role of mdct in blunt abdominal trauma dr. muhammad bin zulfiqar

Role Of MDCT in Blunt Abdominal Trauma

DR MUHAMMAD BIN ZULFIQARPGR III FCPS Services institute of Medical

Sciences/ Services Hospital Lahore

Very Special Thanks to Dr. Bushra Ujala & Radiology Assistant

OBJECTIVES

• Initial evaluation of– Blunt trauma– Penetrating trauma

• Follow up of non-operative management• Rule out injury

INTRODUCTION

• Trauma: leading cause of death under 40• Abdominal trauma: 10%

SPECTRUM OF FINDINGS

ABDOMINAL TRAUMA PROTOCOL

• Blunt injury:– deceleration, crush, weapon(e.g bat)• Venous phase ~ 70 seconds• Delayed scan if injury present; ~ 3-5 minutes

• Penetrating injury: – knives, gun• Same as blunt• Additional scan after rectal contrast material

SPLEEN

• MOST COMMONLY INJURED SOLID ORGAN(25%)

SPLENIC CT INJURY GRADING SCALE ( AAST)

Grade 1– Laceration(s) < 1cm deep– Subcapsular hematoma < 1cm diameter

Grade 2– Laceration(s) 1-3 cm deep– Subcapsular or central hematoma 1-3cm diam

Grade 3– Laceration(s) 3-10 cm deep– Subcapsular or central hematoma 3-10 cm dia

Grade 4– Laceration(s) >10 cm deep– Subcapsular or central hematoma > 10 cm diam

Grade 5– Splenic tissue maceration or devascularization

A CASE OF SPLENIC INJURY

Abdominal Trauma : Role of CT Stephen Ledbetter and Robin Smithuis (Publication date: 2-7-2007)

SPLENIC INJURY-ANOTHER CASE


SPLENIC INJURY


A 22 yr male 3 hr after a snowboarding accident with LUQ & Lt shoulder pain.

SPLENIC INJURY- CONTRAST BLUSH

• 82% failure rate for NOM• 9.2 x more require intervention• Managed with embolization / splenectomy


LIVER

• 2ND MOST COMMONLY INVOLVED ORGAN

LIVER INJURY

Liver injury. The arrows indicate different types of injury.


HEPATIC CT INJURY GRADING SCALE• Grade 1

– Laceration(s) < 1cm deep– Subcapsular hematoma < 1cm diameter

• Grade 2– Laceration(s) 1-3 cm deep– Subcapsular or central hematoma 1-3 cm diameter

• Grade 3– Laceration(s) 3-10 cm deep– Subcapsular or central hematoma 3-10 cm diameter

• Grade 4– Laceration(s) > 10 cm deep– Subcapsular or central hematoma > 10 cm diameter– Lobar maceration or devascularization

• Grade 5– Bilobar tissue maceration or devascularization

LIVER INJURY


LIVER INJURY


Subcapsular hematomaContrast blush

LIVER LACERATIONS


LIVER INJURY


Avulsed Rt hepatic vein

RENAL INJURY

• 90% due to blunt trauma- 10% penetrating• 3rd most common involved organ in adults– 10% of solid visceral injury

• Most common injured organ in children • Evaluation for– Parenchymal injuries– Vascular injuries– Collecting system injuries

RENAL-PENETRATING INJURY


RENAL INJURY


Knife stab in the Rt flank.

RENAL INJURY SCALE (AAST)• Grade 1

– Contusion / Subcapsular hematoma– No parenchymal laceration

• Grade 2– Laceration < 1cm depth of renal cortex– No urinary extravasation

• Grade 3– Laceration > 1cm depth of renal cortex– No urinary extravasation

• Grade 4– Laceration extending through the renal cortex, medulla and into collecting

system– Minor renal artery or vein injury with contained hematoma

• Grade 5– Shattered kidney– Devascularized kidney, hilar avulsion

RENAL INJURY-BLUNT TRAUMA


CATEGORIES OF RENAL INJURIES

Introduced by Michael Federle

BLADDER INJURY

• X-ray of a 65 yr male struck by a car travelling at moderate speed.

• Loss of consciousness for 2 min.

• Foley catheter was passed & there was gross hematuria.


BLADDER INJURY

Images of the routine trauma.


BLADDER INJURY


Pre-cystogram Post-cystogram

BADDER INJURY


Sagittal Coronal

Reconstruction

ARTERIAL BLEEDING IN PELVIC INJURY

Pre-cystogram image


PANCREATIC INJURY

• Uncommon- 0.4%• 1.1% penetrating

trauma• 0.2% blunt trauma• Isolated injury-Rare• Part of `package injury`

VECTORS OF FORCE- TRAUMA ``PACKAGES``

Right-sided Midline Left-sided

R hepatic lobe Left hepatic lobe SpleenR kidney Pancreatic body L kidneyDiaphragm Aorta DiaphragmPancreatic head Transverse colon Pancreatic tailDuodenum DuodenumIVC Small bowel

PANCREATIC TAIL INJURY-LT SIDED PACKAGE INJURY


RT PACKAGE INJURY-PANCREATIC HEAD & BODY


PANCREATIC INJURY-ISOLATED

An unrestrained driver who had a car accident. Vitals were stable and there was only a mildly tender abdomen.


DIAPHRAGMATIC INJURY

• Incidence: – 1-6% of blunt trauma patients– Penetrating 2x > blunt

• Frequently other injuries (75-100%)• Left > Right– Blunt 75%– Penetrating 56%

• Bilateral 1-5% of cases• Posterolateral : most frequent site

DIAPHRAGMATIC INJURY

• Specific signs– Herniation of abdominal viscera into thorax– CT ``collar`` sign

• Non-specific signs– Discontinuity of the crus– Thickening of the diaphragm– ``dependent viscera `` sign

LT DIAPHRAGMATIC INJURY

Chest film of a 79 yr restrained driver in a car accident



CT images with IV contrast in late arterial phaseAbdominal Trauma:Role of CT

Stephen Ledbetter& Robin Smithuis (2-7-2007)


CT findings in same pt. ( oral contrast )


CT `COLLAR` SIGN


Coronal reconstruction

`DEPENDENT VISCERA` SIGN


RT DIAPHRAGMATIC INJURY

Chest film in a pt. with right sided injury


`COLLAR` SIGN –RT SIDED DIAPHRAGMATIC RUPTURE


Axial image Sagittal MPR

AORTIC INJURY


An unrestrained 22 yr male involved in a high speed motor vehicle accident

AORTIC INJURY

Consecutive images of the aorta at the level of the diaphragm.


BOWEL INJURY

• Direct Findings:– Bowel wall disruption– Oral contrast extravasation

• Indirect Findings:– Free intraperitoneal / retroperitoneal air– Free intraperitoneal / retroperitoneal fluid– Focal area of bowel wall thickening– Abnormal bowel wall enhanement.

BOWEL INJURY-CONTRAST EXTRAVASATION

Abdominal Trauma: Role of CT Stephen Ledbetter and Robin Smithuis (Publication date: 2-7-2007)

BOWEL INJURY

15 yr boy with blunt trauma to abdomen and a perforated stomach.

Bowel, Trauma: Multimedia;Raul N Uppot, MD, Updated: sep 2, 2005.

BOWEL INJURY

Female with blunt abdominal trauma and duodenal perforation.

Bowel, Trauma: Multimedia; Raul N Uppot, MDUpdated:Sep 2, 2005

BOWEL INJURY-INDIRECT FINDING

Patient in a motor vehicle collision with injury to the spleen.

Bowel, Trauma: Multimedia; Raul N Uppot, MD,Updated: Sep 2, 2005

Take Home Message

• By using MDCT we can evaluate blunt abdominal trauma patients and help surgeons in management.

• We can confidently suggest Whether surgical intervention is mandatory or not.

REFERENCES

• Imaging of Renal Trauma: A Comprehensive Reviewby Akira Kawashima, MD, Carl M. Sandler, MD, Frank M. Corl, MS, O. Clark West, MD, Eric P. Tamm, MD, Elliot K. Fishman, MD and Stanford M. Goldman, MDRadiographics. 2001;21:557-574

• PDF format: American College of Radiology, ACR Appropriateness Criteria® for Blunt Abdominal Trauma This review considers the issue of blunt abdominal trauma in adults. A continued trend is noted for detection of specific findings that do predict the need for therapeutic surgery or for angiographic embolization or that predict a period of close observation is needed for an injured patient. This trend in imaging parallels a strong trend in trauma therapy toward nonoperative management of injuries of the spleen, liver, and kidney even when hemoperitoneum is present.

• Optimization of Selection for Nonoperative Management of Blunt Splenic Injury: Comparison of MDCT Grading Systems by Helen Marmery et al. AJR 2007; 189:1421-1427

role of mdct in blunt abdominal trauma dr. muhammad bin zulfiqar

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