EMERGENCY MEDICINE PRACTICE

EBMEDICINE.NET
AN EVIDENCE-BASED APPROACH TO EMERGENCY MEDICINE

An Evidence-Based November, 2006

Volume 8, Number 11

Thoracic Imaging Authors

Curriculum for Gary R Strange, MA, MD, FACEP

Professor and Head, Department of Emergency

Emergency Medicine Medicine, University of Illinois, Chicago, IL

Bruce MacKenzie, MD, FACEP, FAAEM

Emergency Physician, Resurrection West
Suburban Hospital, Oak Park, IL

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

Upon completing this article, you should be able

to:
1. Describe the general guidelines for the
interpretation of chest radiographs.
2. Select the most appropriate imaging modality
for the evaluation of patients with injuries and
illnesses involving thoracic structures.
3. Compare and contrast plain radiographs,
computed tomography, magnetic resonance
imaging, and echocardiography in terms of
sensitivity and specificity for the evaluation of
the major types of thoracic pathology.
4. Identify areas of overuse or misuse of imaging
techniques in the assessment of thoracic
pathology.
Date of original release: November 1, 2006.
Date of most recent review: October 13, 2006.
See “Physician CME Information” on back page
heart failure. No sooner than when you hang up, the
patient arrives propped upright on the stretcher
appearing anxious, uncomfortable, and tachypneic. You
note normal neck veins and the lung sounds are clear,
but markedly diminished on the right. Listening again,
you think maybe this isn't just another episode of acute
decompensated heart failure ...
I n the short span of 15 minutes, this busy ED
physician has been called on to consider the role of
various modalities for thoracic imaging in the
evaluation of his first four patients of the day.
Management decisions included how to best evaluate
suspected aortic dissection, pulmonary embolism,
complications of reactive airway disease, and
pneumothorax. In each case, the imaging strategy must
take into consideration the patient's acuity and stability
and the availability, risks, and benefits of the test. This
issue of Emergency Medicine Practice provides an
overview of thoracic imaging modalities and guidance
on the indications for each test in emergency practice.
Abbreviations Used In This Article
AP - Antero-Posterior
CT - Computed Tomography
CXR - Chest Radiograph
EFAST - Extended Focused Abdominal Sonogram for
Trauma
ECG - Electrocardiogram
ECHO - Echocardiography
FAST - Focused Abdominal Sonogram for Trauma
HF - Heart Failure
LBBB - Left Bundle Branch Block
LVH - Left Ventricular Hypertrophy
MRI - Magnetic Resonance Imaging
PA - Posteroanterior
SPECT - Single Photon Emission Computed
Tomography
TEE - Transesophageal
TTE - Transthoracic
V/Q - Ventilation / Perfusion
Critical Appraisal Of The Literature
The selection of thoracic imaging studies ideally should
be based on carefully designed studies which determine
the sensitivity, specificity, and positive and negative
predictive values of the test. Many times, such specific
data is not available and clinicians must base their
choice on local practice or non evidence-based
recommendations from books or other publications.
One of the goals of this article is to establish
recommendations available in the literature and to place
them in the context of the evidence from which they
were derived. This article also hopes to identify areas
in need of further study.
Thoracic imaging studies range from those
used routinely and frequently, such as the chest
radiograph, to those that the practicing emergency
Emergency Medicine Practice © 2006
physician will probably consider relatively infrequently
and perhaps only in highly acute situations, such as
imaging for aortic dissection. The chest radiograph is
so ubiquitous that it is often ordered routinely without
much consideration for the indications. For example,
the portable anteroposterior chest radiograph is, along
with a lateral cervical spine film and an anteroposterior
pelvis, part of the basic screening radiology evaluation
of the trauma patient, as recommended by the American
College of Surgeons Advanced Trauma Life Support
Course (ATLS).1 While this recommendation is
appropriate for the major trauma patient, its application
to many patients with far less than major, multi-system
trauma as part of the “cookbook” approach to the
trauma patient, has unquestionably led to countless
unnecessary studies.
The ATLS recommendations are voluminous and
detailed. However, this particular set of expert
consensus guidelines does not specify the methodology
used to create the recommendations and does not
specify the strength of the evidence upon which they
are based. Therefore, the user cannot easily differentiate
between strong recommendations based on prospective
studies using a gold standard, and weak
recommendations based on case studies and anecdotal
experience. While each chapter of the ATLS text
contains a compendium of references, recommenda-
tions are not specifically referenced to the source(s). 1
The American College of Radiology has developed
a novel set of guidelines for the use of imaging studies
and has published these as “ACR Appropriateness
Criteria.”2-8 Each guideline was developed by a panel of
experts and begins with a summary and critique of the
literature. This review is then used to assess the
appropriateness of individual imaging studies for
various clinical situations and the appropriateness is
rated on a scale of one to nine, with one being the least
appropriate and nine being the most appropriate. For
example, for adults less than 65 years of age with
possible rib fracture, rib films are given an
appropriateness rating of two, while the chest
radiograph is given an appropriateness rating of eight.2
The indications for chest radiography in patients
of various ages with respiratory symptoms have been
outlined in guidelines from the American College of
Radiology, the American Thoracic Society, and the
American College of Emergency Physicians.3,-6,8-10 In
addition, there are a number of prospective studies
covering this topic.11-15 Similarly, the American College
of Radiology and a number of prospective studies have
verified the lack of utility of the chest radiograph in
acute asthma exacerbations.4,16-19 However, this
conclusion cannot be expanded to patients with chronic
obstructive pulmonary disease, where chest radiograph
has been shown to have a much higher level of
appropriateness.4,20
The use of ultrasonography in the evaluation
for thoracic pathology is a rapidly developing field.
Prospective studies to determine the sensitivity of
ultrasound for various clinical problems have been
2 EBMedicine.net • November 2006
published, but, in most cases, results have to be
considered preliminary due to the limited number of
confirmatory studies. This remains an area in need of
study and an opportunity for emergency medicine
researchers to perform well-designed prospective
studies and meaningfully add to the emergency
medicine literature.
Similarly, with the advent of multi-row detectors,
the use of computed tomography (CT) scanning of the
chest has greatly expanded. As a result of the
technological advances, the sensitivity and specificity
of the test for various indications have increased.
Strong, validated evidence shows that CT is now the
modality of choice for the diagnosis of mediastinal
hemorrhage, aortic trauma, aortic dissection, and aortic
aneurysm.21,22
The evaluation of the patient with dyspnea
and potential pulmonary embolism has also undergone
marked change. This has been an area of intense study
with many robust studies of the use of CT scanning. 23-33
There are large, well-designed, prospective studies in
this area, as well as meta-analyses and thoughtful
editorials to assist in assimilating this data.34-39
The use of imaging in patients with possible
EBMedicine.net • November 2006
acute coronary syndromes is also undergoing rapid
change. The American College of Cardiology (ACC),
the American Heart Association (AHA), and the
American Society of Echocardiography have issued
joint guidelines for the clinical use of
echocardiography.40 With the American Society for
Nuclear Cardiology, the ACC and AHA have issued
joint guidelines for the use of nuclear medicine
scanning in the diagnosis of acute coronary
syndromes.41 Recently, multi-detector computed
tomography (MDCT) for non-invasive coronary
angiography has received attention in regard to
diagnosing acute coronary syndromes.42-48 However, a
recently published report of a large multicenter trial
found a high rate of unevaluable segments, leading to
questions regarding the clinical role of MDCT in
evaluating coronary artery stenosis.49
Thoracic Imaging Modalities
In choosing an imaging modality, the emergency
physician attempts to optimize diagnostic accuracy,
rapidity of testing, patient safety, and expense. Prudent
3 Emergency Medicine Practice © 2006
medical decision making begins with a deliberate
history and physical examination yielding a reasonable
differential diagnosis. The list of pathology to be
excluded directs what imaging is pursued.
The chest radiograph (CXR) serves as a fast
initial study for most thoracic complaints. The CXR
exposes the patient to minimal radiation and does not
necessarily require travel out of the ED. These
advantages can contribute to overuse however.
The ventilation/perfusion (V/Q) scan was once
the prevailing study for the evaluating pulmonary
embolism, but the pulmonary scintigram has been
widely supplanted by MDCT. Limitations of the V/Q
scan include radiation exposure and handling radio
nuclides, lengthy image acquisition time, transport of
patients to areas where close monitoring is challenging,
and frequent difficulty in study interpretation,
especially in patients without a normal chest x-ray.23
MDCT provides excellent detail of the aorta
and pulmonary vasculature with scans acquired in a
single breath-hold.21 MDCT may reveal alternate
diagnoses. As new ED designs incorporate CT
scanners within the department, transport times and
risks of decompensation away from the ED are
minimized. Risks of IV contrast administration include
renal impairment and allergic reaction, though these
effects have been mitigated by newer generations of
ionic contrast agents.
Echocardiography (ECHO) is particularly
useful in patients too unstable to leave the resuscitation
room. ECHO may detect right ventricular dilitation
suggestive of pulmonary embolism or confirm aortic
dissection without radiation. Diagnostic accuracy is
operator dependent.50
Magnetic Resonance Imaging (MRI) provides
excellent detail of thoracic pathology without radiation.
This use in ED patients is often limited by prolonged
Table 2. Typical Reimbursement Rates For Thoracic Imaging Studies
Procedure
Study
Code
CXR PA & Lateral 71020
V/Q Scan 78588
Transesophageal Echocardiography 93318
CT Chest with IV Contrast 71260
MRA Chest 71555
Aortogram (Interpretation) 75605
Aortogram (Procedure) 36200
Pulmonary Angiogram (Interpretation) 75743
Pulmonary Angiogram (Procedure) 36014
Based on Medicare reimbursement rates for Oak Park, Illinois.
Emergency Medicine Practice © 2006
image acquisition, distance from the clinical area, and
expense.51,52 Another limitation of MRI is that it can not
be used in patients with implaned devices such as
pacemakers and automatic inplantable cardioverter
defibrillators.
Cost Considerations
Emergency physicians face both continued emphasis on
cost containment and the introduction of newer, often
more expensive, imaging options. An evidence-based,
cost-effectiveness analysis directs rational utilization of
limited medical resources. Although charges or
reimbursement may serve as proxies for cost, they often
do not accurately reflect the resources consumed; see
Table 2. Though not easily quantified, hidden imaging
costs include ED staff utilization, opportunity costs, and
risks associated with the procedure. Travel from the ED
for imaging requires staff to deliver and collect the
patient and may occupy a nurse for continuous
monitoring. Longer image acquisition and radiologist
interpretation times delay patient disposition. This
translates into the cost of forgone opportunity to direct
resources toward the next patient in need.
Health Considerations
The risk of exposure to ionizing radiation is also an
imaging cost. The expanded use of computed
tomography, with its associated increase in radiation
exposure compared to plain radiography, has led to
renewed concerns about the total dose of ionizing
radiation and the potential for increased rates of cancer,
which can occur soon after exposure or up to decades
later. This concern is especially high for the pediatric
population because their post-exposure life span is
greater and they have a higher number of dividing cells
Reimbursement Cost
$12.07 $28.70
$146.91 $60.39
$113.92 $249.24
$68.29 $322.76
$100.19 $511.47
$64.01 $574.81
$174.21 $657.08
$91.24 $574.81
$171.83 $766.01
4 EBMedicine.net • November 2006
than adults.53 CT scanning is estimated to account for
about 10% of diagnostic radiology examinations, but is
responsible for up to two-thirds of the total radiation
dose delivered to the population.54 There is no current
consensus on whether there is such a thing as a “safe
dose” or what constitutes a reasonable exposure
threshold.53 While specific guidelines have not been
published, the International Commission on
Radiological Protection is expected to publish
guidelines in 2007 which are anticipated to include
recommendations for limiting exposure via medical x-
ray sources.55 The awareness level concerning radiation
dose and possible risks associated with CT scans is low
among radiologists (47%), emergency physicians (9%),
and patients (3%), based on results of a survey by Lee
et al published in 2004.56
Another concern when considering imaging
techniques is the risk for development of contrast-
induced nephropathy, which is defined as the elevation
of serum creatinine more than 0.5 mg/dL within three
days of contrast media administration. Numerous risk-
reduction strategies have been investigated. Adequate
intravenous volume expansion with isotonic crystalloid,
beginning 3 to 12 hours before the procedure and
continuing for 6 to 24 hours afterward, can lessen the
probability in high risk patients. It is not known
whether oral hydration is effective. According to the
Contrast-Induced Nephropathy Working Panel, of the
pharmacologic agents that have been suggested,
theophylline, statins, ascorbic acid, and prostaglandin
E1 deserve further investigation. N-acetylcysteine has
not been shown to be consistently effective. Diuretics
are considered to be potentially detrimental.
Nephrotoxic drugs, such as non-steroidal anti-
inflammatory agents and aminoglycosides, should be
withdrawn before contrast administration.57
Another approach to the reduction of the risk
for development of contrast-induced nephropathy is
through the use of an isosmolar contrast medium, such
as iodixanol (Visipaque). A recently published meta-
analysis of 16 double-blind studies including 2727
patients found that iodixanol was associated with
smaller rises in serum creatinine and lower rates of
contrast-induced nephropathy than low-osmolar
contrast media.58
can help to limit distance and time outside the ED.
Current use of computed tomography for the acute
evaluation of patients is so extensive that it makes very
good sense to have the CT facility in or adjacent to the
ED. As the use of MRI expands and more acute
indications are explored, the location of MRI units in
close proximity to the ED will also become more
advantageous.
Chest Radiographs
The most commonly ordered imaging study of the
thorax remains the chest radiograph (CXR) with routine
studies including the posteroanterior (PA) and lateral
views. Patients who cannot be transported to the
radiology suite are often studied using a portable
anteroposterior (AP) view.
General guidelines for the interpretation of
chest radiographs have been well-outlined by Schwartz
et al;59,60 see Tables 3 and 4 on page 6.
In the interpretation of the lateral PA and AP
chest (Figures 1 and 2 ), the first concern is to assure
the adequacy of the film. The entire thorax should be
seen, including the apices, lateral chest walls, entire
diaphragm, and both costophrenic angles.
Penetration should be such that the lower
thoracic vertebral bodies are faintly visible behind the
heart and the image should be positioned so that the
mid-point between the clavicular heads is
superimposed over the spinous processes of the
thoracic vertebrae. The film should be shot in
inspiration so that the right costophrenic sulcus is
below the posterior costovertebral junction of the 10th
rib.
Figure 1. Normal Postero-Anterior Chest Radiograph

Emergency Department Management

Obtaining images must never take precedence over

Figure 2. Normal Lateral Chest Radiograph
clinical evaluation and continuous monitoring of
potentially unstable patients. Whenever possible,
imaging should be accomplished at the bedside for
unstable patients. Portable chest radiography and
bedside ultrasound often provide valuable information
without compromising care. However, many patients
will subsequently require more intensive imaging
studies that will involve the transportation of the patient
outside of the ED proper.
Up-to-date planning and designing of facilities

EBMedicine.net • November 2006 5 Emergency Medicine Practice © 2006

 Systematic analysis of the images begins
with the assessment of the bony thorax, including the
ribs, clavicles, shoulders, and thoracic vertebral bodies.
Heart size is considered normal if the
cardiothoracic ratio is less than 0.5; cardiomegaly is
present if the cardiothoracic ratio is greater than 0.5.
Thoracic width is measured at the widest point, i.e., the
lung base. The cardiac contours are assessed for
evidence of chamber enlargement.
Mediastinal widening is present when the
mediastinum measures greater than 8 cm at the aortic
arch in adults or the mediastinum:chest width ratio is
greater than 0.25 in children. The trachea should be in
the midline. The contours of the mediastinum are
assessed, noting the aortic knob, descending aorta,
Table 3. Systematic Analysis Of The Frontal Chest
Radiograph
Adequacy Assess penetration, rotation,
inspiration
Bones Ribs, clavicles, shoulders,
thoracic vertebrae
Chest Wall Chest wall masses,
subcutaneous air, breasts
Soft Tissues
Heart Size (cardiothoracic ratio), contours
Mediastinum Widening, tracheal outline, contours
(aortic knob, descending aorta,
aorticopulmonary window, left
subclavian artery, superior vena cava),
pleural reflection lines (right
paratracheal stripe, left paraspinous
line)
Hila Lymphadenopathy, masses,
increased vascularity, calcification
Diaphragm Contour, effusion (costophrenic
angles), intraabdominal
abnormalities (free Air)
Lungs Symmetry of lung markings (normal
ranching vascular structures): Airspace
filling (opacification, silhouette signs,
indistinct lung markings, air
bronchograms), interstitial processes
(reticular or nodular patterns, septal
lines Kerley A or B lines), pleural
thickening, effusion, or pneumothorax
Reproduced from Wagner MJ, Wolford R, Hartfelder B,
Schwartz DT in Schwartz DT, Reisdorf EJ (eds):
Emergency Radiology. New York: McGraw-Hill, 2000, p
454. With permission from McGraw-Hill.
Emergency Medicine Practice © 2006
aorticopulmonary window, left subclavian artery,
superior vena cava, right paratracheal stripe, and left
paraspinous line.
The hila of the lungs are assessed looking
for adenopathy, masses, vascularity, and calcifications.
The diaphragm is evaluated looking at the
contour, costophrenic sulci, and for any evidence of
free air in the space beneath the diaphragm.
The lungs are evaluated for symmetry.
Lung markings should be visible as a branching
vascular pattern. The air spaces are evaluated for
evidence of opacification, silhouette signs, or air
bronchograms. The retrosternal space, retrocardiac
space, and interlobar fissures are assessed. Interstitial
processes may be detected as a reticular pattern, a
nodular pattern, or as septal lines (Kerley A or B lines).
The pleura may show thickening or the pleural
space may contain fluid (effusion) or air
(pneumothorax).
Post-Endotracheal Intubation
The CXR is an essential part of the assessment of
endotracheal tube placement (Figure 3). The preferred
location is 3 to 4 cm above the carina. In addition, the
CXR may exclude pneumothorax and can potentially
confirm various diagnoses, such as pneumonia or
congestive heart failure.61
Figure 3. CXR For Endotracheal Tube Placement
Table 4. Systematic Analysis Of The Lateral
Chest Radiograph
Adequacy Penetration, inspiration, rotation
Bones Vertebral bodies, ribs, sternum,
scapulae
Soft Tissues Heart, aorta, hila, trachea,
diaphragm
Lungs Review airspaces from front
to back: Retrosternal, lung
overlying the heart, retrocardiac,
lung overlying the vertebrae,
interlobar fissures
Reproduced from Wagner MJ, Wolford R, Hartfelder B,
Schwartz DT in Schwartz DT, Reisdorf EJ (eds):
Emergency Radiology. New York: McGraw-Hill, 2000,
p 456. With permission from McGraw-Hill.
6 EBMedicine.net • November 2006
Central Line Placement
Ultrasound guidance of central line placement may
decrease the time required and the number of attempts
necessary prior to successful cannulation.62 However,
while it has the potential to improve successful line
placement and to minimize complications, such a
reduction in complication rate has yet to be
63,64
confirmed.
A chest radiograph has long been recommended
following any attempt at placement of a cervical or
thoracic central line. CXR allows for the assessment of
the location of the tip of the catheter (Figure 4) and
assists in ruling out pneumothorax or hemothorax,
although supine films are of limited value in assessing
for pneumothorax or hemothorax due to anterior
layering of air and/or posterior layering of
blood in these views. However, confirmatory
radiographs may not be needed after straight-forward
65
placements.
Figure 4. CXR Post Central Line Placement
Thoracic Imaging In Trauma
Blunt Multi-System Trauma
The portable AP chest radiograph, along with a lateral
cervical spine film and AP pelvis, remains a part of the
screening radiology evaluation for the blunt multi-
system trauma patient, as recommended by the
American College of Surgeons Advanced Trauma Life
Support Course.1 In addition, the focused abdominal
sonogram for trauma (FAST) is recommended not only
for the evaluation of potential intra-abdominal injury
but for the evaluation of the pericardial sac
(Figure 5).1,66-68
Figure 5. Subcostal Sonographic View Of Pericardial Effusion
EBMedicine.net • November 2006
In addition to the sub-costal view of the heart
and pericardium, standard views include the right upper
quadrant, the left upper quadrant, and the pelvis. Views
of the right and left paracolic gutters are often added
and it may be possible to visualize blood superior to the
hyperechoic diaphragm in the presence of
hemothoraces. While the FAST exam is relatively
reliable in detecting free intraperitoneal blood, it has
limited utility in detecting solid organ injury or
retroperitoneal bleeding.
Ultrasound has been shown to be more
sensitive than supine AP chest radiograph for the
detection of traumatic pneumothoraces69 and, in some
centers, thoracic ultrasound is performed routinely
along with the traditional FAST scan, creating the
extended focused abdominal sonogram for trauma
70
(EFAST).
Penetrating Trauma
In the setting of penetrating trauma, no imaging is
required if the patient is hemodynamically unstable and
does not respond to resuscitation with crystalloids and
blood. Operative intervention is required in these
cases. In stable patients with penetration above the
umbilicus or for those with suspected thoracoabdominal
injury, an upright CXR is the most commonly used
study to evaluate for the presence of hemothorax
(Figure 6), pneumothorax, (Figure 7 on page 8), or
intraperitoneal air (Figure 8 on page 8). Serial CXR's
may be used when suspicion is high and initial
screening radiographs are negative.1 Using the supine
AP CXR, the presence of subcutaneous emphysema or
the radiographic deep sulcus sign may be useful in
diagnosing small pneumothoraces. The deep sulcus sign
is detected by noting lucency and a sharp, angular
appearance of the costophrenic angle on the involved
side.71
Figure 6. CXR Revealing Right Hemothorax
7 Emergency Medicine Practice © 2006
 Figure 7. CXR Revealing Left Pneumothorax
Figure 8. Free Air Under The Right Diaphragm
However, some studies showed that ultrasound is
more sensitive than the CXR in diagnosing
pneumothoraces69 and hemothoraces.8 An ultrasonic
deep sulcus sign may be noted sonographically.72
As with blunt trauma, the FAST scan is used to
evaluate the pericardial sac (Figure 5 on page 7) and to
assess for blood in Morison's pouch (the hepatorenal
interface), the splenorenal interface, and in the pelvic
spaces; the EFAST scan can be used to evaluate the
thorax simultaneously. 1,70
MDCT scan is superior to supine chest radiographs
in diagnosing pulmonary contusion. On CT, contusions
appear as patchy or diffuse air space filling that tends to
be peripheral, nonsegmental, and geographic in
distribution. CT is also the imaging study of choice for
transmediastinal gunshot wounds, since CT is able to
visualize wounds that penetrate the great vessels,
pericardium, esophagus, trachea, and thoracic spine.
CT is less expensive, less time-consuming, and less
invasive than angiography or endoscopy and these tests
can generally be avoided if MDCT confirms that the
wound track does not come in close proximity to these
structures.73
Fractures of the Bony Thorax
Rib views have traditionally been used for detection of
rib fractures in patients who have been subjected to
direct blows or compressive injuries to the chest, but
often add little to the management of the patient. The
ACR rates specialized rib views as having a low level
of appropriateness (2/9) for adults less than 65 years of
age.2 While not specifically indicated, the ACR rates
these views at a moderate level of appropriateness (5/9)
for adults greater than 65 years of age.
The ACR recommends rib views as more
appropriate for children under 14 years of age (8/9)
since children have more compliant rib cages and the
Emergency Medicine Practice © 2006
presence of fracture(s) is associated with significant
trauma and increased associated injury. In children less
than three years of age, rib fractures are frequently a
marker of abuse.74
The chest radiograph is appropriate at any age (8 to
9/9) when the diagnosis of rib fracture is under
consideration, and is primarily used to rule out
2
associated pulmonary injury.
In the past, the literature has stressed the
importance of rib fractures, especially those of the first
and second ribs, as predictors of aortic injury.
However, several studies have demonstrated no
increased likelihood of aortic injury with upper rib
2,75
fractures. No additional imaging studies are
mandated by these findings alone.
Sternal fractures (Figure 9) are reported to
be associated with severe injuries. In a retrospective
review of 200 sternal fractures, von Garrel et al
reported injuries to the thoracic vasculature, including
the heart, in approximately 30% of cases, and such
injuries were increased with displacement of sternal
fragments. Fatal heart injuries were frequently seen in
conjunction with sternal fractures in patients who fell
from significant heights. Spinal injuries were associated
with sternal fractures in 13% of cases and were most
likely in fractures with involvement of the
manubriosternal joint.78
Figure 9. Sternal Fracture
Hemothorax
Hemothorax is most often detected by the finding of
fluid in the pleural cavity on screening CXR (Figure 6
on page 7). However, ultrasonography can detect
hemothoraces not evident on CXR and is rapid and
accurate; sensitivity of ultrasound is reported at 92%,
specificity at 100%, positive predictive value at 100%,
and negative predictive value at 98%.79, 80
Angiography plays a role in the evaluation
of the patient with hemothorax and may identify
occlusion, active hemorrhage, or pseudoaneurysm. A
potential advantage of angiography is that, when
specific bleeding sites are identified, one can proceed to
selective embolization of the internal mammary or
intercostal artery, which may be an effective alternative
to thoracotomy.81,82 While this treatment modality is
promising, the number of cases studied is small.
8 EBMedicine.net • November 2006
Further study is needed before firm recommendations
can be made.
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
skin folds can simulate pneumothoraces. Ultrasound is
more sensitive than AP CXR for the detection of
pneumothorax and demonstrates good agreement with
CT scan.69
Pneumopericardium
Pneumopericardium may result from blunt chest
trauma, pneumothorax, pneumoperitoneum,
pneumomediastinum, tracheobronchial tears, or
esophageal tears. It may be seen on CXR (Figure 10),
but is best diagnosed using CT scan of the thorax and
abdomen (Figure 11) which allows for the additional
detection of concomitant injuries.86,87
Figure 10. CXR Showing Streaks Of Air In The
Mediastinum; Suspicious For Pneumopericardium
Figure 11. CT Of The Thorax Showing
Pneumomediastinum & Pneumopericardium
Mediastinal Hemorrhage
Hemorrhage into the mediastinum is suspected when
the supine AP CXR shows abnormal mediastinal
contours (Figure 12). A number of radiographic
findings have been promulgated as indicative of
EBMedicine.net • November 2006
Figure 12 . CXR Showing Widening Of The Mediastinum
mediastinal hemorrhage, but, in a study comparing
radiograph interpretation in normal patients and
patients with mediastinal hemorrhage, Woodring found
88
only five signs to be helpful; see Table 5. The aortic
contour is considered to be abnormal when the aortic
knob is enlarged, irregular, or indistinct. The
mediastinum is considered to be widened on the supine
AP CXR when the width is 8 cm or greater when
measured just above the aortic knob. An apical cap is
formed when blood dissects above the lung on either
side; but a left apical cap is more indicative of
mediastinal bleeding than one on the right.
Displacement of a nasogastric tube to the right at the
level of T4 is also suggestive of a mediastinal
hematoma. The right paratracheal stripe is a space
between the right tracheal wall and the adjacent lung
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
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)
Based on Woodring JH, Loh FK, Kryscio RJ:
Mediastinal hemorrhage. Radiology
1984;151(1):15-21.
9 Emergency Medicine Practice © 2006
 90
100%, giving an overall diagnostic accuracy of 99.7%.
CT is accurate for the detection and localization of both
hemomediastinum and direct signs of aortic injury, and
has largely supplanted aortography for the diagnosis of
these problems.90
Aortic Trauma
Chest radiography is frequently used as an initial
screening tool in patients with possible aortic injury,
but there are no CXR findings with both high
sensitivity and high specificity for aortic injury. A
mediastinum greater than 8 cm at the level of aortic
knob (Figure 12 on page 9) has a sensitivity greater
than 90% but a low specificity. Thoracic spine fracture,
first rib fracture, rightward deviation of a nasogastric
tube, depression of the left mainstem bronchus, and
widened paraspinal line are all findings with specificity
greater than 90% but low sensitivity, and no significant
improvement in overall accuracy was achieved by
91
combining radiographic findings. False positive and
false negative findings occur with each x-ray sign, and
in 1 to 2% of cases, the supine AP CXR is normal in the
presence of a great vessel injury.92
As follow up for an abnormal CXR, computed
tomography of the chest has a sensitivity of 100% and
specificity of 99.7%.90
When there is evidence of aortic injury on CT,
either aortography or surgery is indicated. An
aortogram is useful when there is evidence of
mediastinal hematoma adjacent to the aorta, but no
aortogram is required for negative CT or for
hematomas not adjacent to the aorta.90
Pulmonary Contusion
A retrospective review of 200 patients with chest
trauma found that pulmonary contusion (Figure 13)
was the most common thoracic injury.93
CT gives the ability to better define the extent
of the injury. Contusions appear radiodense and are
usually peripheral, nonsegmental and nonlobar. The
increased lung density is due to distal lung hemorrhage
and edema.94
Figure 13. Pulmonary Contusion
Penetrating Trauma To The Heart And Lung
In the setting of penetrating trauma to the heart or lung,
evaluation for pericardial hemorrhage is best carried
out by echocardiography. The best view is the sub-
costal view in which fluid or blood will appear as an
Emergency Medicine Practice © 2006
anechoic area surrounding the heart (Figure 5 on page
7). Fluid will collect posteriorly first. If seen only
anteriorly, the finding may be due to fatty deposition.
Other potentially useful views are the parasternal long
axis, parasternal short axis, and apical views.
Sensitivity is reported to be 100% and specificity is
96.9% to 100%.97,98
Cardiac tamponade is a cardiovascular
emergency requiring rapid diagnosis.99 Sonographic
criteria for the diagnosis of tamponade include diastolic
collapse of the right ventricle or right atrium, possible
collapse of the left atrium and ventricle, and distended
inferior vena cava without respiratory variation.
Transthoracic drainage under ECHO guidance is the
recommended treatment, and has largely replaced the
standard “blind” subxiphoid approach to
pericardiocentesis commonly employed in the past.100
Tracheobronchial Injury
In the setting of tracheobronchial injury, lateral neck
films may show air in soft tissues. CXR may show
pneumomediastinum or pneumothorax (Figure 7 on
page 8).101 CT of the chest with 3-D reconstruction of
the tracheobronchial tree may be equivalent or superior
to bronchoscopy.102,103
Esophageal Tears
Based on a retrospective review of 14 patients with
esophageal perforation, Ghanem et al reported that the
most common CXR finding was pleural effusion
(64%), which was bilateral 60% of the time. When the
effusion was unilateral, it was more commonly on the
left. Pulmonary infiltrates were present in 64% of the
cases and were most commonly bilateral. If unilateral,
left-sided infiltrates were more common. Other CXR
findings included pneumomediastinum (21%),
pneumothorax (14%), and pneumopericardium (14%).
Esophagography is indicated when an esophageal tear
is suspected.86 The initial study should use water-
soluble contrast medium, followed by a barium study if
the water-soluble contrast study is negative. Positive
findings on either study include extravasation (64%)
and submucosal contrast medium collection (36%).
Historically, endoscopy has been recommended if there
is a high probability of injury and negative
esophagography. However, CT has been shown to have
sensitivity and specificity of 100% after suspected
perforation.104 CT findings of mediastinitis include
increased attenuation of mediastinal fat (100%), pleural
effusions (85%), free mediastinal gas bubbles (58%),
localized mediastinal fluid collections (55%), sternal
dehiscence (40%), mediastinal lymph nodes (35%),
lung infiltrates (35%), pericardial effusion (28%), and
pleuromediastinal fistula (3%).104
Diaphragmatic Injury
According to ATLS, CXR findings consistent with
diaphragmatic injury include elevation or blurring of
the diaphragm (Figure 14), hemothorax, abnormal gas
shadow obscuring the hemidiaphragm, or gastric tube
10 EBMedicine.net • November 2006
positioned in the chest.1
Findings on CT are similar. Based on the
review of CT examinations of 179 patients with blunt
trauma, Nchimi et al reported the following findings as
strong predictors of blunt diaphragmatic rupture:
Discontinuity, thickening, segmental non-recognition,
intrathoracic hernia of abdominal viscera, elevation,
hemothorax, and hemoperitoneum. Although not yet
validated by other studies, the combination of
discontinuity, thickening, and segmental non-
recognition was reported to be 100% sensitive.105 While
CXR findings, especially displacement of a gastric
tube, may be diagnostic of diaphragmatic injury, CT
105
increases the accuracy of the diagnosis significantly.
Figure 14. Diaphragmatic Injury
With NG Tube In The Thorax
Thoracic Imaging In Medical Emergencies
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
thromboembolic disease may also be seen. For those
under the age of 40 with a negative physical
examination, the appropriateness is described as being
influenced by severity and duration of dyspnea and the
presence of other symptoms or risk factors for
cardiovascular, pulmonary, and neoplastic diseases.3
While CT is not recommended for the initial evaluation
of patients with dyspnea, except for patients with
suspected pulmonary embolism, the ACR rates CT as
appropriate (8/9) at any age when clinical evaluation,
plain films, and laboratory studies are non-diagnostic.3
Plain CT is useful for detecting many diseases that may
present with dyspnea, such as emphysema, sarcoidosis,
and lung cancer.
Pulmonary Embolism
Ventilation/perfusion (V/Q) lung scanning has been the
primary tool for imaging pulmonary embolism in the
past. In the Prospective Investigation of Pulmonary
Embolism Diagnosis (PIOPED) study, the sensitivity of
a normal or near-normal V/Q scan was shown to be
EBMedicine.net • November 2006
99%, with specificity of 98%. However, 78% of scans
were read as low or intermediate probability. In
addition, the overwhelming majority of patients without
pulmonary embolism still had abnormal scans.23 V/Q
scans require two hours to perform. One advantage is
that V/Q scans result in less exposure to ionizing
radiation than CT scans so they may be considered
more useful for pregnant patients and patients that
cannot tolerate intravenous contrast due to
hypersensitivity or renal insufficiency.23
CT angiography of the chest has several
advantages over either V/Q scanning or pulmonary
angiography in the evaluation of the patient with
possible pulmonary embolism. It is faster than either
V/Q scanning or angiography. It is more practical in
dyspneic patients and requires less contrast than
angiography. It is generally more available than V/Q
scanning or angiography and it may detect other
important diagnoses when pulmonary embolism is not
present24.
By 2001, CT scanning was being used more
than lung scanning to investigate suspected pulmonary
embolism.25 Even with older generation scanners, CT
could image from the main pulmonary arteries to the
segmental and possibly sub-segmental arteries (Figure
15),24 but inter-observer agreement was poorer for sub-
segmental arteries26.
Figure 15. Pulmonary Embolism
With 16-slice multidetector-row CT scanners now
commonly available, the entire chest can be imaged
with excellent resolution, requiring a breath-hold of less
than 10 seconds. These scanners can reliably diagnose
tiny emboli in sub-segmental vessels.106 The clinical
significance of sub-segmental emboli is unclear. In a
study that included 67 patients with isolated
subsegmental pulmonary emboli, Eyer et al reported
that 37% did not receive anticoagulation and that there
was no evidence of recurrent thromboembolism on
follow up.107 Further study to confirm these findings is
needed.
A positive CT result is an intraluminal filling
defect or vascular occlusion24 (Figure 15). Reported
sensitivities vary widely, being affected significantly by
the generation of scanner used. While large series
using specific generations of scanners are yet to be
published, Russo et al published a meta-analysis of the
relevant literature from 1995 to 2004. This review
showed the sensitivity and specificity to have increased
from 37 to 94% and from 81 to 100% respectively,
primarily due to the possibility of depicting
11 Emergency Medicine Practice © 2006
subsegmental clots.108
The PIOPED II trial was a prospective, multicenter
investigation of the accuracy of multidetector CT
angiography alone and combined with venous-phase
imaging (CT angiography-CT venography) for the
38
diagnosis of acute pulmonary embolism. Combined
CT angiography-CT venography was found to have
higher diagnostic sensitivity than CT angiography
alone, but the increased diagnostic yield is probably not
enough to justify the additional radiation.39 The
predictive value of either approach is high when the
result is concordant with clinical assessment, but
clinicians should be wary and consider additional
testing when results are discordant with clinical
38,39
probability.
Echocardiography is not a sensitive test for
pulmonary embolism. Sonographic criteria for
pulmonary embolism include right ventricular dilation,
septal wall motion abnormality, decreased right
ventricular contractility, elevated pulmonary artery or
right ventricular pressures, moderate to severe tricuspid
regurgitation, and visualization of the clot in the right
ventricle or pulmonary artery. Sensitivity is only 41%
and specificity is 91%.33,110
Magnetic resonance imaging of the chest can be
performed relatively rapidly, but continues to have
limited availability. The diagnostic performance of
MRI is similar to that for V/Q scanning. One
advantage is that MRI does not use ionizing radiation
and therefore may be safer for imaging pregnant
patients.24
Acute Asthma
ACR’s Appropriateness Criteria for CXR in
uncomplicated asthma is only 4/9.4 A CXR is often
recommended for the first episode of wheezing. Based
on a retrospective review of 90 episodes of acute
asthma in adults, Findley et al reported that the chest
radiograph findings were most commonly normal
(55%), hyperinflated (37%), or showed interstitial
changes previously identified on radiographs (7%).
Only one new alveolar infiltrate was found in this series
(1%). They concluded that, in the setting of acute
asthma, the chest radiograph is indicated only when
pneumonia or pneumothorax is suspected.16 Abnormal
CXR findings are more common in children with first
episodes of wheezing (6 to 16%), but, in the absence of
clinical variables, these findings rarely affect the acute
management of the patient.17-19
Acute Exacerbation Of Chronic Obstructive
Pulmonary Disease
Approximately one-fourth of radiographic
abnormalities seen in patients with apparent
exacerbations of chronic obstructive pulmonary disease
are not predictable on the basis of high-risk criteria.
Consequently, routine chest radiography should be
considered.20 ACR’s Appropriateness Criteria for
uncomplicated COPD is 7/9; the appropriateness rating
increases to 9/9 in the presence of leukocytosis,
Emergency Medicine Practice © 2006
bandemia, chest pain, or cardiac history.4
Acute Respiratory Distress Syndrome
In the acute or exudative phase of acute respiratory
distress syndrome (ARDS), CXR findings include
bilateral, patchy, assymetrical pulmonary infiltrates.
There may be associated pleural effusions (Figure 16
A). The pattern is indistinguishable from cardiogenic
111
pulmonary edema. CT findings include alveolar
filling, consolidation and atelectasis, predominantly
112
independent lung zones (Figure 16 C).
In the fibrosing alveolitis phase, the CXR shows
linear opacities, consistent with evolving fibrosis and
possibly pneumothorax which is seen in approximately
10% of cases (Figure 16 B). CT shows diffuse
111,112
interstitial opacities and bullae (Figure 16 D). In
the recovery phase, radiographic abnormalities resolve
111,112
completely.”
Figure 16. CXR And CT Findings In The Acute-Exudative Phase
(Panels A & C) And The Fibrosing-alveolitis Phase (Panels B & D)
Of Acute Respiratory Distress Syndrome
Pulmonary Infections
The CXR gets a relatively low ACR appropriateness
rating (4/9) for adults less than 40 years of age with
acute respiratory symptoms, negative physical
examination, and no other signs, symptoms, or risk
factors for pulmonary disease. The appropriateness
rating goes up to 8 when the patient is greater than 40
years of age or has dementia, hemoptysis, leukocytosis,
hypoxemia, or cardio-respiratory disease.4
The 2001 American Thoracic Society Guidelines
lists the indications for CXR as newly acquired
respiratory symptoms, such as cough, sputum
production, dyspnea, associated fever, or auscultatory
findings.9 For patients with advanced age113 or
inadequate immune response, additional indications
include confusion, failure to thrive, worsening of
underlying illness, falls, and tachypnea114.
The CXR may help to determine which patients
should be hospitalized. Admission is indicated when
the CXR shows bilateral involvement (Figure 17),
multilobar involvement, cavitation, rapid progression,
or pleural effusion (Figure 18). In addition, the CXR
may help in differentiating pneumonia from other
conditions, may suggest specific etiologies, and may
detect coexisting conditions, such as lung abscess or
bronchial obstruction.
12 EBMedicine.net • November 2006
 Figure 17. Bilateral Pneumonia
Figure 18. Right Lower Lobe Pneumonia
With Pleural Effusion
In 2002, Rothrock et al proposed a decision rule
for when to obtain a CXR for non-traumatic presentations.
They concluded that the presence of any of 10 criteria
necessitates CXR and that, when used in this fashion, the
CXR has a sensitivity of 95% and specificity of 40% for
acute pulmonary pathology;11 see Table 6.
Table 6. Criteria For Obtaining A CXR In Patients
With Non-Traumatic Complaints
l Age greater than 60
l Temperature greater than 380C
l Oxygen saturation less than 90%
l Respiratory rate greater than 24
l Hemoptysis
l Rales
l Decreased breath sounds
l Alcohol abuse
l History of tuberculosis
l History of thromboembolic disease
Emerman et al found that physician judgment
as to when to order a CXR outperformed many decision
rules with a sensitivity of 86% and a specificity of 58%.12
Traditional classification of pneumonia into lobar and
bronchial is less useful than a more clinical classification;
see Table 7. 115
EBMedicine.net • November 2006
Table 7. Radiology Of Bacterial Pneumonia
Type of Bacterial Typical Radiographic
Pneumonia Pattern
Community Airspace consolidation
Acquired limited to one lobe or
Pneumonia segment
Aspiration Bilateral multicentric
Pneumonia opacities most
commonly in the lower lobes
Nosocomial Variable but most
Pneumonia commonly diffuse
Multifocal involvement
with associated pleural
Effusion
Pediatric Respiratory Infections
Chest radiography has traditionally been recommended
as a part of the work up for febrile children (greater than
380C or 100.40F) younger than three months. However,
based on meta-analysis of three studies including a total
of 617 infants, the chance of a positive chest radiograph
in a febrile infant younger than three months of age with
no pulmonary signs or symptoms was found to be only
approximately 1%.10,13,14 For children older than three
months of age, CXR should be considered for febrile
children with temperature greater than 390C or 102.20F
and a WBC count greater than 20,000/mm3.15 CXR is
usually not indicated in febrile children older than three
months of age with temperature less than 390C without
clinical evidence of acute pulmonary disease.10
Chest radiograph cannot, by itself, be used to
differentiate between viral and bacterial disease.116
Alveolar (lobar) infiltrate is an insensitive but
reasonably specific indication of bacterial infection.116
Acute Pulmonary Infections in HIV Positive Patients
ACR’s Appropriate Criteria gives chest radiograph a
highly appropriate (9/9) rating for the evaluation of HIV
positive patients with cough, dyspnea, chest pain, or
fever. CT of the chest is also appropriate (8/9) in HIV
positive patients with acute respiratory symptoms and
negative or non-specific CXR findings. If there is a
high clinical suspicion for a pulmonary infection in the
setting of a normal chest radiograph, a high-resolution,
non-contrast CT scan may be warranted to assess for
subtle abnormalities. Patients who have a normal chest
radiograph and PCP will usually exhibit focal areas of
ground-glass opacity on CT.5
CT is only moderately appropriate (4/9) when
CXR shows diffuse infiltrates. It is highly appropriate
(8/9) when non-infectious diseases are suspected. CT
findings can frequently suggest the diagnosis, or at least
limit the diagnostic possibilities, and may identify
optimal sites for obtaining a biopsy.5
13 Emergency Medicine Practice © 2006
Tuberculosis
The radiological presentation of primary tuberculosis is
variable. Parenchymal infiltrates anywhere in the lung
fields are possible and pleural effusion may be
associated or may occur alone. Hilar adenopathy is
sometimes the only finding.117
The typical radiological presentation of post-
primary tuberculosis in adults (reported in 58% of
patients) is with infiltration nodules in the upper zones,
with or without cavitation (Figure 19).117 Pediatric post-
primary pulmonary tuberculosis typically shows
consolidation, cavitation, multi-focal ill-defined
airspace opacities in the upper lobes, apical pleural
thickening, and evidence of prior pulmonary
118
tuberculosis.
Figure 19. Cavitary Post-Primary TB
Screening chest radiography is indicated for
patients with positive screening tests but need not
include lateral views. Meyer et al compared PA CXR
with PA and lateral CXR in 535 cases and found that
the lateral view identified findings not present on the
PA view in only 0.4% cases, and in no case did the
unique findings on the lateral view alter patient
management.119 High resolution CT has been used to
predict activity.120
Hemoptysis
Chest radiography should be included in the initial
evaluation of patients presenting with hemoptysis.121
Based on a retrospective review of records of 119
bronchoscopies performed for hemoptysis, O'Neil et al
concluded that patients with less than two risk factors
for malignancy and negative CXR may be managed
with observation; see Table 8.121 CT and bronchoscopy
are complementary examinations in patients with two
or more risk factors for malignancy or with
persistent/recurrent hemoptysis and negative CXR.122
ACR s Appropriateness Criteria for CT in this setting
is high at 8/9.6 In patients with two or more risk factors
for malignancy and positive chest radiograph, ACR s
Appropriateness Criteria for CT is also 8/9.6
Table 8. Criteria For High-Yield On Bronchoscopy
In Patients With Hemoptysis
l Male sex
l Age greater than 40 years
l Smoking history greater than 40 years
Emergency Medicine Practice © 2006
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14 EBMedicine.net • November 2006
those most pertinent for emergency department patients
have to do with the evaluation of chest pain patients and
establishing the diagnosis and prognosis of chronic
ischemic heart disease. Per the ACC/AHA/ASE
guidelines, ECHO is a class I recommendation for the
evaluation of chest pain in patients with suspected acute
myocardial ischemia when baseline ECG and
laboratory markers are non-diagnostic and when the
study can be obtained during pain or within minutes
after its abatement. The use of ECHO in this way,
however, generally requires the physical presence of a
cardiologist trained in the use of ECHO for the
detection of wall motion abnormalities early in the
course of the event, which is not achievable in many
centers. ECHO is not indicated for chest pain of
apparent non-cardiac etiology nor is ECHO indicated
for patients who have electrocardiographic changes
40
diagnostic of myocardial ischemia/infarction.
ECHO is also indicated for patients with chest
pain who have hemodynamic instability or who are
suspected of having valvular, pericardial, or aortic
disease.40
Exercise or pharmacological stress ECHO
is recommended as a class I intervention for the
diagnosis of myocardial ischemia in symptomatic
individuals or for selected patients in whom the ECG
assessment is less reliable. These patients include those
with intermediate pretest likelihood of coronary artery
disease and digoxin use, left ventricular hypertrophy
(LVH) of 1 mm or more of ST depression at rest, pre-
excitation syndrome, or complete left bundle branch
block (LBBB). Exercise echocardiography is also
recommended at the class IIa level for the detection of
myocardial ischemia in women with a low or
intermediate pretest likelihood of coronary artery
disease. ECHO is not indicated for the screening of
asymptomatic patients with a low likelihood of
coronary artery disease or as routine periodic
reassessment for stable patients. Stress ECHO should
not be used as a routine substitution for treadmill
exercise testing in patients for whom ECG analysis is
expected to suffice.40
A meta-analysis based on three studies of rest
echocardiography used to assess for acute cardiac
ischemia in the ED setting reported that sensitivity was
excellent at 93% and specificity was rated as good at
66%.127 A subsequent report in 2002 cited the
sensitivity at 91%, but noted that false negative studies
may be associated with small MI's.128
Cardiac Arrest: In the setting of cardiac
arrest, echocardiography can be used for the detection
of cardiac motion. Patients without cardiac activity do
not survive regardless of electrical activity.129,130
Echocardiography may also be used to evaluate for
tamponade as a cause for pulseless electrical activity.130
Pericardial tamponade and electromechanical
dissociation are truly emergent and potentially lethal
cardiovascular conditions requiring emergency
diagnosis.99
EBMedicine.net • November 2006
Nuclear Medicine Scanning: Both thallium-201 and
technetium-99m radiopharmaceuticals are commonly
used for myocardial scanning with imaging using single
photon emission computed tomography (SPECT).
Several technetium-99m labeled agents are available
but the most used and studied is sestamibi.131
The ACC/AHA/ASNC Guidelines for clinical use
of cardiac radionuclide imaging recommend cardiac
stress myocardial perfusion SPECT at the class I level
in order to identify the extent, severity, and location of
ischemia in patients who are able to exercise and who
have a baseline ECG abnormality that interferes with
the interpretation of exercise-induced ST-segment
changes, i.e., pre-excitation syndromes, LVH, digoxin
therapy, or greater than 1 mm ST depression.
Adenosine or dipyridamole myocardial perfusion
SPECT is recommended in patients with left bundle
branch block or electronically-paced ventricular
rhythms and for those patients unable to exercise. The
use of exercise myocardial perfusion SPECT as the
initial test for patients who are considered to be at high
risk (e.g., diabetics) is given a class IIa
recommendation.41
The diagnostic accuracy of rest myocardial
perfusion imaging in patients who have acute chest pain
and normal or non-diagnostic ECGs has been found to
be high. Based on eight studies between 1979 and
2002, sensitivity was reported to be 90 to 100%,
specificity 60 to 92%, and negative predictive value 99
to 100%.132 Studies performed in lower-risk patients
have demonstrated that emergency department
perfusion imaging does offer incremental value. In a
large, prospective, randomized, controlled study, 2475
patients were randomized to routine care or to routine
care with myocardial perfusion imaging. A
significantly lower admission rate was achieved in the
imaging group without reducing appropriate admission
for patients with acute ischemia.133 Nevertheless, there
are several problems that limit the use of myocardial
perfusion imaging. First, there are some technical
problems in obtaining high quality images that allow
differentiation of diaphragm and breast shadows from
pathologic perfusion defects. Second, detection of new
perfusion defects is complicated in patients with
previous myocardial infarction. In many centers,
availability of the test is limited to certain hours of the
day, and the lack of availability of experienced readers
may limit the usefulness of the scans. Finally, there
continues to be some controversy over whether the
injection of radioactive tracers must be performed
while the patient is experiencing ischemic symptoms or
whether the injection may occur soon after symptom
resolution.134
Exercise SPECT myocardial perfusion imaging is
preferred in patients with greater than 1 mm ST
depression or pre-excitation syndrome on their resting
ECG, as well as for those who have undergone
percutaneous transluminal coronary angioplasty
(PTCA) or coronary artery bypass grafting (CABG).131
In addition, patients with less than 1 mm ST depression
15 Emergency Medicine Practice © 2006
on their resting ECG, those on digoxin, and those with
LVH, LBBB, and ventricular pacing may be considered
for SPECT myocardial perfusion imaging.131
Pericardial Effusion
Echocardiography performed by emergency physicians
has been shown to be a reliable technique for
evaluating suspected pericardial effusions (Figure 5 on
page 7). In a study of 515 high-risk patients with
images captured on video and subsequently reviewed
by cardiologists, emergency physicians detected
pericardial effusion with a sensitivity of 96% and a
specificity of 98%.136 ECHO has been suggested for
use in further evaluating ED patients presenting with a
complaint of dyspnea but for whom no cause has been
found after standard ED evaluation. In a prospective
observational study of 103 patients who presented with
new-onset dyspnea but lacked any pulmonary,
infectious, hematological, traumatic, psychiatric,
cardiovascular, or neuromuscular explanation for their
dyspnea after ED evaluation, Blaivas found a 14%
incidence of pericardial effusion and recommended the
use of bedside ultrasound in the evaluation of such
patients.137
Pericardial effusion appears as a dark band
between the pericardium and myocardium on sub-costal
view (Figure 5 on page 7). Evaluation for tamponade
is accomplished by looking for “swinging heart sign,”
right ventricular collapse during mid-late diastole, or
inferior vena cava plethora.
Echocardiographic guidance for drainage of
pericardial fluid is the standard of care and has a 97 to
100% success rate with a complication rate of 5% and a
major complication rate of 1.2%; the most commonly
reported complications are hemothorax and
infection.100,138 The use of a pericardial catheter for
extended drainage has become more common, with a
concomitant reduction in the rate of recurrence and
subsequent pericardial surgery.138
Infective Endocarditis
In patients suspected of having infective endocarditis,
the diagnosis can be facilitated by the identification of
vegetations on heart valves. Echocardiography has
therefore assumed a vital role in the diagnosis of this
disorder. The Duke Criteria has improved the
specificity and sensitivity of the diagnosis of infective
endocarditis by assigning major and minor criteria,
including echocardiographic findings of an oscillating
intracardiac mass or vegetation, an annular abscess or
new valvular regurgitation, or prosthetic valve partial
dehiscence.40,139
While both TTE and TEE can identify valvular
vegetations, TEE can identify much smaller vegetations
and has significantly greater sensitivity, 44% and 94%
respectively. Specificity is similar for the two
techniques at 98% and 100% respectively.140 When the
diagnosis of infective endocarditis is suspected, obtain
prompt cardiology consultation. Transthoracic ECHO
may be used as the initial screening test, followed by
Emergency Medicine Practice © 2006
TEE if the results are negative or equivocal.50
Spontaneous Aortic Dissection And
Hemomediastinum
Chest radiograph findings of hemomediastinum include
widened mediastinum (greater than 8 cm at aortic arch
in the supine position), blurred aortic knob (Figure 12
on page 9), left apical pleural cap, opacified
aorticopulmonary window, widened right paratracheal
stripe (greater than 4 mm), and left pleural effusion.
Additionally, the calcium sign, consisting of a
discontinuity of the calcification within the aortic knob
or a separation of the calcified intima from the outer
aortic border of greater than 1 cm, suggests dissection.
Chest radiograph findings are usually abnormal in
the presence of aortic dissection and CXR has a
reported sensitivity of 90%. The presence of a normal
aorta and mediastinum on CXR decreases the
probability of dissection, but does not exclude it. The
141
negative likelihood ratio is 0.3. Positive findings
include change in aortic silhouette, widening
(especially if progressive compared to old films),
indistinct contour or blurred aortic knob, irregularity
and separation of outer vessel wall, and intimal calcium
(Figure 21). In addition, displacement of adjacent
structures may be seen as the esophagus with
nasogastric tube to the right and posterior, trachea to the
right and anterior, or left mainstem bronchus
inferiorly.141
The contrast-enhanced multi-slice CT scan has
become a standard test for aortic dissection.21 In fact,
multi-slice CT scanning now appears to be the modality
of choice for complete examination of the entire aorta.22
Computerized tomography provides excellent
visualization of the aorta and branch vessels and their
relationship to surrounding structures (Figure 22). 21,22
Contrast is required to optimally depict the vessel
lumen.51
Figure 21. CXR Of Thoracic Aotic Dissection
16 EBMedicine.net • November 2006

The sensitivities of TEE, CT, and MRI for
detecting dissection are similar at about 98%. TEE
may provide more information on detailed anatomy of
the valves in the setting of proximal dissection, and can
provide functional data on regurgitation that CT cannot.
By contrast, the sensitivity for TTE is only 59%.51
Specificities are 77% for TEE, 83% for TTE, 87% for
CT, and 98% for MRI. CT was reported to be less
effective in detecting an entry site or aortic
regurgitation. Based on these findings, a noninvasive
diagnostic strategy of using MRI in hemodynamically
stable patients and TEE in unstable patients has been
proposed.51
MRI provides at least equivalent visualization to
CT and can be effectively used with or without contrast.
Drawbacks include the lack of availability or poor
accessibility in the emergency situation and difficulty in
visualizing distal branch vessels. However, the use of
MRI may obviate the need for conventional
angiography in some cases.51,52
Thoracic Aortic Aneurysm
Chest radiography usually shows widening of the
mediastinum, enlargement of the aortic knob, tortuosity,
calcification, or tracheal deviation when there is
aneurysmal dilatation of the thoracic aorta, but actual
size is difficult to assess (Figure 12 on page 9).142,143
However, the chest radiograph can be completely
normal.144 If the chest film shows abnormalities
consistent with thoracic aortic aneurysm, one should
have a low threshold for ordering a contrast-enhanced
CT scan to better define the aortic anatomy.142,143
Contrast-enhanced CT scanning (Figure 23) and
magnetic resonance angiography (MRA) are the
preferred modalities to define aortic (and branch vessel)
anatomy, and both accurately detect and size thoracic
aortic aneurysms. When aneurysms involve the aortic
root, MRA is preferable since CT images the root less
well and is less accurate in sizing its diameter.142,143
Transthoracic echocardiography is effective for
imaging the aortic root, but it does not consistently
visualize the mid or distal ascending aorta or the
descending aorta. TTE should generally not be used for
diagnosing or sizing thoracic aortic aneurysms. TEE
can visualize the entire thoracic aorta well, but, due to
EBMedicine.net • November 2006
its semi-invasive nature, it is generally not favored for
routine imaging of stable patients.143
Figure 23. CT Of Thoracic Aortic Aneurysm
Congestive Heart Failure/Pulmonary Edema
The chest radiograph (Figure 24) is rated as highly
appropriate (9/9) when new onset heart failure (HF) is
suspected based on symptoms and physical
examination, and is rated as highly appropriate (9/9)
with previously diagnosed HF and new or worsening
symptoms. CXR is less appropriate (4/9) for patients
with previously diagnosed HF and stable symptoms.8
Based on the analysis of the Acute Heart Failure
National Registry (ADHERE) database, Collins et al
reported that nearly 20% of patients admitted to the ED
with acutely decompensated heart failure (ADHF)
showed no signs of pulmonary congestion on chest
radiography and suggested that clinicians not rule out
heart failure in patients with no radiographic signs of
congestion.144 While the initial ED CXR may be
insensitive in predicting a hospital discharge diagnosis
of ADHF, CXR is a simple test that remains helpful in
the diagnosis of the majority of patients with ADHF and
in establishing alternative diagnoses in many others.145
Congestive heart failure is readily diagnosed on CT
obtained for other indications, but symptoms of
congestive heart failure do not, of themselves, provide a
sufficient indication for CT scanning (ACR
appropriateness rating: 2/9). 8
Figure 24. CXR Showing Acute Decompensated
Heart Failure
Controversies And Cutting Edge
Some issues in the area of thoracic imaging remain
controversial and some approaches are in the process of
change due to recently published research. Still others
are currently undergoing intensive investigation. In this
17 Emergency Medicine Practice © 2006
section, we will attempt to describe some of these
current issues and controversies.
Ultrasound In The Evaluation Of Thoracic
Trauma
Ultrasound has been shown to be more sensitive than
supine AP chest radiograph for the detection of
69
traumatic pneumothoraces and ultrasound is useful
for the detection of hemothorax. In some centers,
thoracic ultrasound is performed routinely along with
the traditional FAST scan, creating the extended
focused abdominal sonogram for trauma (EFAST).70
Ultrasonography has been reported to have
greater sensitivity in detecting chest wall fractures
than either clinical acumen or radiography; 80% vs
76
26% vs 24%. In addition to rib fractures, this
includes sternal fractures. While not commonly used
for this purpose in the United States, ultrasound is a
rapid and reliable method for identifying bony
disruptions, especially in the superficial, readily
accessible ribs and sternum.77 This application
represents an opportunity for additional study by
emergency ultrasound researchers.
Significance Of Upper Rib Fractures
In the past, the literature has stressed the importance
of rib fractures, especially those of the first and
second ribs, as predictors of aortic injury. However,
several studies have demonstrated no increased
likelihood of aortic injury with upper rib fractures.2,75
No additional imaging studies are mandated by these
findings alone.
Significance And Diagnosis Of Myocardial
Contusion
The clinical significance of myocardial contusion
following blunt chest trauma is unknown. A number
of diagnostic approaches have been used for
diagnosis, including electrocardiography, serial
enzyme measurement, and both TTE and TEE. TTE
has proven inadequate, but TEE appears to be safe and
to provide excellent quality images. Based on a
retrospective study of 81 patients who received TEE
in the evaluation of blunt chest trauma, Weiss et al
found myocardial contusions, diagnosed by wall
motion abnormalities, in almost a quarter of these
patients. They noted an increase in mortality rate
associated with this diagnosis.95 However, a more
recent prospective study by Lindstaedt et al of 180
patients with blunt chest trauma found only a 12%
incidence of myocardial contusion, and none of their
patients experienced any cardiac complications. They
concluded that myocardial contusion is a frequent
finding in polytraumatized patients, but that the
outcome and prognosis is favorable.96
Diagnosis Of Pulmonary Embolism
Since first generation scanners missed approximately
a third of pulmonary emboli in one study, they could
not be used alone to diagnose or exclude pulmonary
Emergency Medicine Practice © 2006
embolism.27 Additional tests that have been used in
conjunction with early generation CT scanners included
serial venous ultrasonography of the legs30 and CT
venography of the pelvis and legs.31,109 With advanced
generation scanners, it now appears feasible to use
clinical risk stratification, D-dimer measurement, and
multi-detector CT scanning to reliably and safely
diagnose or exclude clinically significant pulmonary
34-37
emboli. A systematic review published in 2005 of 15
studies published between 1990 and 2004 containing
3500 patients found that the use of CT ruled out
pulmonary embolism. An overall negative predictive
value of 99.1% for a chest CT negative for pulmonary
embolism was found, even though all generations of
scanners were included in the review. This is a similar
negative predictive value as that for conventional
pulmonary arteriography. Furthermore, the use of
advanced generation scanners should improve the
negative predictive value.32
Evaluation Of The Patient With Hypertension
The chest radiograph is often included in the work-up
of the hypertensive patient, presumably to evaluate for
the presence of LVH. However, the CXR is insensitive
for the detection of LVH and is not clearly indicated in
uncomplicated cases.7 CXR is possibly indicated in
patients with moderate to severe hypertension and
probably should be reserved for patients with
cardiorespiratory symptoms or signs.7,146 Echocar-
diography is the non-invasive modality of choice for the
detection of the cardiac effects of systemic
147,40
hypertension, the most common cause of LVH.
The Role Of CT In The Evaluation Of Pulmonary
Infection In Immunocompromised Patients
If there is a high clinical suspicion for a pulmonary
infection in the setting of a normal chest radiograph, a
high-resolution, non-contrast CT scan may be
warranted to assess for subtle abnormalities. Patients
who have a normal chest radiograph and PCP will
usually exhibit focal areas of ground-glass opacity on
CT.5
The Role Of CT In The Diagnosis Of Coronary
Artery Stenosis
Electron beam computed tomography (EBCT) has been
in use for many years as a means of measuring coronary
artery calcium and estimating the overall coronary
atherosclerotic plaque burden. EBCT has proven useful
in identifying individuals with or at risk for coronary
heart disease. However, there is still controversy as to
the prognostic significance of calcium, as some
investigators believe that the presence of coronary
calcification may stabilize the atherosclerotic plaque.135
High-resolution images obtained rapidly by MDCT
have recently improved image quality to the point
where it may soon be possible to consider non-invasive
48
coronary angiography as a routine clinical tool.
MDCT shows promise as a means of excluding
coronary artery stenosis in a non-invasive fashion
18 EBMedicine.net • November 2006
(Figure 25). Reports of the use of 16-slice MDCT for
non-invasive coronary angiography have been
appearing in the literature since 2002, and in 2005,
reports of the use of 64-slice MDCT began to appear.
Figure 25. Matched MDCT And Coronary
Angiography Of Stenosed Coronary Arteries
From six published or reported studies of the use of
MDCT for non-invasive coronary angiography,
sensitivity is reported to be 83 to 100%, specificity is 86
to 98%, positive predictive value is 79 to 87%, and
42-48
negative predictive value is 97 to 100%. However,
Garcia et al have recently reported the evaluation of
1629 nonstented segments in which they used 16-slice
MDCT for the assessment of coronary artery stenosis.
They found only 71% of the segments evaluable by
MDCT. The sensitivity for detecting stenosis greater
than 50% was 89% and the sensitivity for detecting
stenosis greater than 70% was 94%. Negative
predictive value was 99% for both categories of
stenosis. Based on these findings, routine
implementation of MDCT in clinical practice is not
recommended, but MDCT may be useful in excluding
coronary disease in selected patients in whom false
49
positive or inconclusive stress test result is suspected.
Disposition
During each patient's ED evaluation, the emergency
physician decides what, if any, imaging studies are
required. For those patients who receive imaging
studies, an accurate interpretation is necessary to guide
treatment and disposition. Depending on the institution,
imaging modality, and even time of day, studies may be
read initially by the emergency physician only, by a
radiology attending or resident, or by a teleradiologist.
This initial interpretation is often a preliminary
interpretation and definitive final interpretations are
often rendered by an attending radiologist after the
patient has been treated and discharged from the
emergency department. There is a potential for
variance between the preliminary and final
interpretations.
EBMedicine.net • November 2006
Where there is a discrepancy between the
preliminary and final interpretations, a reliable system
for notification of the patient or appropriate physician is
imperative. This system should minimize the medical
consequences and therefore the medico-legal risk
associated with an inaccurate preliminary interpretation.
Routinely inform patients regarding the potential for
revision of a preliminary radiological interpretation and
assure reliable contact information.
In those cases where an incidental finding of
potential significance is noted, such as a pulmonary
nodule, notification of or referral to a primary care
physician for follow up is needed. When the
discrepancy is significant and would alter patient care,
expeditious intervention is required. For admitted
patients, physicians caring for the patient in-house
should be promptly notified of the change. If the
patient was discharged from the emergency department,
the patient should be notified and advised as
circumstances dictate. Based on the specific findings,
some patients will be directed to collect a prescription
while others should be advised to return to the
emergency department or to contact an appropriate
physician. It is essential, therefore, that a current phone
number is recorded when emergency department
patients are registered. Meticulous documentation of
all actions and communications can mitigate medico-
legal risk.
Conclusion
From the opening vignette… The 62-year-old male
who complained of severe tearing inter-scapular pain
was of great concern to you. While intravenous
labetalol and morphine were titrated, you placed a call
to CT scan to expedite his imaging. Cardiothoracic
surgery and the ICU were already on board when the
chest CT with contrast confirmed a descending aortic
dissection.
… The 28-year-old female who was post cesarean
section complaining of pleuritic chest pain was also
worrisome. Anticipating anticoagulation after chest CT,
you concluded the examination with a rectal
examination which was negative for occult blood. After
confirmation of pulmonary arterial filling defects, she
was anticoagulated and admitted.
… The 32-year-old male asthmatic felt better after
treatment. Lung auscultation and peak flow readings
were reassuring. The order for a chest radiograph
placed by your nurse was cancelled and the patient was
discharged.
… The 44-year-old female with dyspnea had a
history of congestive heart failure but her breath sounds
were diminished on the right. You ordered intravenous
analgesia and obtained a portable AP chest radiograph.
Review of the frontal chest film confirmed your
suspicion for pneumothorax. A repeat chest radiograph
after tube thoracostomy demonstrated right lung
expansion; the dyspnea improved and admission was
arranged.
19 Emergency Medicine Practice © 2006
 Ten Pitfalls To Avoid
1. Making decisions based on inadequate
studies. If the films are incomplete or
unacceptable, repeat them or order another
test. In the interpretation of the chest
radiograph, the first concern is to assure the
adequacy of the film. The entire thorax should
be seen, including the apices, lateral chest
walls, entire diaphragm and both costophrenic
angles. Failure to assure adequacy of the film
may lead to significant diagnostic error.
2. Measuring the thoracic width incorrectly.
Thoracic width is measured at the widest
point, i.e., the lung base. Failure to appreciate
this point may lead to errors in assessing the
cardiothoracic ratio and mediastinum:chest
width ratio.
3. Not looking closely enough for
pneumothorax. When evaluating for a
possible pneumothorax, films must be
reviewed carefully since small
pneumothoraces can easily be missed and
overlying skin folds can simulate
pneumothoraces. Look for a deep sulcus or
for subcutaneous air as indirect markers of a
pneumothorax.
4. Waiting for unnecessary films before
making clinical decisions. The CXR gets a
relatively low ACR appropriateness rating for
adults less than 40 years of age with acute
respiratory symptoms, negative physical
examination, and no other signs, symptoms or
risk factors for pulmonary disease. Overuse of
the CXR in this population is a common
problem and may contribute to avoidable
delay in clinical management and disposition
decisions.
5. Using chest x-rays to decide whether a
patient's pneumonia needs antibiotics.
Chest radiograph cannot, by itself, be used to
differentiate between viral and bacterial
disease.
Emergency Medicine Practice © 2006
6. Getting an x-ray for known asthmatics
with typical exacerbations. In the setting of
acute asthma, the chest radiograph is indicated
only when pneumonia or pneumothorax is
suspected or the diagnosis of asthma has not
yet been established
7. Not getting an x-ray for COPD
exacerbations. Almost one-fourth of
radiographic abnormalities seen in patients
with apparent exacerbations of chronic
obstructive pulmonary disease are not
predictable on the basis of high-risk criteria.
Routine chest radiography should be
considered.
8. Looking for ventricular hypertrophy on
chest x-ray in uncomplicated hypertension.
The chest radiograph is often included in the
work-up of the hypertensive patient,
presumably to evaluate for the presence of left
ventricular hypertrophy (LVH). However, the
CXR is insensitive for the detection of LVH
and is not clearly indicated in uncomplicated
hypertension. Echocardiography is the best
modality for the detection of LVH.
9. Ordering an ECHO inappropriately.
Obtaining an echocardiogram is a class I
recommendation for the evaluation of chest
pain in patients with suspected acute
myocardial ischemia, when baseline ECG and
laboratory markers are non-diagnostic and
when the study can be obtained during pain or
within minutes after its abatement. ECHO is
not indicated for chest pain of apparent non-
cardiac etiology, nor is ECHO indicated for
patients who have ECG changes diagnostic of
myocardial ischemia/infarction.
10. Using chest radiography to rule out
dissection. Chest radiographic findings are
often abnormal in the presence of aortic
dissection and CXR has a reported sensitivity
of 90%. However, the presence of a normal
aorta and mediastinum only decreases the
probability of dissection; it does not exclude
it.
20 EBMedicine.net • November 2006
 Key Points
1. Mediastinal widening is present when the
mediastinum measures greater than 8 cm at the aortic
arch or the mediastinum:chest width ratio is greater
than 0.25.
2. In the setting of trauma, serial CXR's may be
indicated when suspicion is high and initial screening
radiographs are negative.
3. The American College of Radiology rates
specialized rib views as having a low level of
appropriateness for adults less than 65 years of age
who have sustained chest trauma and possible rib
fracture(s). However, the chest radiograph is
appropriate at any age when the diagnosis of rib
fracture is under consideration, primarily to rule out
associated pulmonary injury.
4. Ultrasonography has been shown to have greater
sensitivity in detecting chest wall fractures than either
clinical acumen or radiography.
5.Ultrasonography can detect hemothoraces not
evident on CXR, and is rapid and accurate.
6.As follow up for an abnormal CXR, computed
tomography of the chest has a sensitivity of 100%
and specificity of 99.7%.
7. Myocardial contusion is best diagnosed by
transesophageal echocardiography. There are no
complications related to the procedure and high
quality images are generally obtained.
8. In the setting of penetrating trauma to the heart or
lung, evaluation for pericardial hemorrhage is best
carried out by echocardiography. The best view is
the subcostal view in which blood will appear as an
anechoic area surrounding the heart.
9. CT has been shown to have sensitivity and
specificity of 100% after suspected esophageal
perforation.
10. On CT, the combination of discontinuity,
thickening, and segmental non-recognition is
reported to be 100% sensitive for diaphragmatic
injury.
11. With 16-slice multidetector-row CT scanners,
now commonly available, the entire chest can be
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.
EBMedicine.net • November 2006
12. With advanced generation scanners, it now
appears feasible to use clinical risk stratification, D-
dimer measurement, and multi-detector CT scanning
to reliably and safely diagnose or exclude clinically
significant pulmonary emboli.
13. Chest radiography has been recommended for
febrile children (temperature greater than 380C or
100.40F) younger than three months with evidence of
acute respiratory illness. However, the chance of a
positive chest radiograph in a febrile infant less than
three months of age with no pulmonary signs or
symptoms is only approximately 1%.
14. The typical radiological presentation of post-
primary tuberculosis in adults is with infiltration
nodules in the upper zones, with or without
cavitation.
15. CT may be better at defining the cause of
hemoptysis than bronchoscopy and the two
modalities are equally effective at determining the
site of bleeding.
17. Non-contrast CT is easy, fast, and 100% sensitive
for upper esophageal foreign bodies. It should be the
first choice for diagnostic imaging of suspected upper
esophageal foreign bodies not expected to be visible
on plain radiographs.
18. In the acute or exudative phase of acute
respiratory distress syndrome (ARDS), CXR findings
include bilateral, patchy, asymmetrical pulmonary
infiltrates. There may be associated pleural effusions.
The pattern is indistinguishable from cardiogenic
pulmonary edema.
19. High-resolution images obtained rapidly by
multi-detector computed tomography have recently
improved image quality to the point where it is
possible to consider non-invasive coronary
angiography as a routine clinical tool.
20. Echocardiography performed by emergency
physicians has been shown to be a reliable
technique for evaluating for pericardial effusion.
22. The CT scan has become a standard test for aortic
dissection. In fact, multi-slice CT scanning now
appears to be the modality of choice for complete
examination of the entire aorta.
21 Emergency Medicine Practice © 2006
References
Evidence-based medicine requires a critical appraisal
of the literature based upon study methodology and
number of subjects. Not all references are equally
robust. The findings of a large, prospective,
randomized, and blinded trial should carry more
weight than a case report.
To help the reader judge the strength of
each reference, pertinent information about the study,
such as the type of study and the number of patients
in the study, will be included in bold type following
the reference, where available.
1. American College of Surgeons Committee on
Trauma: Advanced Trauma Life Support for
Doctors, 7th Edition. Chicago: American College
of Surgeons, 2004. (Expert Consensus
Guideline)
2. American College of Radiology. “Rib Fractures,”
ACR Appropriateness CriteriaTM, 1999. Available
at http://www.acr.org/acpda. Accessed: February
28,2005. (Expert Consensus Guideline)
3. American College of Radiology. “Dyspnea,”
ACR Appropriateness CriteriaTM, 1999. Available
at: http://www.acr.org/acpda. Accessed: February
28, 2005. (Expert Consensus Guideline)
4. American College of Radiology. “Acute
Respiratory Illness,” ACR Appropriateness
CriteriaTM, 1999. Available at:
http://www.acr.org/ac pda. Accessed: February
28, 2005. (Expert Consensus Guideline)
5. American College of Radiology. “Acute
Respiratory Illness in HIV-Positive Patients,”
ACR Appropriateness CriteriaTM, 2003. Available
at: http://www.acr.org/ac pda. Accessed:
February 28, 2005. (Expert Consensus
Guideline)
6. American College of Radiology. “Hemoptysis,”
ACR Appropriateness CriteriaTM, 1999. Available
at: http://www.acr.org/ac pda. Accessed:
February 28, 2005. (Expert Consensus
Guideline)
7. American College of Radiology. “Routine Chest
Radiographs in Uncomplicated Hypertension,”
ACR Appropriateness CriteriaTM, 1999. Available
at: http://www.acr.org/ac pda. Accessed:
February 28, 2005. (Expert Consensus
Guideline)
8. American College of Radiology. “Congestive
Heart Failure,” ACR Appropriateness CriteriaTM,
2003. Available at: http://www.acr.org/ac pda.
Accessed: February 28, 2005. (Expert
Consensus Guideline)
9. American Thoracic Society. Guidelines for the
management of adults with community- acquired
pneumonia. Am J Respir Crit Care Med
2001;163:1730-1754 (Expert Consensus
Guideline)
Emergency Medicine Practice © 2006
10. American College of Emergency Physicians
Clinical Policies Committee and Subcommittee
on Pediatric Fever: Clinical policy for children
younger than three years presenting to the
emergency department with fever. Ann Emerg
Med 2003;42:530-545. (Expert Consensus
Guideline)
11. Rothrock SG, Green SM, Costanzo KA, et al.
High yield criteria for obtaining non-trauma chest
radiography in the adult emergency department
population. J Emerg Med 2002;23(2):117-124.
(Prospective observational study of 1650
consecutive adults who underwent chest
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2002;52(11):501-503. (Prospective study of 150
newly diagnosed smear positive pulmonary
tuberculosis patients)
118.Shewchuk JR, Reed MH. Pediatric post primary
pulmonary tuberculosis. Pediatr Radiol
2002;32(9):648-651. (Retrospective review of 6
patients)
119.Meyer M, Clarke P, O'Regan AW. Utility of the
lateral chest radiograph in the evaluation of
patients with a positive tuberculin skin test result.
Chest 2003;124(5):1824-1827. (Cross-sectional
study of 535 cases)
120.Wang YH, Lin AS, Lai YF, et al. The high value
of high-resolution computed tomography in
predicting the activity of pulmonary tuberculosis.
Int J Tuberc Lung Dis 2003;7(6):563-568.
27 Emergency Medicine Practice © 2006
 (Prospective study of 148 patients)
121.O'Neil KM, Lazarus AA. Hemoptysis:
indications for bronchoscopy. Arch Intern Med
.1991;151(1):171-174. (Retrospective review of
119 bronchoscopies performed for hemoptysis
in patients with normal or non-localizing chest
roentgenograms)
122.Set PA, Flower CD, Smith IE, et al. Hemoptysis:
comparative study of the role of CT and
fiberoptic bronchoscopy. Radiology
1993;189(3):677-680. (Prospective study of 91
patients who underwent both tests)
123.Revel MP, Fournier LS, Hennebicque AS, et al.
Can CT replace bronchoscopy in the detection of
the site and cause of bleeding in patients with
large or massive hemoptysis.? Am J Roentgenol
2002;179(5):1217-1224. (Retrospective review
of the chest radiographs, CT scans and
bronchoscopic findings of patients with large
or massive hemoptysis over a 4.5 year period)
124.Cremaschi P, Nascimbene C, Vitulo P, et al.
Therapeutic embolization of bronchial artery: a
successful treatment of 209 cases of relapse
hemoptysis. (Case series; 209 cases.
125.Girardi G, Contador AM, Castro-Rodriguez JA.
Two new radiological findings to improve the
diagnosis of bronchial foreign-body aspiration in
children. Pediatr Pulmonol 2004;38(3):261-264.
(Retrospective review of clinical
characteristics and chest X-ray film of 133
children with foreign body aspiration)
126.Marco De Lucas E, Sadaba P, Lastra Garcia-
Baron P, et al. Value of helical computed
tomography in the management of upper
esophageal foreign bodies. Acta Radiol
2004;45(4):369-374. (Prospective study of 36
patients with a history of foreign body
impaction)
127.Ioannidis JP, Salem D, Chew PW, Lau J.
Accuracy of imaging technologies in the
diagnosis of acute cardiac ischemia in the
emergency department: a meta-analysis. Ann
Emerg Med 2001; 37(5):471-477. (Meta-
analysis of 10 studies of rest
echocardiography, 2 studies of dobutamine
stress echocardiography, and 6 studies of
technetium-99m sestamibi scanning)
128.Kontos MC, Kurdziel K, McQueen R, et al.
Comparison of 2-dimensional
echocardiography and myocardial perfusion
imaging for diagnosing myocardial infarction in
emergency department patients. Am Heart J
2002; 143(4):659-667.(Prospective
observational study using mode
echocardiography and myocardial perfusion
imaging with technetium-99m in 141 patients
at low to moderate risk for acute coronary
syndromes)
129.Blaivas M, Fox JC. Outcomes in cardiac arrest
patients found to have cardiac standstill on the
Emergency Medicine Practice © 2006
bedside emergency department echocardiogram.
Acad Emerg Med 2001; 8(6):616-621.
(Prospective observational study of 169
patients in cardiac arrest)
130. Tayal VS, Kline JA. Emergency
echocardiography to detect pericardial effusion in
patients in PEA and near-PEA states.
Resuscitation 2003; 59(3):315-318. (Prospective
observational study of 20 patients with non-
traumatic PEA or near-PEA states)
131.Gibbons RJ. Imaging techniques: myocardial
perfusion imaging. Heart 2000;83:355-360.
(Review)
132.Kontos MC, Tatum JL. Imaging in the evaluation
of the patient with suspected acute coronary =
syndrome. Cardiol Clin 2005;23(4):517-530.
(Review)
133.Udelson JE, Beshansky JR, Ballin DS, et al.
Myocardial perfusion imaging for evaluation and
triage of patients with suspected acute cardiac
ischemia: a randomized controlled trial. JAMA
2002;288(21):2693-2700. (Multicenter
randomized controlled trial with 2475 patients)
134.Barnett K, Feldman JA. Noninvasive imaging
techniques to aid in the triage of patients with
suspected acute coronary syndrome: a review.
Emerg Med Clin North Am 2005;23:977-998.
(Review)
135.Wayhs R, ZelingerA, Raggi P. High coronary
artery calcium scores pose an extremely elevated
risk for hard events. J Am Coll Cardiol
2002;39(2):225-230. (Prospective cohort study
of 98 asymtomatic subjects followed for an
average of 17 months after ungoing EBCT
screening)
136.Mandavia D, Hoffner R, Mahaney K, Henderson
S. Bedside echocardiography by emergency
physicians. Ann Emerg Med 2001;38(4):377-382.
(Prospective observational study of the
accuracy of bedside echocardiography in
detecting pericardial effusions as performed
by emergency physicians; 515 patients at high
risk for pericardial effusion)
137.Blaivas M. Incidence of pericardial effusion in
patients presenting to the emergency department
with unexplained dyspnea. Acad Emerg Med
2001;8(12):1143-1146. (Prospective
observational study of 103 patients)
138.Salem K, Mulji A, Lonn E. Echocardio-
graphically guided pericardiocentesis the gold
standard for the management of pericardial
effusion and cardiac tamponade. Can J Cardiol
1999;15(11):1251-1255. (Prospective
observational study of 46
echocardiographically guided
pericardiocenteses in 41 consecutive patients)
139.Durack DT, Lukes As, Bright DK. New criteria
for diagnosis of infective endocarditis: utilization
of specific echocardiographic findings. Duke
Endocarditis Service. Am J Med 1994;96(3):220-
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 222. (Case series of 405 consecutive cases of
suspected infective endocarditis)
140.Shively BK, Gurule FT, Roldan CA, et al.
Diagnositic value of transesophageal compared
with transthoracic echocardiography in infective
endocarditis. J Am Coll Cardiol 1991;18(2):391-
397. (Prospective study of 66 episodes of
suspected endocarditis using paired
transesophageal and transthoracic
echocardiograms with the presence or absence
of endocarditis determined by pathologic or
nonechocardiographic clinical data)
141.Klompas M. Does this patient have an acute
thoracic aortic dissection? JAMA
2002;287(17):2262-2272. (Meta-analysis
resulting in 21 studies)
142.Rogers RL, McCromack R. Aortic disasters.
Emerg Med Clin North Am 2004;22(4):887-908.
(Review)
143.Isselbacher EM. Thoracic and abdominal
aneurysms. Circulation 2005;111:816-828.
(Review)
144.Collins SP, Lindsell CJ, Storrow AB, Abraham
WT. Prevalence of negative chest radiography
results in the emergency department patient with
decompensated heart failure. Ann Emerg Med
2006;47:13-18. (Analysis of national database
containing 85,376 patients)
145.Cooper RJ. Misleading negative chest
radiographs: Should we ADHERE to the
conclusions? Ann Emerg Med 2006;47:19-21.
(Editorial)
146.Dimmitt SB, West JN, Littler WA. Limited value
of chest radiography in uncomplicated
hypertension. Lancet 1989;2(8654):104. (Letter)
147.Samuelsson O, Hartford M, Wilhelmsen L, et al.
Radiological heart enlargement in treated
hypertensive men: a comparative study of chest x-
ray examination and mode echocardiography. J
Intern Med 1989; 225(2):77-83. (Prospective
controlled study of M-mode echocardiography
in 25 hypertensive men)
CME Questions
65. In assessing a postero-anterior chest radiograph,
the thoracic width is measured at which of the
following sites?
a. Apices
b. Aortic arch
c. Aorticopulmonary window
d. Lung base
e. Right hilum
66. In which of the following presentations would a
routine chest radiograph be most appropriately
indicated?
EBMedicine.net • November 2006
a. 35-year-old patient with acute respiratory
symptoms and normal physical examination.
b. 35-year-old asthmatic with acute bronchospasm
unresponsive to initial therapy.
c. 50-year-old patient with history of chronic
obstructive pulmonary disease presenting with
increased cough.
d. 40-year-old patient with newly diagnosed
hypertension
e. 6-month-old child with fever of 38.5 degrees
centigrade and no evidence of acute pulmonary
disease.
67. The ACC/AHA/ASNC Guidelines for clinical
use of cardiac radionuclide imaging recommend
cardiac stress myocardial perfusion SPECT at the
class I level for which of the following groups of
patients?
a. Those who have a baseline ECG abnormality that
interferes with the interpretation of exercise-
induced ST-segment changes.
b. Those needing initial evaluation to identify the
extent, severity, and location of ischemia.
c. Those with baseline left bundle branch block.
d. Those with electronically-paced ventricular
rhythms.
e. There are currently no class I recommendations
for the use of cardiac nuclear scanning.
68. In addition to evaluation for intraperitoneal
blood, the standard focused abdominal sonogram
for trauma (FAST) is also includes an evaluation
for the presence of which of the following?
a. Hemothorax
b. Pneumothorax
c. Cardiac contusion
d. Hemopericardiaum
e. Pulmonary contusion
69. In which of the following clinical situations
would rib views be most appropriate?
a. 50-year-old male with right rib tenderness after a
fall.
b. 50-year-old female with right rib tenderness after a
fall.
c. 70-year-old female with right rib tenderness after
a fall.
d. 50-year-old patient with left lower rib tenderness
after a fall.
e. 10-year-old child with left rib tenderness after a
fall.
29 Emergency Medicine Practice © 2006
70. Which of the following techniques has the
greatest sensitivity for detecting chest wall
fractures?
a. Ultrasonography
b. Chest radiograph
c. Clinical evaluation
d. Rib or sternal views
e. Repeat chest radiograph in 48 hours
71. Angiography continues to play a role in the
evaluation of the patient with major hemothorax
because:
a. It can detect hemothorax not evident on chest
radiograph.
b. It has a greater specificity than ultrasound.
c. One can proceed to selective embolization if
major arterial bleeding sites are identified.
d. It is not as operator-dependent as
ultrasound.
e. It can identify other pathology.
72. In evaluating for aortic trauma, when is an
aortogram indicated?
a. When there is a wide mediastinum on chest
radiograph.
b. When there is evidence of any mediastinal
hematoma on CT.
c. When there is CT evidence of mediastinal
hematoma adjacent to the aorta.
d. When the CT is negative.
e. There are no indications for aortography.
73. Myocardial contusion is best diagnosed by:
esophageal rupture is true?
a. The most common finding on chest radiograph is a
normal film.
b. The initial esophagography study should use
barium for contrast.
c. The most common finding on esophagography is
submucosal contrast medium collection.
d. CT has been shown to have sensitivity and
specificity of 100% after suspected perforation.
e. The most common CT finding in the setting of
esophageal rupture is pleuromediastinal fistula.
76. Which of the following best describes the
findings of the PIOPED II trial published in
2006?
a. Multidetector CT angiography alone does not
provide sufficiently high predictive value to be
used to exclude the diagnosis of pulmonary
embolism.
b. Multidetector CT angiography can be used as the
only diagnostic test to exclude pulmonary
embolism when the results are concordant with
clinical assessment.
c. It is necessary to combine CT angiography with
CT venography to get a high enough predictive
value to use these tests in excluding pulmonary
embolism.
d. Combining CT angiography with CT venography
does not increase the diagnostic sensitivity.
e. Echocardiography is a more sensitive test than CT
angiography in diagnosing pulmonary embolism.
77. Which of the following best describes the
typical radiologic presentation of primary
tuberculosis?

a. Electocardiography a. Infiltrates or nodules in the upper lung fields.

b. Chest radiograph b. Infitration with cavitation in the upper lung fields.
c. Cardiac markers c. Hilar adenopathy.
d. Transesophageal echocardiography d. Parenchymal infiltrates in the lower lung fields.
e. CT scan e. There is no typical presentation; it is variable.

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?

a. Distension of the right atrium. a. While routine implementation of muli-detector

b. Diastolic collapse of the right ventricle computed tomography (MDCT) in clinical
c. Plethora of the left atrium practice is not currently recommended, MDCT
d. Plethora of the left ventricle may be useful in excluding coronary disease in
e. Collapse of the inferior vena cava without selected patients in whom false positive or
respiratory variation. inconclusive stress test result is suspected.
b. Electron beam computed tomography, once
considered controversial, can now be considered
75. Which of the following statements regarding the standard of care in identifying individuals at

Emergency Medicine Practice © 2006 30 EBMedicine.net • November 2006

 risk for coronary heart disease.
c. The use of exercise myocardial perfusion single
photon emission computed tomography (SPECT)
as an initial test for patients being screened for
coronary disease is a class I recommendation by
the American College of Cardiology.
d. ECHO is a class I American College of
Cardiology recommendation for patients
presenting with a history of chest pain within the
past 24 hours who have non-diagnostic ECG's and
cardiac markers.
e. Stress-ECHO testing is recommended for
screening of asymptomatic patients and for routine
periodic screening for stable patients.
79. In patients suspected of having infective
endocarditis, which of the following is correct?
a. Transthoracic echocardiography has no role in the
diagnosis of this disease.
b. Transthoracic echocardiography can be used for
initial screening, followed by transesophageal
echocardiography if the results are negative or
equivaocal.
c. Echocardiography has been supplanted by CT
scanning.
d. The sensitivity of transthoracic and
transesophageal echocardiography is the same for
the detection of valvular vegetations.
e. Transesophageal echocardiography should be
performed in the cardiac catheterization
laboratory.
80. In patients suspected of having aortic
dissection, which of the following is correct?
a. Chest radiograph has a reported sensitivity of only
50%.
b. CT scanning is much more sensitive than
transesophageal echocardiography and MRI.
c. Since MRI, TEE, and CT have similar
sensitivities, but MRI has higher specificity, a
good approach is to use MRI for stable patients
and bedside transesophageal echocardiography for
unstable patients.
d. CT is superior to other modalities in detecting
aortic regurgitation.
e. Use of contrast for CT scanning of the aorta does
not improve visualization.
EBMedicine.net • November 2006
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31 Emergency Medicine Practice © 2006
 Errata: Volume8, Number 10: Tables on Page 8, the score
for “alternative diagnosis at least as likely as deep-vein
thromobosis” is incorrectly listed as 1. We appologize for this
error. The correct score for this clinical characteristic is -2.
We regret any confusion this caused.
Credit Designation: The Mount Sinai School of Medicine designates this
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per year. Physicians should only claim credit commensurate with the
extent of their participation in the activity.
Credit may be obtained by reading each issue and completing the printed
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post-tests administered at EBMedicine.net.

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
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