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