Milagros Martí de Gracia

Subcutaneous emphysema: diagnostic clue in the emergency room

The objective of this study was to illustrate the wide spectrum of subcutaneous emphysema in the emergency room; to show the key findings on computed tomography, plain radiographs, and echography; and to discuss the differential diagnoses. Subcutaneous emphysema is a common finding in emergency department imaging studies. It has a great importance due to its broad casualty, some of them totally benign, but others potentially lethal. We retrospectively reviewed our database of emergency pathology, analyzing its origins and associated features. SE was associated to traumatic, iatrogenic, or infectious causes (necrotizing fasciitis, Fournier gangrene). It also was found associated with thoracic (causing pneumothorax and pneumomediastinum) and abdominal pathology related to intraperitoneal and retroperitoneal gas. Diagnostic difficulties and differential diagnoses are emphasized. Radiologists must be aware of abnormal gas in soft tissue because it may be the main or unique sign leading to an underlying pathology, which can be lethal.

Trapped on the "whirl": diagnostic sign on emergency CT.

The “whirl sign” is an uncommon finding on emergency CT. However, it is easy to overlook if not kept in mind. Its recognition is of capital importance, being most of its causes potentially lethal. Surgical treatment is also mandatory when signs of complication are found. The whirl sign is usually found associated to midgut, cecal and sigmoid volvulus, small-bowel volvulus and closed-loop obstructions, and post-surgical mesenteric windows (including retroanastomotic hernias). CT is an optimal imaging technique to depict the so-called sign and associated CT features suggesting complication (circumferential wall thickening, pneumatosis intestinalis, pneumoperitoneum, mesenteric fat stranding, free intraperitoneal fluid, mesenteric haziness). Radiologists must be able to recognize the whirl sign and seek associated findings that strongly support the diagnosis of a spectrum of entities, some of them lethal if no treatment is established.The “whirl sign” is an uncommon finding on emergency CT. However, it is easy to overlook if not kept in mind. Its recognition is of capital importance, being most of its causes potentially lethal. Surgical treatment is also mandatory when signs of complication are found. The whirl sign is usually found associated to midgut, cecal and sigmoid volvulus, small-bowel volvulus and closed-loop obstructions, and post-surgical mesenteric windows (including retroanastomotic hernias). CT is an optimal imaging technique to depict the so-called sign and associated CT features suggesting complication (circumferential wall thickening, pneumatosis intestinalis, pneumoperitoneum, mesenteric fat stranding, free intraperitoneal fluid, mesenteric haziness). Radiologists must be able to recognize the whirl sign and seek associated findings that strongly support the diagnosis of a spectrum of entities, some of them lethal if no treatment is established.

Acute complications and outcomes of acute head injury in adult patients with haemophilia.

The aim of the present study is to describe the clinical and epidemiological characteristics, complications and outcome of patients with haemophilia and acute head injury (AHI) at the emergency department (ED), and develop a protocol to prevent early and late complications. This is a retrospective cohort study including all patients with haemophilia and AHI admitted to the ED. We identified 26 patients with AHI. A computed tomography scan was carried out on all patients at admission, and again on two patients (with neurosurgical complications) 48 h later. The discharge diagnosis was as follows: 3.8% subdural haematoma, 3.8% cerebellar epidural haematoma and 92.3% uncomplicated AHI. We propose the following protocol: a computed tomography scan upon arrival and another within 48 h post-AHI, unless there is an absence of clinical symptoms. In addition, all patients must self-administer a clotting factor as soon as possible and be observed in the ED for at least 48 h.

Evaluation of thoracic vascular trauma with multidetector computed tomography.

p M computed tomography (MDCT) is the accepted imaging test used in the comprehensive evaluation of patients with significant rauma. Technological advances, especially short acquisition times and highesolution images that allow high-quality multiplanar and 3-dimensional eformations, have radically changed the diagnostic approach of severe trauatic injuries, many of which are life threatening or associated with a high orbidity if not diagnosed and treated in a timely manner.1-7 These developments have enabled the acquisition of angiographic images and complex multiphasic examinations that can, if necessary, encompass the whole body. These computed tomography (CT) angiograms are specifically designed for assessing the integrity of the vasculature, which has led to a modification in the traditional diagnostic approach to vascular trauma and traumatic hemorrhage.7 MDCT angiography is an effective modality for vascular imaging of the thorax, providing images with exquisite technical quality during a singlebreath hold period. In contrast to conventional angiography, CT angiography (CTA) displays both the lumen of the vessels and the surrounding structures. In addition, CTA is rapid, noninvasive, and widely available and offers a similar accuracy as direct angiography. These advantages render CTA particularly useful for the assessment of vascular emergencies or the thorax.7-11 Traumatic vascular injury may be caused by blunt, penetrating, or iatrogenic trauma and can affect any of the great vessels; aortic injury is particularly important because of its frequency and grave prognosis. Blunt traumatic aortic injury (TAI) occurs in 1% of patients who suffer motor vehicle ollisions, but is responsible for 16%-40% of fatalities12-14 and is the second ost common cause of death in blunt trauma patients, preceded only by ead trauma.14-16 Excellent publications have appeared recently on vascular thoracic trauma, most of them focusing on the aortic blunt trauma injuries, and many on the scope of diagnostic imaging.7,9,12,14,17-19 However, the iagnosis and therapeutic approach of TAI are continually changing in 3 ain directions: better understanding of the lesion’s pathophysiology that as supported the nonsurgical treatment, widespread use of MDCT in the mergency setting, and shift of the surgical techniques to endovascular reair.20 Until recently, catheter aortography was the preferred method for evaluating trauma patients suspected of TAI, especially those with findings suggestive of mediastinal hematoma in the supine chest radiograph (an indirect indicator of TAI). The continuous improvement in CT equipment progressively displaced aortography, and CTA is now considered the imaging modality of choice in patients suspected of having TAI, playing a key role in the initial diagnosis, treatment decision making, surgical planning, and