(Radiographics. 1999;19:1319-1322.)
© RSNA, 1999
1998 PLENARY SESSION: IMAGING SYMPOSIUM |
An Overview of Acute Radiology1
Frederick A. Mann, MD ,
Alisa D. Gean, MD ,
Ella A. Kazerooni, MD and
Lee F. Rogers, MD
1 From the Departments of Radiology, University of Washington, 325 Ninth Ave, Box 359728, Seattle, WA 98104-2499 (F.A.M.); University of California at San Francisco (A.D.G.); University of Michigan Medical Center, Ann Arbor (E.A.K.); Winston-Salem School of Medicine, NC (L.F.R.). From the Plenary Session, Friday Imaging Symposium: Acute Radiology—Where Minutes Count, at the 1998 RSNA scientific assembly. Received March 1, 1999; revisions requested April 30 and received June 7; accepted June 9. Address reprint requests to F.A.M.
Index Terms: Emergency medical service system
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WHAT IS "ACUTE" RADIOLOGY?
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Amid the bustle of a busy day, few medical circumstances present radiologists with the opportunity to heroically change someone else's life (for the better) more than acute radiology. In the practice of acute radiology, radiologists contemporaneously respond to critical conditions for which the opportunity for beneficial intervention is brief: on the order of minutes to, at most, a few hours from the onset of symptoms.
Acute radiology has two defining characteristics. First, effective therapy is generally well established and available. Second, the effectiveness of therapy is greater when it is instituted very early in the pathologic process. As it turns out, these are not rare circumstances, particularly during off-hours, when more than two-thirds of all imaging examinations is either emergent or urgent (1). The rapidity of technologic developments and increasing application of multidisciplinary therapies have thrust radiology into the hot light of time-critical diagnostic and therapeutic challenges.
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IS ACUTE RADIOLOGY NEEDED?
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Numerous reports in the surgical and emergency medicine literatures promote diagnostic and therapeutic imaging by nonradiologists. Central to these arguments are clinicians' complaints of an absence of knowledgeable radiologists who are immediately available to perform and contemporaneously interpret the desired imaging studies.
With this in mind, the Friday Imaging Symposium sought to provide an overview of "hyperacute" scenarios, including both traumatic and nontraumatic emergencies of the head, thorax, and abdomen such as various causes of nontraumatic sudden death or morbidity (eg, occlusive vascular diseases causing stroke and central pulmonary thromboembolism, rupture of arteriosclerotic abdominal aneurysms); persistent hypotension related to medical therapy (eg, barotrauma associated with ventilator therapy [2]); and traumatic closed exsanguination (eg, acute traumatic aortic rupture, retroperitoneal hemorrhage following pelvic ring and acetabular disruptions). Special attention was given to the imaging management of pregnant victims of trauma. Also, a primer on the imaging of gunshot wounds was intended to enlighten radiologists as to the special problems in diagnosis and risk management.
James M. Provenzale, MD, discussed a variety of nontraumatic and traumatic emergent neurologic conditions, such as the "hyperacute" epidural hematoma. A common theme was that the practice of acute radiology requires more than state-of-the-art equipment and experienced technologists. Dr Provenzale stressed the importance of acute stroke as a leading and increasing cause of morbidity, especially for individuals 60 years of age and older. Over the past 5 years, treatment of early stroke has undergone a veritable revolution. Substantial reductions in morbidity following intravenous, and more recently intraarterial, thrombolytic therapy within 3–6 hours after the onset of stroke symptoms can be realized, but only if field recognition, transport, and clinical and radiologic confirmation of nonhemorrhagic stroke are successfully and seamlessly integrated (3). Unfortunately, the majority of patients sustaining acute ischemic stroke are unable to receive therapy because of a delay in diagnosis that prevents the timely implementation of therapy (4).
Kimberley L. McKenney, MD, showed how use of transabdominal ultrasonography (US) has revolutionized the initial evaluation for intraabdominal catastrophes sustained in blunt trauma to the torso (5). Expert US examination—if performed as part of the primary survey of the patient within minutes of arrival in the emergency department—can substantially reduce delays in decision to perform exploratory celiotomy (6). Seamless interaction with the resuscitating trauma team necessitates accuracy, celerity, and facility of contemporaneous diagnosis.
Eric K. Hoffer, MD, discussed the techniques, limitations, and challenges of endovascular damage control in abdominal trauma. Dr Hoffer cited advances in material sciences and in the understanding of endothelial responses to interventional radiologic procedures. This improved knowledge has led to development of promising provisional and permanent endovascular prostheses for use in both traumatic (7) and medical vascular crises (8), such as acute traumatic aortic injuries, symptomatic arteriosclerotic abdominal aortic aneurysms, and acute end artery occlusions (9).
Ella A. Kazerooni, MD, emphasized the enlarging role of helical or spiral computed tomography (CT) in emergent imaging of the thorax and great vessels. For example, helical CT arteriography of systemic and pulmonary arteries has proved to be diagnostically equivalent to standard diagnostic techniques for many surgical and medical emergencies. The new generation of multirow-detector CT scanners will have collimation abilities of 0.5–1.25 mm for the entire thorax without tube cooling, depending on the manufacturer. Use of helical CT enables timely diagnosis, which guides urgent therapy for conditions that include spontaneous and traumatic thoracic and abdominal aortic dissections and "ruptures," acute occlusions of mesenteric arteries, active hemorrhage from intraabdominal and retroperitoneal vessel injuries (10), and central pulmonary thromboembolism (11). Sophisticated understanding of and attention to technical and interpretative details are essential to achieve the accuracy reported in the literature.
Stanford M. Goldman, MD, reviewed the critical role of radiologists and the entire radiology department as members of the trauma team caring for the injured pregnant patient (12). Because maternal demise is the most common cause of fetal demise, all primary care should be focused on the mother (13) but should not forget the conceptus. In the presence of fetal distress, US affords the most reliable estimate of gestational age and viability (14).
Based on the belief that the beginning of wisdom is to call a thing by its right name, Anthony J. Wilson, MB, ChB, asserted that radiologists must arm themselves with the argot of wound ballistics to communicate the radiographic findings of injuries caused by firearms (15,16). Not only is timely and cost-effective patient care guided by understanding the characteristic injury patterns, but thorny medicolegal evidentiary issues arising from inconsistent or naive descriptions of bullets and fragments may be avoided (17,18).
In this issue of RadioGraphics, Drs Provenzale, McKenney, Hoffer, Goldman, and Wilson provide written accounts of their presentations for the Friday Imaging Symposium.
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WHO SHOULD DO ACUTE RADIOLOGY?
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Lee F. Rogers, MD, concluded the symposium with the assertion that, in general, radiologists should do radiology. Specific solutions depend on what works and what is doable in terms of staffing and expertise within each specific practice. Technologic advances and changes in societal expectations have narrowed the time windows of diagnostic and therapeutic opportunity for many medical and surgical conditions. Radiology has become an integral part of real-time medicine, and today it is front row and center.
Despite the apparent tumult of change about us, some needs remain unchanged, as noted in 1915 by E. C. Register: "Gentlemen, the world has found that there are tasks which one man cannot do alone; the day of isolated individual labor is forever gone. There are also tasks in our world of medicine which no man can accomplish alone...Cooperation! What a word! Each working with all, and all working with each" (19). Thus it is that truly exigent care demands that radiologists shape their practices with an eye to the enterprise view and not one that is "radiology-centric" in focus (20,21). The greatest value of imaging services requires the "online" presence of interested, knowledgeable diagnostic radiologists (22). Lives are in the balance. To that end, know what you are doing and be there!
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Acknowledgments
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We thank Lawrence R. Goodman, MD, of Milwaukee, Wisconsin, for suggesting the symposium moniker "Acute Radiology."
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References
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WHAT IS "ACUTE" RADIOLOGY?
IS ACUTE RADIOLOGY NEEDED?
