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Cant Miss Plain Film Dx

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Dustin Williams

on 8 May 2014

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Transcript of Cant Miss Plain Film Dx

Cant Miss Plain Film Diagnoses
Dustin Blake Williams, M.D.
Assistant Professor of Emergency Medicine
UT-Southwestern Medical School
Case 1
36 yo male presents with 3 days chest pain with associated nausea
Case 2
Case 3
36 yo female unrestrained driver in t-bone MVC at highway speed presents with chest pain, dyspnea, and hypotension
110 yo female w/ hx HTN, DM, osteoporosis, CAD w/ ICD, aphasia s/t previous CVA sent from ECF for abd pain and decreased appetite, and "not acting right"
No relevant financial disclosures
"Imagine that its a busy day, and you shrink the San Francisco airport to only one short runway and one ramp and gate. Make planes take off and land at the same time, at half the present time interval, rock the runway from side to side and require that everyone that leaves in the morning return the same day. Then turn off the radar to avoid detection, impose strict restrictions on the radio, fuel the aircraft in place with their engines running. Now wet the whole thing down with salt water and oil and man it with 20-year-olds, half who have never seen an airplane up close."
- air in pleural space
- due to disruption of pleura
- clinical exam is insensitive
- tension pneumo is clinical dx
- US vs CT
"Imagine that its always a busy day and you shrink the entire hospital down to one department and one entrance. Patients come and go every minute or two, wanting to be seen immediately. Any kind of illness may present, in a patient of any age, physical and mental conditions; many patients don't speak the language of the doctors and nurses. Some are drug addicts, often HIV positive, posing real dangers to staff. Then impose severe constraints on time for diagnosis and intervention, the availability of back up staff and beds, fill the area with dangerous drugs, add the threat of violence from a good portion of the patients attending and the frequent presence of the police. Now add a few cases of major trauma, staff the place with 25 year olds who are completely new to this kind of environment and make sure the experienced staff are tied up dealing with administration. Oh, and by the way, try not to kill anyone."
So why do I care?
Pennsylvania Hospital Insurance Company (1977-1981): 19% of 200 ED malpractice cases were due to “misinterpretation of radiographs.” (Trautlein et al.)
Chicago (1975-1994): Retrospective study of 18860 malpractice claims showed 12% involved radiology cases, of which missed diagnoses was the #1 cause of litigation.(Berlin and Berlin)
On a positive note...
Lufkin et al., Radiologist's Review of Radiographs Interpreted Confidently by Emergency Physicians Infrequently Leads to Change in Patient Management. Ann Emerg Med, Feb 1998;31: 202-207
16,410 xrays
9,599 confidently
6,811 non-confidently
1.2% discordance
(118 films)
3.1% discordance
only 11 films clinically significant (0.1%)
- clear visceral pleura line
- absence of lung markings bw lung edge and chest wall
- +/-subcutaneous emphysema
- Deep sulcus sign?
Take Home Points
- look for subtle signs aortic injury
- Remember AP window
- Deep sulcus signs on supine cxr
- Free air in the belly is bad
- KUB can have subtle signs with high mortality

- gas in the biliary system
- think of ascending cholangitis
- fever, RUQ pain, jaundice
- instrumentation?
Abdominal Aortic Aneurysm (AAA)
- double diaphragm sign
- double wall sign
- look for aortic wall calcification
- > 3cm diameter
- seen in 60-75% pts w AAA large enough to cause symptoms
on supine AP cxr
Full transcript