TRAUMA IMAGING – WHAT,

WHERE AND WHEN…

Neil Parry MD FRCSC FACS

OBJECTIVES

� Appropriate trauma room radiology

� Advantages/disadvantages

� What radiology to do before transfer

ATLS

� Adjuncts to Primary Survey – AP Chest & Pelvis

ATLS

� Adjuncts to Primary Survey – lateral C-spine & FAST

FAST

� Detect fluid (blood) in pericardium and/or peritoneum

� Performed by surgeon, ER physician, radiologist

� Well validated for all blunt abdominal trauma and penetrating thoracoabdominal injuries

FAST – RIGHT UPPER QUADRANT

FAST

Sensitivity of FAST approaches 100% with precordial or transthoracic wounds and with hypotensive patients with blunt abdominal trauma.

CASE

� 29 year old male

� Just “minding his own business”

� Stabbed in epigastrium/xyphoid area

� Initially protecting his airway (verbally abusive) and BP 100mmHg systolic

CASE

Pericardium

Heart{PericardialEffusion

Entrance Wound

Distended Neck Veins

FAST – Penetrating Precordial Wound

Penetrating Chest Wound

FAST

Positive Equivocal Negative

OR OR (pericardial window)

Further imaging (Echo,CT)

Observation Repeat FAST

FAST – Blunt Abdominal Trauma

Blunt Trauma

FAST

Positive Equivocal Negative

Stable Unstable Stable Unstable Repeat FAST/ further imaging

CT OR CT or DPL OR or DPL

ATLS – Secondary Survey

ATLS – Secondary Survey

CT SCANS

� External Trauma - high suspicion

� Mechanism of Injury

� Altered LOC – unable to examine

� “Pan Scan” – CT head, C-spine, Chest, Abdomen/Pelvis

WHOLE BODY CT SCAN

Retrospective review of German Trauma Registry (4600 patients, ISS>16)Estimated probability of survival on TRISS, RISC & SMRCompared patients who underwent whole body CT scan vs selected CT scan

Whole body CT scan was an independent predictor for survival (p<0.002)

WHOLE BODY CT SCAN

Compared whole body MSCT as sole radiologic procedure vs conventional radiology, U/S and organ specific CT scan

Time to complete diagnostic workup and move patient to definitive treatment was faster with MSCT

CT SCAN

� Risk of radiation exposure - LHSC experience- mean 3.6 CT scans/trauma patient- mean dose of 28 mSv

� Average background dose of natural radiation is 3 mSv/yr

� Radiation worker’s annual exposure limited to 20 mSv/yr

IMAGING BEFORE TRANSFER

� Must be knowledgeable of your own institution’s capabilities and limitations

� Quickly identify patients that exceed local resources

� Identify high risk patients

� Avoid unnecessary procedures

IMAGING BEFORE TRANSFER

� Manage life threatening injuries and stabilize disabling injuries

� Everyone should have AP chest and FAST (if available) +/- AP pelvis

TO SCAN or NOT TO SCAN???

Identify Injuries Avoid Delay in Transfer

TO SCAN or NOT TO SCAN???

� Case25 year old male MVC, StableGCS 10Open femur fracturePositive FAST

� Should this patient be scanned prior to transfer?

SUMMARY

� AP chest, pelvis & FAST in Primary Survey

� CT scan excellent test…

� Identify patients quickly that exceed local resources to avoid delay in transfer

� Avoid unnecessary tests if they will not change management

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