Imaging in abdominal trauma
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Transcript of Imaging in abdominal trauma
Imaging in abdominal trauma
S THIYAGARAJAN
Abdominal trauma
• Trauma causes I0% of deaths worldwide
• The third commonest cause of death after malignancy and vascular disease
Blunt abdominal trauma
• Vehicular trauma (75%)• Blow to the abdomen (15%) • Fall from height (6-9%)• Others
– Domestic accidents – Fights– Iatrogenic cardiopulmonary
resuscitation
Mechanism of injury
• Direct impact or movement of organs
• Compressive, stretching or shearing forces
• Solid Organs > Blood Loss
• Hollow Organs > Blood Loss and Peritoneal Contamination
• Retroperitoneal > Often asymptomatic initially
Penetrating abdominal injury
• Accidental• Homicidal• Iatrogenic• Stab wounds• Gun shot wounds• Shrapnel wounds• Impalements
Vectors of Force - Trauma "Packages"
Right-sided Midline Left-sided
R hepatic lobeR kidney Diaphragmpancreatic head duodenum IVC
Left hepatic lobe Pancreatic body AortaTransverse colon Duodenum Small bowel
SpleenL kidney Diaphragm Pancreatic tail
Right-sided Trauma "Packages"
ACR Appropriateness Criteria
Category A• Hemodynamically unstable• Clinically obvious major abdominal
trauma• Unresponsive profound hypotension• Resuscitation with volume
replacement.• Not respond to resuscitation
• Operating room without imaging
UNSTABLE
INVESTIGATION AVAILABILITY
F A S T D P L
FREE FLUID
BLOOD
NO YES
CONTINUERESUSCITATION LAPAROTOMY
HEMODYNAMIC STABILITY ?
Category B• Hemodynamically stable• Mild to moderate responsive
hypotension• Significant trauma and have at
least moderate suspicion of intra-abdominal injury based on clinical signs and symptoms
• These patients should be evaluated by imaging
Category C
• Hemodynamically stable• Patients with hematuria after
blunt abdominal trauma• All patients with gross hematuria
and pelvic fracture require additional imaging of the bladder to exclude bladder rupture
STABLE
CONSCIOUS , RESPONSIVE
YES NO
SUSPICION OF ABDOMINAL INJURY
YESNO C T
CLINICAL FOLLOW-UP
What is FAST?
• A focused, goal directed, sonographic examination of the abdomen
• Goal is presence of haemoperitoneum or haemopericardium
• An extension of clinical examination
• Part of the Primary Survey of any patient with signs of shock or suspicion of abdominal injury
Focused Assessment with Sonography for Trauma
What FAST is NOT
• A definitive diagnostic investigation
• A substitute for CT• The answer to all our problems
The ABCDE of Trauma
• A - Airway• B - Breathing• C - Circulation (FAST) • D - Disability• E - Environment and Exposure
The FAST examination
• FAST examines four areas for free fluid:
Perihepatic & hepato-renal space Perisplenic Pelvis Pericardium
The perihepatic scan• The hepatorenal
space (pouch of Morison)
• most dependent part of the upper peritoneal cavity
• The probe is placed in the right mid- to posterior axillary line at the level of the 12th ribs.
The perihepatic scan
The perihepatic scan
Blood shows as a hypoechoic black stripe between the capsule liver and the fatty fascia of the kidney
Perihepatic scan
Perisplenic window• Transducer
positioned in left posterior axillary line between 10th and 11th ribs with beam in coronal plane.
• Demonstrates spleen, kidney and diaphragm
• May be marred by acoustic shadows from ribs
• May be improved by imaging patient whilst in full inspiration.
Abnormal perisplenic window
The pelvic scan
• The pelvic examination visualises the cul-de-sac: the Pouch of Douglas in females and the rectovesical pouch in the male
• Most dependent portion of the lower abdomen and pelvis, where fluid will collect
• The transducer is placed midline just superior to the symphysis pubis
The pericardial scan
• The pericardial examination screens for fluid between the fibrous pericardium and the heart
• The transducer is placed just to the left of the xiphisternumand angled upwards under the costal margin.
Subxiphoid view of cardiac anatomy
Subxiphoid view
Normal subcostal view of pericardiumPositive FAST demonstrating pericardial effusion
Quantification of hemoperitoneum
Huang and associates scoring systems• Total Score ranging from 0 to 8• One point was assigned to each
anatomic site in which free fluid was detected during the FAST scan
• Fluid of more than 2 mm in depth in the hepatorenal or the splenorenal space was given 2 points instead of 1
• Floating loops of bowel were given 1 point
• Scores > 3 required exploratory laparotomy
Approximately…
• FAST can detect between 100-250ml0.5 cm in Morison's Pouch = 500ml1 cm in Morison's Pouch = 1000ml
CT can detect volumes of free fluid as low as 100ml
FAST: Strengths and LimitationsStrengths
• Rapid (~2 mins)• Portable• Inexpensive• Technically simple,
easy to train • Can be performed
serially• Useful for guiding
triage decisions in trauma patients
Limitations• Does not typically
identify source of bleeding
• Requires extensive training to assess parenchyma reliably
• Limited in detecting <250 cc intraperitoneal fluid
• Particularly poor at detecting bowel and mesentery damage
• Difficult to assess retroperitoneum
• Limited by habitus in obese patients
Extended FAST (eFAST)
• Evaluation of pneumo and hemothorax in addition to intraperitoneal injuries.
• Hemothorax– Ultrasound is much more sensitive
for detecting pleural fluid and can identify as little as 20mL in the pleural space
• Pneumothorax– Using ultrasound to evaluate for a
pneumothorax is a relatively new concept but it is easy to learn
Anterior Thoracic Views
• Probe is usually placed on the anterior chest in the 3-4th intercostal space and midclavicular line
• When “Sliding sign”(seashore sign) is not present, a pneumothorax is suspected.
• Comparing one side of the chest to the other may be helpful.
eFAST
DPL Procedure• To identify
hollow viscus injury (stomach, small bowel, colon) or diaphragmatic injury
• Introduce catheter infraumbilically and infuse fluid
DPL• Highly sensitive to intraperitoneal
blood, but low specificity nontherapeutic explorations.
• Significant injuries may be missed– Diaphragm– Retroperitoneal hematomas– Renal, pancreatic, duodenal– Minor intestinal– Extraperitoneal bladder injuries
CT in Abdominal Trauma
• Initial evaluation of– blunt trauma– penetrating trauma
• Follow up of non-operative management
• Rule out Injury
Abdominal Trauma Protocol
• Blunt injury -deceleration, crush, weapon (e.g. bat)– venous phase ~70 secs– Delayed scan if injury present; ~3-5
mins• Penetrating injury: knives, gun
– Same as blunt– Additional scan after rectal contrast
material
• The findings to look for in abdominal trauma are the following:– Hemoperitoneum– Pneumoperitoneum– Contrast blush consistent with active
extravasation– Subcapsular hematomas– Laceration– Contusions– Devascularization of organs or parts
of organs
CT findings of shock• Collapse of inferior vena cava• Small aorta• Persistent nephrogram without excretion• Hypodense spleen, without enhancement
and normal vascular pedicle• Increased enhancement of the small bowel
wall• Increased enhancement of the adrenal
glands• Sometimes findings of right cardiac
insufficiency with reflux into the hepatic veins
HemoperitoneumHyperdense intraperitoneal fluid collection
0–20HU Preexisting ascitesBileUrineDigestive fluidDiluted or old blood
30–45HU Free Unclotted intraperitoneal blood
45–70HU Clotted blood/sentinel clot sign hematoma
>100 HU Extravasation of contrast medium(vascular or urinary)
Volume
• Detection of fluid in each paracolic gutter indicates that atleast 200 ml of blood must be present in each gutter.
• CT visualisation of blood in the abdomen and pelvis corresponds with the amounts of more than 500 ml.
SENTINEL CLOT SIGN
• Clotted blood adjacent to the site of injury is of higher attenuation value than unclotted blood which flows away .
• When the source of intraperitoneal bleed not evident, the location of highest attenuating blood clot is a clue to the most likely source
Ascites – Radiographic findings
• Obliteration of inferior edge of liver• Widening of distance b/n flank stripe
&asding colon• AF b/n liver & lateral abd wall may result
in visualization of a lucent band –Hellmer’s sign
• Dog ear sign or ‘Mickey mouse ears’ sign(100-
150ml)- fluid density lateral to rectal gas shadows.
• Separation and floating of bowel loops• Bulging properitoneal flank stripe • Poor definition of major abd. organs and
psoas • Overall abdominal haziness
PNEUMOPERITONEUM
• FREE AIR SENSITIVITY OF IMAGING STUDIES– COMPUTED TOMOGRAPHY- 99%– AP UPRIGHT CHEST RADIOGRAPH -
76% – LEFT DECUBITUS ABDOMEN
RADIOGRAPH 80 - 90%– SUPINE ABDOMEN RADIOGRAPH -
56%
Signs of a pneumoperitoneum on the supine radiograph
Right upper quadrant gas Perihepatic Subhepatic Morrison’s pouch Fissure for the ligamentum teres
Rigler’s (double wall) signLigament visualization
Falciform (ligamentum teres) Umbilical (inverted V sign) medial and lateral
UrachusTriangular airThe cupola signFootball or air domeScrotal air (in children)
Spleen
• The spleen is the most commonly injured organ in blunt abdominal trauma
• 40% of all solid organ injuries
Plain film findings for spleen trauma
• left lower rib fracture • The classic triad indicative of acute
splenic rupture • Left hemidiaphragm elevation• Left lower lobe atelectasis• Pleural effusion
Parenchymal Contusion
Hypodense intraparenchymal area with irregular contours
Parenchymal Laceration
• Superficial, linear hypodensity, usually less than 3 cm in length
• Fracture - involves two visceral surfaces, or if its length is more than 3 cm
• Multiple fractures - Scattered spleen
Subcapsular Hematoma
• Crescent-shaped perisplenic• Compresses the splenic parenchyma
Vascular Trauma
• The most dangerous vascular traumatic lesions are arterial lesions
• Irregular area of increased density relative to background spleen
• Typically the attenuation value is within 10 HU of the adjacent artery
Delayed splenic rupture• Bleeding due to splenic injury
occurring more than 48 h after blunt trauma following an apparently normal CT examination
• Due to ruptures of subcapsular splenic haematomas.
Splenic CT Injury Grading Scale
Grade I Laceration(s) < 1 cm deepSubcapsular hematoma < 1cm diameter
Grade II Laceration(s) 1-3 cm deepSubcapsular or central hematoma l-3cm diameter
Grade III
Laceration(s) 3-10 cm deepSubcapsular or central hematoma 3-10 cm diameter
Grade IV
Laceration(s) > 10 cm deepSubcapsular or central hematoma > 10cm diameter
Grade V
Splenic tissue maceration or devascularization
A way to remember this system is: • Grade 1 is less than 1 cm.• Grade 2 is about 2 cm (1-3 cm). • Grade 3 is more than 3 cm.• Grade 4 is more than 10 cm.• Grade 5 is total devascularization
or maceration.
The shortecommings of this grading scale are:• Often underestimates injury extent.• Significant inter observer variability.• Does not include:
– Active bleeding– Contusion– Post-traumatic infarcts
• Most importantly: no predictive value for non-operative management
Contrast blush• A contrast blush is defined as an area
of high density with density measurements within 10 HU compared to the nearby vessel (or aorta).
• The differential diagnosis is:– Active arterial extravasation– Post-traumatic pseudoaneurysm– Post-traumatic AV fistula
Splenic CT Injury Grading Scale
Grade I Laceration(s) < 1 cm deepSubcapsular hematoma < 1cm diameter
Grade II Laceration(s) 1-3 cm deepSubcapsular or central hematoma l-3cm diameter
Grade III
Laceration(s) 3-10 cm deepSubcapsular or central hematoma 3-10 cm diameter
Grade IV
Laceration(s) > 10 cm deepSubcapsular or central hematoma > 10cm diameter
Grade V
Splenic tissue maceration or devascularization
American Association for the Surgery of Trauma ( AAST)organ injury severity scale grading system for splenic injury
Grade 1
Small subcapsular haematoma, less than 10% of surface area
Grade 2
Moderate subcapsular haematoma on 10 –50% ofsurface area; intraparenchymal haematoma less than 5 cm in diameter; capsular laceration less than 1 cm deep
Grade 3
Large or expanding subcapsular haematoma on greater than 50% of surface area; intraparenchymal haematoma greater than 5 cm diameter; capsular laceration 1 –3cm deep
Grade 4
Laceration greater than 3 cm deep; laceration involving segmental or hilar vessels producing major devascularization ( >25%)
Grade 5
Shattered spleen; hilar injury that devascularizes the spleen
SPLENIC INJURIES - Management
• Often arterial hemorrhage, therefore nonoperative management less successful.
• Predictive factors for nonop success: – Localized trauma to flank/abdomen– Age<60– No associated trauma precluding obs– Transfusion <4u rbcs– Grade I-III
• Grade IV-V: almost invariably require operative intervention
• Delayed hemorrhage (hours to weeks post-injury): 8-21%
Liver
• The liver is the second most commonly injured organ in abdominal trauma.
• Between 70 and 90% of hepatic injuries are minor
• Right lobe most commonly affected
• Associated injuries:2/3 have hemoperitoneum45% have associated splenic injury33% have rib fracturesDuodenal or pancreatic injuryBiliary injury: hematobilia, biloma, biliary ascites, bile duct disruption
• Ultrasound sensitive for grade 3 or greater
Radiological overview of liver injury:
• Right lobe> left lobe; 3:1• Posterior segment most common
(fixed by coronary ligament)• CT imaging method of choice
Features with impact on the management and the prognosis
• Number of segments involved by the lacerations (significant if at least three segments are involved)
• Central or subcapsular location of the lacerations and contusions
• Extension of lesions within the porta hepatis or the gallbladder fossa
• Importance of the hemoperitoneum• Vascular lesions with active bleeding or
sentinel clot sign
The CT report should • Precisely mention the lobar or
segmental• Superficial or central topography
of the contusions• Along with their extent and
location in relation to the vascular elements.
Classification(AAST)
I-Subcapsular hematoma<1cm, superficial laceration<1cm deep.
II-Parenchymal laceration 1-3cm deep, subcapsular hematoma1-3 cm thick.
III-Parenchymal laceration> 3cm deep and subcapsular hematoma> 3cm diameter.
IV-Parenchymal/supcapsular hematoma> 10cm in diameter,
lobar destruction,
V- Global destruction or devascularization of the liver.
VI-Hepatic avulsion
Periportal Edema
• Periportal hypodensities running in parallel to the portal branches
• Causes– Diffusion from intraparenchymal
bleeding– Dilatation of periportal lymph
vessels – Vascular or focal bile duct dissection
Complications
• Biloma • Delayed hemorrhage• Hemobilia• Hepatic infarcts• Pseudoaneurysm• AV fistula
• Indications for surgical treatment in liver trauma– Shock– Active venous bleeding– Trauma of the gallbladder– Choleperitoneum– Abdominal surgery necessary for
other causes
Retroperitoneal Hemorrhage
• Retroperitoneal hemorrhage may arise from injuries to major vascular structures, hollow viscera, solid organs, or musculoskeletal structures or a combination
Small zone I (central) retroperitoneal
hematoma
Large zone I (central) retroperitoneal
hematoma with active extravasation
Large zone II (lateral) retroperitoneal
hematoma
Pancreas
• Uncommon injury• 1.1% incidence in penetrating
trauma and only 0.2% in blunt trauma.
• Rarely an isolated injury.• Usually part of a 'package injury'
Laceration of the pancreatic neck
without duct injury
Pancreatic transection (neck) with duct injury
Subtle pancreatic contusion
Indirect Signs• Edema with global pancreatic
enlargement and loss of lobulation• Peripancreatic fat infiltration• Peripancreatic fluid, especially if it is
located around the SMA or the omental bursa
• Hematic fluid between the dorsal surface of the pancreas and the splenic vein
• Thickening of the left anterior pararenal fascia or fluid in the anterior pararenal space
• Concomitant duodenal injury
AAST GRADING OF PANCREAS INJURY
GradeType of Injury Description of Injury
I Hematoma Minor contusion without duct injury
Laceration Superficial injury without duct injury
II Hematoma Major contusion without duct injury or tissue loss
Laceration Major laceration without duct injury or tissue loss
III Laceration Distal transection or parenchymal injury with duct injury
IV Laceration Proximal transection or parenchymal injury with probable duct injury (not
involving ampulla)b
V Laceration Massive fragmentation of pancreatic head
Imaging of Renal Trauma
• Computed tomography (CT) is the modality of choice in the evaluation of blunt renal injury
• Injury to the kidney is seen in approximately 8%– 10% of patients with blunt or penetrating abdominal injuries
Renal criteria for performing CT in
abdominal trauma• Macroscopic hematuria• Microscopic hematuria with shock• Important renal ecchymosis or
fracture of the lumbar transverse process
• Open trauma involving the retroperitoneum
• Mechanism of deceleration (risk of pedicle injury)
• In children all types of posttraumatic hematuria
Computed Tomography
• Early and delayed CT scans through the kidneys are necessary
• Excretory-phase contrast (3min)• The preferred technique
– Helical CT performed from the dome of the diaphragm
• Scanning parameters include – Collimation of 7 mm, – Pitch of 1.3, – Image reconstruction intervals of 7 mm.
Subcapsular hematoma (category I)
Crescent shaped hyperdensity, located in the periphery of the
kidney
Laceration
• Hypodense, irregularly linear areas, typically distributed along the vessels and filled with blood.
• They are best analyzed at arterial phase– Superficial (<1 cm from the renal
cortex) – Deep (>1 cm from the renal cortex) – Renal medulla– Collecting tubule system
Simple renal laceration (category I)
Major renal laceration without involvementof the collecting system (category II)
Major renal laceration involving the collecting system (category II)
Multiple renal lacerations (category III)
Shattered kidney (category III)
Segmental Infarct
• Triangular parenchymal area, with a widest part at the cortex, which is not enhanced during the different phases, with clear delineation
Segmental renal infarction (category II)
Traumatic occlusion of the main renal artery (category III)
Traumatic occlusion of the
main renal artery (category III)
Active arterial extravasation(category III)
Vein Pedicle Injury
• Incomplete or absent opacification of the renal vein
• Persistent nephrogram• Reduction in excretion• Nephromegaly
Laceration of the renal vein (category III)
Urinoma/Urohematoma
• Presence of a more or less significant breach of the collecting tube system, with urine escape reflected by extravasation of contrast medium on delayed imaging, in an extrarenal location
Avulsion of the ureteropelvic junction (category IV)
AAST organ injury severity scale grading system for kidney injury
Grade 1 Contusion or contained and non -expanding subcapsular haematoma, without parenchymal laceration; haematuria
Grade 2 Non -expanding, confined, perirenal haematoma or cortical laceration less than 1 cm deep; no urinary extravasation
Grade 3 Parenchymal laceration extending more than 1 cm into cortex; no collecting system rupture or urinary extravasation
Grade 4 Parenchymal laceration extending through the renal cortex, medulla and collecting system
Grade 5 Pedicle injury or avulsion of renal hilum that devascularizes the kidney; completely shattered kidney;thrombosis of the main renal artery
BLADDER INJURY
CT Cystography
• Empty the bladder• Instill the contrast retrograde
through the foley catheter of avg. 350-400 cc of contrast
• Image the pelvis
CT classification
TYPES1. Bladder contusion2. Intraperitoneal rupture3. Interstitial bladder injury4. Extraperitoneal rupture
A. simpleB. complex (bladder neck involved)
5. Combined bladder injury
Intraperitoneal rupture (type 2)
• Cystography– Contrast in paracolic gutters,
around bowel loops, pouch of Douglas and intraperitoneal viscera
– ± Pelvic fracture• CT cystography
– Contrast in paracolic gutters, around bowel loops, pouch of Douglas and intraperitoneal viscera
Cystogram of intraperitoneal bladder rupture
Extraperitoneal rupture (type 4)
• Cystography– Simple (type 4A): Flame-shaped
extravasation around bladder– Complex (type 4B): Extravasation
extends beyond the pelvis– Extravasation best seen on post-
drainage films
• CT cystography– Perforation by bony spicules– "Knuckle" of bladder: Trapped
bladder by displaced fracture of anterior pelvic arch
– Simple (type 4A): Extravasation is confined to perivesical space
– Complex (type 4B): Extravasation extends beyond perivesical space; thigh, scrotum, penis, perineum, anterior abdominal wall, retroperitoneum or hip joint
– "Molar tooth sign": Rounded cephalic contour (due to vertical perivesicle components of extraperitoneal fluid)
MOLAR TOOTH SIGN
CT of extraperitoneal bladder rupture
Type 5(combined) rupture.
URETHRAL INJURY
• Urethral injury is a common complication of pelvic trauma
• Occurs in as many as 24% of adults
• With pelvic fracturesTypically involve the proximal (posterior) portion
CLASSIFICATION OF URETHRAL INJURIES
Colapinto & McCallum
Goldman & Sandler
Grade I Posterior urethra stretched, but intact
Posterior urethra stretched but intact
Grade II Posterior urethral tear above intact urogenital diaphragm (UGD)
Partial or complete posterior urethral tear above intact UGD
Grade III Posterior urethral tear with extravasation through torn UGD
Partial or complete tear of combined anterior and posterior urethra with torn UGD
Grade IV — Bladder neck injury with extension to the urethra
Grade IVa — Injury to bladder base with extravasation simulating type IV (pseudo grade IV)
Grade V — Isolated anterior urethral injury
Goldman type I injury
Stretching or elongation of the otherwise intact posterior urethra
Intact but stretched urethra
Goldman type II injury
Urethral disruption above the urogenital diaphragm while the membranous segment remains intact
Contrast agent extravasation above the urogenital diaphragm only
Goldman type III
Disruption of the membranous urethra, extending below the urogenital diaphragm and involving the
anterior urethra
Contrast agent extravasation below the urogenital diaphragm, possibly extending to the pelvis or perineum;
intact bladder neck
Goldman type IV injury
Bladder neck injury extending into the proximal urethra
Extraperitoneal contrast agent extravasation bladder neck disruption
Goldman type IVa injury
Bladder base injury simulating a type IV injury
Periurethral contrast agent extravasation; bladder base disruption
Intestinal and Mesenteric Traumas
• Bowel or mesentery injury occurs in 5% of patients with abdominal blunt trauma
• More common following open trauma, especially in injuries caused by firearms
• Four CT findings should alert the radiologist1. Focal fat infiltration2. Interloop hematoma (sentinel clot
sign)3. Bowel wall thickening4. Free intraperitoneal air
Small Bowel Injury• Diffuse circumferential thickening
– Hypoperfused "shock" bowel• Focal thickening
– Usually non-transmural injury • Specific findings, rare
– Bowel content extravasation– Focal bowel wall discontinuity
• Most common finding– Unexplained non-physiologic free fluid (84%)– Mesenteric stranding– Focal bowel thickening– Interloop fluid
• If in combination, strongly suggestive
GI Perforation
The direct CT sign • Transparietal continuity solution,
mainly located on the mesenteric side of the bowel
• The perforation may occur intraperitoneally or retroperitoneally
Indirect findings of traumatic bowel
perforation• Peritoneal findings
– Sentinel clot– Focal mesenteric infiltration
• GI findings– Pneumoperitoneal air bubbles
localized within the mesentery– Focal wall thickening
Traumatic duodenal intramural hematoma
Periduodenal hemorrhage
• Causes of bowel thickening related to trauma– Contusion/hematoma– Perforation– Distal ischemia due to mesenteric
lesion– Bowel shock– Secondary to peritonitis– Bowel spasm
GI Ischemia• Bowel ischemia
– Segmental (distal branch vessel injury)
– Diffuse thickening of small bowel wall - hypotensive shock bowel
• Typical CT signs– Lack of parietal enhancement– Thickening of bowel wall – Parietal pneumatosis with presence
of air inside the bowel wall– Air in the mesentery and portal
venous system
Role of Interventional Radiology
• Embolization– Spleen– Liver– Pelvis
• Angioplasty + Stent– Renal artery dissection
Principles of hemostatic embolization
• Treatment should be derived from the physiological process of hemostasis
• Resorbable material may be sufficient to initiate local thrombus
• It should take place at the site of injury
• Minimal tissue loss• Rebleeding should be avoided by
formation of a stable clot
Agents for embolizations
• Gelfoam– Soaked in an antibiotic solution– resorable– Can be cut in variable size– May result in too distal embolization– Risks for tissue infarction or late abscess
formation• Coils
– Have variable size, length, diameter– Precise targeted delivery– Expensive– Need normal coagulation
• Metal stents– Large-caliber patent artery
Spleen Embolization
Advantages• Embolization can decrease the
amount of resuscitation fluid to maintain vital sign.
• Embolization can decrease shock index
• Operation with adjunct embolization can decrease the mortality rate
• Early embolization may decrease the mortality rate
• Embolization is a promising way for stopping bleeding
Reference • TEXTBOOK OF RADIOLOGY AND IMAGING by DAVID
SUTTON• Grainger & Allison's Diagnostic Radiology: A
Textbook of Medical Imaging, 4th ed.• Imaging of Renal Trauma - RadioGraphics
2001; 21:557–574• Urethral Injuries after Pelvic Trauma -
RadioGraphics 2008; 28:1631–1643• http://
www.radiologyassistant.nl/en/466181ff61073
• American College of Radiology - ACR Appropriateness Criteria
• CT of the Acute Abdomen - Patrice Taourel• http://www.sonoguide.com/FAST.html
Reference • TEXTBOOK OF RADIOLOGY AND IMAGING by DAVID
SUTTON• Grainger & Allison's Diagnostic Radiology: A
Textbook of Medical Imaging, 4th ed.• Imaging of Renal Trauma - RadioGraphics
2001; 21:557–574• Urethral Injuries after Pelvic Trauma -
RadioGraphics 2008; 28:1631–1643• http://
www.radiologyassistant.nl/en/466181ff61073
• American College of Radiology - ACR Appropriateness Criteria
• CT of the Acute Abdomen - Patrice Taourel• http://www.sonoguide.com/FAST.html
Thank you