Tuesday, May 31, 2011

Osteoid Osteoma-Ulna

15 years old girl comes with pain along the extensor carpi ulnaris tendon ( ECU) with clinical diagnosis of extensor carpi ulnaris groove syndrome.


Case Submitted By-
  1. DR.M.G.K.MURTHY, SR.CONSULTANT RADIOLOGIST
  2. MR.ABDUL HAMID

Teaching Points
- ECU arises by two tendons one from lateral epicondyle and the other the mid 1/3rd of the posterior ulna and its inserts into the posterior base of the 5th metacarpal. ECU passes the groove on the medial side of the distal ulna and its covered by the annular ligament.

 
- CT shows small well defined, regular, subperiosteal, septated mixed density lesion with a hyperdense speck as the nidus with no soft tissue abnormality or joint abnormality with no significant periosteal response suggesting osteoid osteoma.

- Osteoid osteoma, and tenosynovitis along the ECU are difficult to differentiate on clinical grounds.

 

Glenoid Fracture- Teaching Points

Questions between Reporting doctor and Professor. Submitted by Dr MGK Murthy


What is this?
Answer- it is a fracture

Where?
Involves infraglenoid tubercle and axillary(lateral border)of scapula

What is the importance?
Triceps get origin from infraglenoid tubercle and teres muscles get attachment from the border

How is the joint ?
Gleno-humeral joint is maintained

What causes it?
Scapular neck fractures most frequently result from an anterior or posterior force applied to the shoulder. Glenoid rim fractures most often result from force transmitted along the humerus after a fall onto a flexed elbow. Stellate glenoid fractures usually follow a direct blow to the lateral shoulder

Types ?
Classification of glenoid cavity fractures: IA - Anterior rim fracture; IB - Posterior rim fracture; II - Fracture line through the glenoid fossa exiting at the lateral border of the scapula; III - Fracture line through the glenoid fossa exiting at the superior border of the scapula; IV - Fracture line through the glenoid fossa exiting at the medial border of the scapula; VA - Combination of types II and IV; VB - Combination of types III and IV; VC - Combination of types II, III, and IV; VI - Comminuted fracture

Which is this ?
It is possible type II

What next
MDCT with reconstructions

Thursday, May 26, 2011

Leber's Optic Atrophy-DTI

18 yr old student has developed sudden visual loss in one eye with history of maternal uncles having been blind in youth. Clinical exam and eye evaluation suggested hereditary optic atrophy . MRI showed symmetrical thinning of the optic nerves in introorbital regions consistent with lebers variety of hereditary optic atrophy. Case by Dr MGK Murthy and Mr Hari Om.






Teaching points

• It is mitochondrial neurodegenerative disease acquired through the mutated genes. Females pass it on and affected males do not
• It is bilateral with simultaneous(25%) or sequential (75%)involvement of both eyes
• Starts in young age with males(24 years mean) affected earlier than females(31years)
• Sometimes coexists with Multiple sclerosis when it is called Hardings syndrome
• LHON plus is referred to the Lebers Atophy with other diseases like movement disorders and cardiac arrhythmias
• Pathology is limited to retinal ganglion cell layer with reduced glutamate transportation

Optic nerve has various components and MRI can delineate them all
  1. Intraocular component 1mm
  2. Intraorbital 25 mm
  3. Intracanalicular 5mm
  4.  Intracranial 10 mm
Visual pathway
Optic nerves- optic chiasma- optic tracts- lateral geniculate bodies in the pulvinar –superior colliculi of brainstem-visual cortex of occipital lobes . This could be effectively depicted on Diffusion Tractography

Wednesday, May 25, 2011

Doctors Need to be on Social Media -Are Radiologists Listening?

Noted Medblogger KevinMD has these comments on his blog today- “Doctors who are not active online risk being marginalized. Facebook and Twitter users, half of whom are under of age of 34, rely on the web for most of their information. As this demographic ages, it’s conceivable that they will consult social media first to answer their health questions.

These statements pobably should serve as an eye opener to many doctors especially in India who still dont realize the importance of internet in this web 2.0 era.  You cant just ignore the facebook generation.

Monday, May 23, 2011

Patellar Sleeve Avulsion Fracture-Plain Film


Young male with sporting macro-trauma history with pain and tenderness of lower patellar region with soft tissue swelling of 2 months duration. X ray shows  lower polar irregularity , heterogenous opacities and soft issue swelling – compatible with patellar sleeve avulsion fracture of children. Case submitted by Dr MGK Murthy




Teaching points

1.    Patella is sesamoid bone  in the tendon of quadriceps muscle with dense cancellous bone with thin compact lamina.
2.    Ossifies from single ossification center(sometimes two) appearing from 2-6 yrs age and completes by puberty.
3.    Affects chondro-oseous junction  with an extensive sleeve of cartilage pulled of the main body ,with patellar tendon disruption


Avulsion Injury-Plain Film



An adolescent with athletic injury shows bony avulsion of anterior superior iliac spine –avulsion fracture. Most benign of bony injuries generally. Heals with conservative management in 4-6 weeks. Case submitted by Dr MGK Murthy




Teaching points
  • Avulsion fractures are common in appendicular skeleton with most occurring in the growing age due to athletic activity, and immature bony skeleton.
  • Anterior superior iliac spine- gives origin to Sartorius and tensor fascia lata.
  • Anterior inferior  iliac spine (just below the Superior spine)has two parts, upper gives origin to – origin to straight head of rectus femoris  and lower part give attachment to iliofemoral ligament and reaches to form the acetabular margin. 
  • Ischial tuberosity- gives origin to hamstrings(Biceps femoris, semitendinosis and semimembranosis)
  •   Greater tuberosity-attachement to hip rotators(piriformis, gemellus superior and inferior, obturator internus and externus , quadrates femoris)
  •   Lesser tuberosity-to iliopsoas


      

    Errors in Radiology



    How often we have seen that showing a same chest xray or mammogram to two different radiologists will get us different results. Do they get counted as errors? Often somebody labels the bronchovascular markings as prominent while other will call it normal. Even PNS xrays sometimes, one radiologist will call sinus hazy and other will call it clear. Looking back at the medical college days where each report was double or triple read, junior resident-then registrar then-faculty. Probably makes some sense to have some kind of standard double reads in the process to increase accuracy and to cut down on ambiguity.  It is also often postulated that computer may play a significant role in future in pattern recognition and radiologists will superread the studies, this will increase the efficiency and reduce errors of missing a significant pathology.

    What do you think of this? How you ever tried reporting same xray on two different days and found yourself writing different reports? Comments and suggestions are welcome.

    Thursday, May 19, 2011

    Trauma Metacarpophalangeal joint


    Adolescent male with sporting injury to thumb clinically

    Xray shows widening of the ulnar side of thumb MCP joint with no bony injury  and sof tissue haziness in periarticular location-possibly sprain in the  form of collateral ligament injury, sesamoids though atypical in position are not injured. MRI would  help delineate the ligamentous injury and occult bone marrow oedema. Case submitted by Dr MGK Murthy.

    Teaching points--
    Hinged(condyloid joint) with shallow proximal phalanx base articulation with spherical(thumb rather quadrilateral)metacarpal head
    Thumb MCP gets more often injured than relatively stable finger MCP
    Factors for stability include soft issue contractility including volar plate, true and accessory collateral ligaments , sagittal band, dorsal capsule, extrinsic and intrinsic tendons
    Range permitted usually is 30 deg hypertext, 120 deg flexion, 30 to 40deg mediolateral laxity and small rotation
    Volar plate is most susceptible for injury
    Usually trauma leads to sprains in the form of  collateral ligament  injury(25 to 40%)
    When dislocated, dorsal more common than palmar
    Dorsal is described simple if no soft tissue interposed and complex other wise
    Two level dislocations are when concomitant Bennett or interphalangeal joint is involved as well
    Xray is adequate particularly if additional views (to AP/Lat and Obique ) are added
    (a) Brewertons view- place proximal phalanx touching on the cassette after flexing MCP joint to 65 degrees and angulate the beam 15 degress from ulnar to radial side
    (b) True lateral of the digit/thumb concerned rather than hand
    1. Hands have 5 sesamoids (nodule of calcium within tendons or joint capsule) , with 2 at MCP joint, and 1 at interphalangeal joint of thumb, with  rest at MCP joints of index and small fingers
    2. Position of the sesamoids while could help, decide the articulation postion, they usually do not dislocate , however could be fractured, infected, inflamed, or turn neoplastic 

    Wednesday, May 18, 2011

    ALL PULSE GENERATORS IN CHEST XRAY ARE NOT CARDIAC


    Since it has become universal not  to receive clinical notes for any Chest Xray, it has become that much more difficult for the residents and consultants to become aware that all pulse generators of the chest are  not cardiac pacemakers. This an example of chest X ray done with history of cough  with DBS generators with leads travelling cranially. Submitted by Dr MGK Murthy.


      (A) DBS- Deep Brain stimulator (DBS) is used to stimulate and control the various movement disorders particularly dystocia and parkinsonism. It consists of an electrical pulse generator and insulated wires.  Electrodes extend from the thalamus subcutaneously down the patient's neck and connect to a pulse generator usually located under the clavicle

    (B) Others include
    ·   Repetitive  vagal stimulator for refractory seizures and more recently  for intractable hiccups
    ·    Spinal cord stimulator -Placed for intractable pain management  with leads at D9 to L1 in epidural space and generator beneath the abdominal skin laterally
    ·    Gastric stimulators for gastroparesis to enhance emptying
    ·     Urinary bladder stimulators
    ·    Diaphragmatic stimulators with receivers beneath the domes and leads along the phrenic nerves paraspinally
    ·     Bone stimulators in close contact to promote healing  

    Monday, May 16, 2011

    Post Spinal Anesthesia Intramedullary Injury


    A young lady  2months after undergoing Caesarean section  complaints of both lower limbs weakness with non-specific distribution . In he history, during the  epidural anesthesia for caesarean, she experienced severe shooting pain in to the Right lower limb, which resolved with medication. MRI shows longitudinal  ill defined  cord signal abnormality possibly hydrosyrinx from D11 to conus with no bleed, expansion or arachnoiditis  or epidural collections. Submitted by Dr MGK Murthy and Mr Hari Om.




    Epidural anaesthesia  is one of the safest procedures, but occasional complications are known. This case represents possibly

    (i) inadvertent injection of local anesthetic  in to low lying   variant radiculomeduallry artery  branch, feeding the anterior spinal artery , leading to vascular injury

    The other possibilities include
    (ii) direct intradural administration of LA leading to chemical injury
    (iii) direct long needle injury to the cord in high injection
    (iv)hypotension injury to the cord during the procedure
    (v) post infective sequelae (myelomalacia)
    (vi)unusual epidural venous plexus injection leading to venous hypertension and infarction
    (vii) unrelated to the procedure and incidental finding due to other  causes including trauma, Chiari malformation etc

    Evolution of Radiology Learning

    According to an article in Academic radiology, Vol. 14, No. 9. (September 2007), pp. 1113-1120-"Currently, residents prefer the Internet when researching a question, with Google as the Web site most commonly used. Case review or requisite books are more commonly used than are traditional textbooks. Radiology resident learning has rapidly shifted from traditional textbooks and journals to the Internet and short case review books."

    Given the vast resources available on the internet these days and modern radiologists having so many tools at hand from smart phones, to ipads to notebooks.. this hardly is surprising.

    Do you think text books will soon be thing of the past? Comments and opinions requested.

    Tuesday, May 10, 2011

    Ankle Fracture For Radiologist

    Only 15% show fractures.  Ottawa rule says , weight bearing immediately after injury or for the radiograph usually excludes severe bony injury.  Radiographs usually AP, Lat and Mortise view(15 to 20 deg internal rotation view)

    • Look for (apart from routine bones, alignments ,and soft tissues and tibial plafond ) FLOAT-most commonly missed fractures, Fifth Metatarsal base, Lateral malleolus, Os trigonum or posterior malleolus, Anterior Process of calcaneum, and Talar dome





    Radiographic evaluation

    AP View

     Medial clear space of >3mm=deltoid/syndesmotic strain

     Tibifibular space<6mmis normal

     Standing AP, syndesmotic widening>3mm=syndesmotic strain


    Mortise View

     Lateral clear space>2mm=syndesmotic strain

     TibioFibular overlap should be normally>1mm

     Normal medial clear space <4mm OR difference between medial and lateral <2mm

    ALL displaced medial malleolar fractures and oblique fibular fractures proximal to joint by2-3 inches will have ligamentous injuries. Teaching points by Dr MGK Murthy.

    iPhone and Stroke

    "Doctors can make a stroke diagnosis using an iPhone application with the same accuracy as if they use a medical computer workstation. According to researchers  this can be particularly useful in rural medical settings."

    Reference and Further reading- Healthcare IT News

    Monday, May 09, 2011

    Radiology MCQs- AIIMS May 2011

    Questions submitted by DAMS students

    Q1 Contrast radiography all are true EXCEPT:
    a)      Jejunum has feathery appearance.
    b)      Ileum is featureless
    c)       Colon shows asymmetric haustrae.
    d)      Distal duodenum shows a cap like appearance

    Answer-  d) Distal duodenum shows a cap like appearance
    Reference -  Review of Radiology- Sumer Sethi, 5th edition.
    Proximal duodenum called as duodenal bulb is shaped like a cap. The duodenal cap or duodenal ampulla is the very first part of the duodenum which is slightly dilated.It is the part which is intraperitoneal and is about 2 cm long. It is mobile and has a mesentery. It is also smooth walled.

    Q2 All the following are pure beta emitters EXCEPT
    a)      Yttrium-90
    b)      Phosphorus-32
    c)       Strontium- 89
    d)      Samarium 135

    Answer- d) samarium
    Reference -  Review of Radiology- Sumer Sethi, 5th edition. Pg 122
    Radioisotopes in Treatment of Osseous Metastases
    PHOSPHORUS 32--Radiophosphorus-labeled phosphates were the first radionuclides used to treat bone metastases. Since then, many reports have been published about the use of 32P in patients with prostate and breast carcinoma. The currently available product, 32P orthophosphate, is economically priced compared with similar beta-emitting radionuclides used for this purpose, but it has fallen into disuse because of the widely held impression that current 32P approaches are too toxic.
    STRONTIUM 89 CHLORIDE--Although 89Sr is, like 32P, a pure betaemitting radioisotope, it has several theoretical advantages as a treatment agent for bony metastases. Strontium is found in the same periodic table family as is calcium and is metabolized in a similar fashion, with significant concentrations found in the skeleton and small amounts elsewhere in the body.

    SAMARIUM 153 LEXIDRONAM-- The US Food and Drug Administration has recently approved samarium 153 lexidronam chelated to ethylenediamene-tetramethylenephosphonic acid (153Sm-EDTMP) for the relief of pain in patients with osteoblastic bone metastases. This radioisotope, like 32P and 89Sr, emits low-energy electrons. Unlike the other approved agents, however, 153Sm has a shorter half-life (less than 2 days) and gamma emission suitable for imaging and prospective dose estimation.
    RHENIUM 186 AND RHENIUM 188--- Rhenium 186 (Sn) hydroxyethylidene diphosphonate (186Re-HEDP) has characteristics similar to those of 153Sm-EDTMP, with a beta emission half-life of 90.64 hours and a gamma emission suitable for imaging.
    YTTRIUM 90- is also beta emitter.

    Q3 Protein loosing enteropathy is diagnosed by all EXCEPT:
    a)      Tc 99 Sotisumab
    b)      Tc 99 Dextran
    c)       Tc 99 Albumin
    d)      In 111 Transferrin

    Answer- a )  Tc 99 Sotisumab

    Reference –
     Semin Nucl Med 37:269-285- 2007

    The diagnosis of protein losing enteropathy was first performed using 131I polyvinyl pyrrolidone. It was replaced by131-I albumin, which was considered to be more physiologic. This marker was limited by 131I thyroid uptake and absorption of 131I albumin into the intestinal tract sometimes yielding indeterminate results.69 51Cr labeled albumin overcame difficulties associated with 131I albmumin and became the radionuclide of choice for these studies.

    99mTc-labeled albumin has been used for diagnosis of protein losing enteropathy, but has the added advantage of permitting imaging of the gastrointestinal tract with potential localization of a site of protein loss, thereby, assisting in the diagnosis of the underlying condition, or directing resectionfor surgically correctable causes of enteric protein loss. 99mTc- HSA scans were more likely positive in patients with lower albumin and total protein levels, possibly related to higher rates of protein loss.
    99mTc-dextran was evaluated for its use in detecting protein losing enteropathy. The findings suggested improved sensitivity compared with previous documented studies using 99mTc-HSA, possibly because of faster background clearance, less electrostatic repulsion from vascular endothelium, less hepatic uptake, and better in vivo stability.

    111-In transferrin was evaluated for its ability to provide both imaging and detection of protein-losing enteropathy through one examination.Other possible advantages of 111In transferrin imaging includes its stability with significantly less likelihood for urinary excretion compared with 99mTc HSA.

    Q4  Central Dot sign is seen in
    a)      Caroli Disease
    b)      Polycystic liver disease
    c)       Primary sclerosing cholangitis
    d)      Liver hamartoma

    Answer-a )  Caroli Disease

    Reference- Hepatobiliary CME-AIIMS-MAMC –PGI series for radiology Post graduates

    Computed tomographic (CT) scans of the liver shows tiny dots with strong contrast enhancement within dilated intrahepatic bile ducts (the central dot sign). These intraluminal dots on CT scans corresponded to intraluminal portal veins on sonograms, findings indicating portal radicles surrounded by dilated intrahepatic bile ducts. This is a classical sign for Caroli’s disease


    Q5 In Left ventricular failure which of the following is not found:
    a)      Kerley B lines
    b)      Oligaemic lung fields
    c)       Increased vascularity in upper lobes
    d)      Increase pulmonary capillary wedge pressure

    Answer- b) Oligaemic lung fields

    Reference- Pg 32-33 Review of Radiology, Sumer Sethi, 5th edition.  
    Pulmonary Edema or LVF
    PCWP(mmHg)
    Pathology
    CXR
    9-12
                                              Normal
    12-19
    Early Pulm Edema/Cardiac Decompensation
    Dilated UL Pulm Veins
    20-24
    Interstitial Edema
    Kerley Lines
    >25
    Alveolar edema
    Batwing Appearance, Perihilar
    Fluffy opacities

    Q6  Gold standard investigation for recurrent gastrointensinal stromal tumour is :
    a)      MRI
    b)      MIBG
    c)       USG
    d)      PET

    Answer- d) PET

    Reference- The radiology of gastrointestinal stromal tumours (GIST). D Michael King. Cancer Imaging. 2005; 5(1): 150–156.The management of malignant GISTs has been revolutionised by the development of Imatinib  which is, uniquely, a therapeutic agent that targets a specific abnormal intracellular signalling molecule. The effective management of patients with these tumours requires regular imaging assessment for which CT has conventionally been the method of choice. Whilst it remains most valuable in the initial diagnosis and staging of GISTs, it is now clear that PET imaging, preferably combined with CT is the gold standard method for assessment of response by virtue of its unique dynamic functional characteristic which, when combined with CT, provides a more accurate assessment and prediction of the quality of response.

    Q7 On abdominal ultrasound gall bladder shows diffuse wall thickening with hyperechoic nodule at neck with comet tail artifacts. The most likely diagnosis is :
    a)      Adenomyomatosis
    b)      Adenocarcinoma of gall bladder
    c)       Xanthogranulomatous cholecystitis
    d)      Porcelain gall bladder

    Answer-a ) Adenomyomatosis

    Reference- DAMS class test. Repeat from AIIMS November 2008.
    Cholesterol crystals within Rokitansky- Aschoff sinuses produce the characteristic ‘comet tail’or ring-down artifact seen in adenomyomatosis. Both gallbladder, carcinoma and adenomyomatosis can cause focal wall thickening in the gallbladder, but the visualization of hyper echoic sinuses is typical of the latter. A porcelain gallbladder is a complication of chronic cholecystitis causing mural calcification: the gallbladder wall appears hyperechoic with marked  acoustic shadowing.

    Sunday, May 08, 2011

    Radioisotopes in Treatment of Osseous Metastases

    PHOSPHORUS 32
    Radiophosphorus-labeled phosphates were the first radionuclides used to treat bone metastases. Since then, many reports have been published about the use of 32P in patients with prostate and breast carcinoma. The currently available product, 32P orthophosphate, is economically priced compared with similar beta-emitting radionuclides used for this purpose, but it has fallen into disuse because of the widely held impression that current 32P approaches are too toxic.

    STRONTIUM 89 CHLORIDE

    Although 89Sr is, like 32P, a pure betaemitting radioisotope, it has several theoretical advantages as a treatment agent for bony metastases. Strontium is found in the same periodic table family as is calcium and is metabolized in a similar fashion, with significant concentrations found in the skeleton and small amounts elsewhere in the body.

    SAMARIUM 153 LEXIDRONAM

    The US Food and Drug Administration has recently approved samarium 153 lexidronam chelated to ethylenediamene-tetramethylenephosphonic acid (153Sm-EDTMP) for the relief of pain in patients with osteoblastic bone metastases. This radioisotope, like 32P and 89Sr, emits low-energy electrons. Unlike the other approved agents, however, 153Sm has a shorter half-life (less than 2 days) and gamma emission suitable for imaging and prospective dose estimation.


    RHENIUM 186 AND RHENIUM 188

    Rhenium 186 (Sn) hydroxyethylidene diphosphonate (186Re-HEDP) has characteristics similar to those of 153Sm-EDTMP, with a beta emission half-life of 90.64 hours and a gamma emission suitable for imaging.

    Friday, May 06, 2011

    How to read X-ray after the TSA (total shoulder arthroplasty)

    Shoulder Replacement  is uncommon compared to hips and knees,. Presently 3 types classical modular, inverse and Cup varieties. Another way of differentiating various types are Hemiarthroplasty,Total and Reverse Total replacements.
    How to read X-ray after the TSA(total shoulder arthroplasty).
    Teaching point by Dr MGK Murthy

    Technique: True AP and Axial projections mandatory

    Look for
    (a) Type of the prosthesis and components used
    (b) Alignment
    (c) Radiolucent lines along the humeral component
    (d) Exact visualization of the interface between the glenoid component and bone (or cement-bone interface) along with similar bone and implant interface in humeral component is important to study osteolysis which is common
    (e) Glenoid component is usually fixed by screws to the bone and an osteolysis is often present at the inferior pole of the glenoid component due to prosthesis bone notching.
    (f) Dissociation between components is to be mentioned including dislocations
    (g) Any other unusual events like in other joint replacements



    This is a middle aged person with history of shoulder replacement surgery for rheumatoid arthritis for routine post procedure X-ray shows

    (a) The position of the prosthesis (apparently total shoulder replacement ) is satisfactory
    (b) Interface between bone and cement in both glenoid and humeral component is normal
    (c) No loosening
    (d) No significant soft tissue heterotopic ossification, thought he minimal spiky opacity at the caudal end of the humeral stem is possibly reactive new bone formation
    (e) No significant osteolysis






    Tuesday, May 03, 2011

    "Teleradiology Providers" in Business Today

    Another player is the four-year-old Teleradiology Providers, which seeks its clients among Asian and African countries. "We started with two radiologists and focused initially on the subcontinent, in contrast to other companies, which were started for US clients," says Sumer Sethi, Director at the New Delhi company. The company now has tie-ups with hospitals in six countries. "There is plenty of growth potential if quality is maintained," says Sethi


    This is how May edition of Business Today, Top business magazine in India goes about, in their article Imaging the world, remotely, India's teleradiology companies thrive.  The article discusses main business models in country in Teleradiology and its pros and cons. For our company, this gives us more encouragement and recognition of our business model.

    Monday, May 02, 2011

    Barriers to Telemedicine: India and the world


    Hurdles in developement of telemedicine are different in developing and developed countries.


    In developing countries:

    1.  cost 
    2.  infrastructure lack


    In developed countries

    1. Legal issues over the protection of data 
    2. Licensing issues.
    3. relatively more penetration of healthcare facilties,leading to less of felt need.

    Communicating Critical and/or Discrepant Results for Radiology Department

    This has been defined as Notification of the patient’s doctor when the radiologist determines that an imaging study has new and unexpected findings that could result in mortality or significant morbidity. This is in accordance with ACR guidelines.

    Accordingly we also need to develop similar alert systems and communication system for the referring physicians in India as well, many a times we have seen delay in communication to the referring doctor results in serious problems for the physician. It is high time that even in India radiologist training incorporates this and trains radiologists for not only reporting the cases but makes them aware of their responsibility to communicate this as well.

    We have now included sms alert to referring physician in our teleradiology service as well and we are the first one in the country to introduce this as value addition in patient care objective.

    According to Brigham Radiology, successful communication should occur within the following timelines, which depend on the urgency level of the findings:

    1. Red alert (new/unexpected findings that are potentially immediately life-threatening): 60 minutes

    2. Orange alert (new/unexpected findings that could result in mortality or significant morbidity if not appropriately treated) 3 hours

    3. Yellow alert (new/unexpected findings that could result in mortality or significant morbidity if not appropriately treated, but are not immediately life-threatening or urgent): 15 days


    Reference and Details on-


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