Trauma Radiography

Chapter 13Chapter 13Trauma RadiographyTrauma Radiography

Heather Johnson, A.S., R.T. (R)

Trauma CentersTrauma Centers

• Many types of facilities provide emergency medical care, ranging from major metropolitan medical center to small outpatient clinics in rural areas.

• The term “Trauma Center” signifies a specific level of emergency medical care as defined by the American College of Surgeons Commission on Trauma.

Trauma LevelsTrauma Levels

Level I = is the most comprehensive, usually a university-based center, research facility, or large medical center, complete imaging capabilities 24 hours a day, specialty physicians are available on site 24 hours a day

Trauma LevelsTrauma Levels

Level II = same as level one, but not a research facility, may not have as many specialists

Level III = no specialists, can stabilize patient for transport to a higher level center, may not have 24 hour imaging

Level IV = clinics, attend minor injuries, some stabilization before transfer

IntroductionIntroduction

Trauma is defined as a sudden, Trauma is defined as a sudden, unexpected, dramatic, forceful, or violent unexpected, dramatic, forceful, or violent eventevent

Blunt, penetrating, explosive, and thermalBlunt, penetrating, explosive, and thermal forces are common causes of traumatic forces are common causes of traumatic injuriesinjuries

IntroductionIntroduction

Trauma affects persons in all age rangesTrauma affects persons in all age ranges

Radiographers in the emergency Radiographers in the emergency department (ED) must be prepared for a department (ED) must be prepared for a variety of procedures on patients in all age variety of procedures on patients in all age groupsgroups

Preliminary ConsiderationsPreliminary Considerations

Specialized trauma imaging systems Specialized trauma imaging systems reduce the amount of time required to reduce the amount of time required to obtain diagnostic imagesobtain diagnostic images– One type provides greater flexibility in IR/CR One type provides greater flexibility in IR/CR

maneuverabilitymaneuverability– Another type scans the entire body in a few Another type scans the entire body in a few

secondsseconds

STATSCAN

Mobile radiography is often used for ED Mobile radiography is often used for ED proceduresprocedures

Preliminary ConsiderationsPreliminary Considerations

Mobile fluoroscopy units, or C-arms, may Mobile fluoroscopy units, or C-arms, may be used in fracture reduction or foreign be used in fracture reduction or foreign body localizationsbody localizations

Immobilization devices are a necessity in Immobilization devices are a necessity in trauma imagingtrauma imaging– Trauma patients often cannot hold the Trauma patients often cannot hold the

required positionrequired position

Radiographer’s Role in TraumaRadiographer’s Role in Trauma

Depends upon department protocol and Depends upon department protocol and staffingstaffing

Primary responsibilitiesPrimary responsibilities– Perform quality diagnostic imaging Perform quality diagnostic imaging

proceduresprocedures– Practice ethical radiation protectionPractice ethical radiation protection– Provide patient careProvide patient care

Radiographer’s Role in TraumaRadiographer’s Role in Trauma

Patient Patient level of consciousnesslevel of consciousness changes changes are common in traumaare common in trauma

““Best Practices” in Trauma Best Practices” in Trauma RadiographyRadiography

SpeedSpeed– Efficiency in producing quality images in the Efficiency in producing quality images in the

shortest possible timeshortest possible time

AccuracyAccuracy– Optimum image quality, minimum repeatsOptimum image quality, minimum repeats

QualityQuality– Quality cannot be sacrificed for speedQuality cannot be sacrificed for speed– Do not use patient condition as an excuse for Do not use patient condition as an excuse for

poor quality imagespoor quality images


PositioningPositioning– Important not to aggravate patient’s condition Important not to aggravate patient’s condition

when obtaining imageswhen obtaining images– Move tube and IR, instead of patient, Move tube and IR, instead of patient,

whenever possiblewhenever possible

Practice standard precautionsPractice standard precautions– Expect to be exposed to body fluids in EDExpect to be exposed to body fluids in ED– Do not touch a patient without gloves!Do not touch a patient without gloves!

Disclaimer:Disclaimer:The following three slides are The following three slides are

gruesome.gruesome.


AnticipationAnticipation– Some injuries require follow-up procedures; Some injuries require follow-up procedures;

knowing what to do increases appreciation for knowing what to do increases appreciation for radiographer’s role in EDradiographer’s role in ED


Attention to detailAttention to detail– Pay careful attention to patient’s condition, Pay careful attention to patient’s condition,

which could change at any timewhich could change at any time

Attention to ED protocol and scope of Attention to ED protocol and scope of practicepractice– Know the protocol and scope of practice in Know the protocol and scope of practice in

your facilityyour facility

ProfessionalismProfessionalism– Adhere to Code of EthicsAdhere to Code of Ethics

Radiographic Procedures in Radiographic Procedures in TraumaTrauma

Slide 28

General Procedural General Procedural GuidelinesGuidelines

Slide 29

General Procedural GuidelinesGeneral Procedural Guidelines

Patient preparationPatient preparation

IR sizeIR size

SIDSID

ID markersID markers

Radiation Radiation protectionprotection

Patient instructionsPatient instructions

ImmobilizationImmobilization

DocumentationDocumentation

Image critiqueImage critique

Patient PreparationPatient Preparation

Use good communication skills with Use good communication skills with appropriate touch and eye contactappropriate touch and eye contact– Trauma often causes anxietyTrauma often causes anxiety

Check patient for potential artifactsCheck patient for potential artifacts– Explain what you are removing and whyExplain what you are removing and why– Secure all personal effects using proper Secure all personal effects using proper

procedure for your facilityprocedure for your facility

IR SizeIR Size

IR size for trauma procedures are the IR size for trauma procedures are the same as for routine proceduressame as for routine procedures

Use smallest IR that will demonstrate Use smallest IR that will demonstrate anatomyanatomy

Collimate field size to anatomy of interestCollimate field size to anatomy of interest

SIDSID

SID is standardized as a part of procedural SID is standardized as a part of procedural protocolprotocol– When SID is not specified under a projection, When SID is not specified under a projection,

40 to 4840 to 48– 60 to 7260 to 72 SID recommended for projections SID recommended for projections

with increased OIDwith increased OID

ID MarkersID Markers

Right or left side markers must be included Right or left side markers must be included on each imageon each image

Other required ID markers must be in the Other required ID markers must be in the blocker or elsewhere on the final imageblocker or elsewhere on the final image

Markers used for penetrating trauma to Markers used for penetrating trauma to identify entrance and exit woundsidentify entrance and exit wounds

Just Kidding…..

Radiation ProtectionRadiation Protection

Shield pediatric patients and patients of Shield pediatric patients and patients of reproductive age reproductive age

Warn other staff of exposure when Warn other staff of exposure when performing mobile imagingperforming mobile imaging

Other radiation protection measuresOther radiation protection measures– Close collimation Close collimation – Optimum technique factors Optimum technique factors

Patient InstructionsPatient Instructions

Explain and demonstrate positions, when Explain and demonstrate positions, when possible possible

Explain respiration instructions for patients Explain respiration instructions for patients who can cooperatewho can cooperate

Use short exposure times to eliminate Use short exposure times to eliminate possibility of imaging motionpossibility of imaging motion

ImmobilizationImmobilization

Many ED patients arrive in some sort of Many ED patients arrive in some sort of immobilization deviceimmobilization device

Immobilization devices are Immobilization devices are notnot to be to be removed unless ordered by a physicianremoved unless ordered by a physician

Imaging procedures are often performed Imaging procedures are often performed without removal of the immobilizationwithout removal of the immobilization

Images are used to rule out injury and Images are used to rule out injury and show if it is safe to remove immobilizationshow if it is safe to remove immobilization

DocumentationDocumentation

Because deviation or adjustment of routine Because deviation or adjustment of routine procedures is often required to procedures is often required to accommodate a patient’s injury, accommodate a patient’s injury, documentation is importantdocumentation is important

Make sure that deviation from routine is Make sure that deviation from routine is still within your scope of practice!still within your scope of practice!

Document deviation (AP, X-table, etc.), Document deviation (AP, X-table, etc.), time, portabletime, portable

Image Critique CriteriaImage Critique Criteria

Image evaluation for trauma procedures is Image evaluation for trauma procedures is the same as for routine proceduresthe same as for routine procedures

Image quality is critical for an accurate Image quality is critical for an accurate diagnosisdiagnosis

It is poor practice to accept lower quality It is poor practice to accept lower quality images due to patient condition or difficulty images due to patient condition or difficulty of procedureof procedure

Trauma ProjectionsTrauma Projections

Lateral Cervical SpineLateral Cervical Spine

Horizontal CR centered to midpoint of IRHorizontal CR centered to midpoint of IR

Pre-vertebral soft tissue must be Pre-vertebral soft tissue must be visualizedvisualized

Image should demonstrate entire C-Image should demonstrate entire C-spine from sella turcica to top of T1spine from sella turcica to top of T1

– If all seven cervical vertebrae are not seen, If all seven cervical vertebrae are not seen, then a swimmer’s view is requiredthen a swimmer’s view is required


Patient and IR centered for trauma lateral of C-spinePatient and IR centered for trauma lateral of C-spine


Lateral projection of C-spine in dorsal decubitus position; dislocation of C3-C4; C7 not demonstrated, so Lateral projection of C-spine in dorsal decubitus position; dislocation of C3-C4; C7 not demonstrated, so swimmer’s view is neededswimmer’s view is needed

Swimmer’s (cervicothoracic)Swimmer’s (cervicothoracic)

Required if C7 and top of T1 not Required if C7 and top of T1 not demonstrated on lateral C-spinedemonstrated on lateral C-spine

Trauma usually requires dorsal decubitus Trauma usually requires dorsal decubitus positionposition

Patient supine without rotationPatient supine without rotation

Ask patient to raise arm opposite the x-ray Ask patient to raise arm opposite the x-ray tube over headtube over head– Assist patient and provide supportAssist patient and provide support

Cervicothoracic SpineCervicothoracic Spine

Relax shoulder closer to x-ray tubeRelax shoulder closer to x-ray tube

Vertical IR centered just above jugular Vertical IR centered just above jugular notchnotch

Horizontal CR centered to C7-T1 Horizontal CR centered to C7-T1 interspace and midcoronal planeinterspace and midcoronal plane

Use breathing technique if possibleUse breathing technique if possible– Blur ribs and lung markings to better Blur ribs and lung markings to better

demonstrate spinedemonstrate spine


Image demonstrates lower cervical and Image demonstrates lower cervical and upper thoracic vertebrae in profile between upper thoracic vertebrae in profile between the shouldersthe shoulders


Patient and IR positioned for trauma lateral projection of cervicothoracic vertebrae using Patient and IR positioned for trauma lateral projection of cervicothoracic vertebrae using dorsal decubitus positiondorsal decubitus position


Lateral projection, dorsal decubitus position of cervicothoracic vertebraeLateral projection, dorsal decubitus position of cervicothoracic vertebrae

AP Axial Cervical SpineAP Axial Cervical Spine

Patient is supinePatient is supine– Usually immobilized with collar and spine Usually immobilized with collar and spine

boardboard

Place IR under spine board, if present, Place IR under spine board, if present, centered to C4 (Adam’s apple)centered to C4 (Adam’s apple)

Head and shoulders without rotationHead and shoulders without rotation– Ask patient to look straight aheadAsk patient to look straight ahead


CR directed 15 to 20 degrees cephalad to CR directed 15 to 20 degrees cephalad to enter MSP at C4enter MSP at C4

Image demonstrates C3-T1 or T2, Image demonstrates C3-T1 or T2, including all soft tissuesincluding all soft tissues– If backboard is present, unavoidable artifacts If backboard is present, unavoidable artifacts

may be seenmay be seen


Patient and IR positioned for trauma AP axial C-spine


Trauma AP axial C-spine; complete dislocation at C2-C3

AP Axial Oblique Cervical SpineAP Axial Oblique Cervical Spine

TRAUMA OBLIQUESTRAUMA OBLIQUES

Patient is supinePatient is supine– Usually immobilized with collar and spine Usually immobilized with collar and spine

boardboard

Place IR under spine board (not bucky), if Place IR under spine board (not bucky), if present, centered to C4 and adjacent present, centered to C4 and adjacent mastoid processmastoid process– About 3About 3 lateral to MSP lateral to MSP


Head and shoulders without rotationHead and shoulders without rotation– Ask patient to look straight aheadAsk patient to look straight ahead

CR has double angleCR has double angle– 45 degrees lateromedially45 degrees lateromedially– 15 to 20 degrees cephalic15 to 20 degrees cephalic

CR enters lateral to MSP at level of C4CR enters lateral to MSP at level of C4


CR exit should be in center of IRCR exit should be in center of IR

Image demonstrates side opposite CRImage demonstrates side opposite CR– C1-T1 or T2 bodies and disk spacesC1-T1 or T2 bodies and disk spaces– Intervertebral foramina openIntervertebral foramina open– If backboard is present, unavoidable artifacts If backboard is present, unavoidable artifacts

may be seenmay be seen


Patient and IR positioned for trauma AP axial oblique C-spine


Trauma AP axial oblique C-spine

Thoracic and Lumbar SpineThoracic and Lumbar Spine

X-table laterals performed firstX-table laterals performed first

Vertical grid and IRVertical grid and IR– Top of IR 1.5Top of IR 1.5 to 2 to 2 (3.8 to 5 cm) above (3.8 to 5 cm) above

shoulders for thoracic spineshoulders for thoracic spine– Centered to level of iliac crests for lumbar Centered to level of iliac crests for lumbar

spinespine

Have patient cross arms on anterior chestHave patient cross arms on anterior chest


CR horizontal CR horizontal – Centered to spine and IRCentered to spine and IR

Breathing technique improves visualization Breathing technique improves visualization of thoracic vertebraeof thoracic vertebrae

Exposure made on suspended respiration Exposure made on suspended respiration for lumbar vertebraefor lumbar vertebrae


Thoracic image demonstrates T3 or T4 to Thoracic image demonstrates T3 or T4 to L1L1

Lumbar image demonstrates T12 to Lumbar image demonstrates T12 to sacrumsacrum

Vertebral bodies and spinous processes in Vertebral bodies and spinous processes in profileprofile

Trauma Lateral Lumbar SpineTrauma Lateral Lumbar Spine

CR and IR positioned for trauma lateral projection of lumbar spine using dorsal decubitus position

Trauma Lateral Lumbar SpineTrauma Lateral Lumbar Spine

Lateral projection of thoracolumbar spine, dorsal decubitus position; note fracture and dislocation of L2 and spine board artifacts

ChestChest

Supine position used if general survey Supine position used if general survey image of chest desiredimage of chest desired

Check for need to demonstrate air-fluid Check for need to demonstrate air-fluid levelslevels– If air-fluid levels are suspected, use X-table If air-fluid levels are suspected, use X-table

laterallateral– If patient’s condition permits, lateral decubitus If patient’s condition permits, lateral decubitus

position with patient lying on affected side will position with patient lying on affected side will also show air-fluid levelsalso show air-fluid levels

Trauma AP ChestTrauma AP Chest

Obtain help to lift patient for IR placementObtain help to lift patient for IR placement– Top of IR placed about 1.5Top of IR placed about 1.5 to 2 to 2 above above

shouldersshoulders

Arms abductedArms abducted

MCP parallel to IRMCP parallel to IR

Use maximum SID to reduce heart Use maximum SID to reduce heart magnificationmagnification


Ensure chin extended out of anatomy of Ensure chin extended out of anatomy of interestinterest

CR directed perpendicular to center of IRCR directed perpendicular to center of IR– look for light field slightly above shoulders and look for light field slightly above shoulders and

on sides of chest, CW or LWon sides of chest, CW or LW

Exposure made upon second full Exposure made upon second full inhalation, if possibleinhalation, if possible


Image demonstrates lung fields in their Image demonstrates lung fields in their entiretyentirety– Minimal rotation and distortion presentMinimal rotation and distortion present

AbdomenAbdomen

If transfer to x-ray table is not possible, If transfer to x-ray table is not possible, obtain lift help for IR placementobtain lift help for IR placement

IR centered to MSP at level of iliac crestsIR centered to MSP at level of iliac crests

Check for possibility of fluid accumulation Check for possibility of fluid accumulation in abdominal cavityin abdominal cavity– Affects exposure factorsAffects exposure factors– Requires close monitoring of patient for status Requires close monitoring of patient for status

change during procedureschange during procedures

AbdomenAbdomen

Mark entrance and exit wounds, if presentMark entrance and exit wounds, if present

Align shoulders and hips in same planeAlign shoulders and hips in same plane

MCP parallel to tableMCP parallel to table

CR perpendicular to center of IRCR perpendicular to center of IR

Image demonstrates entire abdomen with Image demonstrates entire abdomen with pubic symphysis visible at lower borderpubic symphysis visible at lower border

PelvisPelvis

Pelvic fractures have a high risk of Pelvic fractures have a high risk of hemorrhage – pay close attention to hemorrhage – pay close attention to patient for status changepatient for status change

Obtain lift help for IR placement if transfer Obtain lift help for IR placement if transfer to x-ray table is not possibleto x-ray table is not possible

IR centered 2IR centered 2 above pubic symphysis or above pubic symphysis or 22 below ASIS below ASIS

MCP parallel to IRMCP parallel to IR

PelvisPelvis

Lower limbs internally rotated only if Lower limbs internally rotated only if possiblepossible

Ensure arms are not in anatomy of interestEnsure arms are not in anatomy of interest

CR perpendicular to center of IRCR perpendicular to center of IR

Exposure made on suspended respirationExposure made on suspended respiration

Image demonstrates entire pelvis and Image demonstrates entire pelvis and proximal femoraproximal femora

Trauma AP PelvisTrauma AP Pelvis

Trauma AP pelvis; note fracture of left ilium and separation of pubic bones

CraniumCranium

Patients with head trauma are often Patients with head trauma are often referred to CT firstreferred to CT first

When x-rays are ordered, a general When x-rays are ordered, a general survey requires AP and lateral projectionssurvey requires AP and lateral projections

Generally, the patient is supineGenerally, the patient is supine– Lateral projection uses dorsal decubitus Lateral projection uses dorsal decubitus

position position

Trauma Lateral CraniumTrauma Lateral Cranium

Elevate head on radiolucent supportElevate head on radiolucent support– Ensure C-spine injury has been ruled outEnsure C-spine injury has been ruled out

Trauma Lateral CraniumTrauma Lateral Cranium

Trauma lateral projection of cranium; note multiple fractures in frontal bone

Trauma AP Cranium Trauma AP Cranium

Check with physician to determine Check with physician to determine anatomy of interestanatomy of interest– AP projection demonstrates anterior craniumAP projection demonstrates anterior cranium– AP axial projection (Towne) demonstrates AP axial projection (Towne) demonstrates

posterior craniumposterior cranium

Trauma CraniumTrauma Cranium

Patient and IR positioned for trauma AP cranium

Patient and IR positioned for trauma AP axial cranium

Trauma AP CraniumTrauma AP Cranium

Trauma AP cranium; note fracture line

Facial BonesFacial Bones

Patients with facial bone injuries are often Patients with facial bone injuries are often referred to CT firstreferred to CT first

Anticipate profuse bleeding and use Anticipate profuse bleeding and use universal precautionsuniversal precautions

Upper and Lower LimbsUpper and Lower Limbs

Obtain lift help for IR placementObtain lift help for IR placement

Injured limbs should be lifted with support Injured limbs should be lifted with support atat both jointsboth joints– Lift only enough to place IRLift only enough to place IR

Two projections at 90 degrees from each Two projections at 90 degrees from each other requiredother required– Do not attempt to rotate severely injured limbs Do not attempt to rotate severely injured limbs

for true positionsfor true positions

Upper and Lower LimbsUpper and Lower Limbs

Long bones require demonstration of Long bones require demonstration of adjacent jointsadjacent joints– Take separate projections, if necessaryTake separate projections, if necessary

Maximize patient safety and comfort by Maximize patient safety and comfort by moving IR and CR, rather than injured limbmoving IR and CR, rather than injured limb

Other Imaging Procedures in Other Imaging Procedures in TraumaTrauma

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Other Imaging in TraumaOther Imaging in Trauma

CT is extensively used in trauma patientsCT is extensively used in trauma patients– Often, CT is modality of choiceOften, CT is modality of choice

Angiography may be used for vascular Angiography may be used for vascular injuriesinjuriesContrast studies are often ordered for Contrast studies are often ordered for evaluation of urinary system evaluation of urinary system – Blunt abdominal trauma and suspected pelvic Blunt abdominal trauma and suspected pelvic

fractures often result in injury to urinary fractures often result in injury to urinary systemsystem

Time for the “good stuff”!Time for the “good stuff”!

Trauma Radiography

Health & Medicine

Transcript of Trauma Radiography