future editions. RG FG 2008 viii Ackowledgements We would like to thank OUP for their help in the preparation of this book, especially Chris Reid and Fiona Goodgame who have been very supportive throughout the project. We would also like to thank Professor Adrian Dixon for writing the foreword to the book. Above all, we are indebted to our many teachers, students, and patients, all of whom have taught us everything we know.