Emergency Radiology: ���What We Can Offer In Trauma Care

Rathachai Kaewlai, MD Division of Emergency Radiology, Department of Radiology Ramathibodi Hospital, Mahidol University, Bangkok, Thailand Joint Conference in Medical Sciences, Centara Grand @CentralWorld, Bangkok, Thailand | 6 Jun 2015

Ramathibodi Emergency Radiology

Outline

Trauma care: time-conscious process

CT imaging of solid organs and vascular injuries Pan-scan Endovascular treatment in trauma

Trimodal Death Distribution due to injury

Image credit: ATLS, 9th edition

Trimodal Death Distribution due to injury

First Peak: Seconds to minutes Apnea, massive hemorrhage Prevention only

Image credit: ATLS, 9th edition

Trimodal Death Distribution due to injury

Second Peak: Minutes to hours SDH/EDH, hemopneumothorax Visceral bleeding Pelvic fracture “Golden Hour of Care”

Image credit: ATLS, 9th edition

Trimodal Death Distribution due to injury

Third Peak: Days to weeks

Sepsis, multiorgan failure Long-term outcome depends on initial Rx

Image credit: ATLS, 9th edition

Initial Imaging Assessment and Management

AP chest radiograph

AP pelvic radiograph FAST

Spine x-ray

Extremity x-ray CT

Endovascular treatment

Time-conscious Care

Effective use of time to

-  Obtain valuable information from imaging

-  Minimize time spent

Valuable Information

Time

Trauma: Now It’s Time for CT

Quick

7-15 seconds (scanner time) 5-10 mins (in-room time) 15-20 mins (pan-scan)

Trauma: Now It’s Time for CT

Valuable

2D & 3D: easy to understand Accurate for traumatic injuries

Presence or absence

Grading Associated injuries

Epidural hematoma

Trauma: Now It’s Time for CT

Valuable

2D & 3D: easy to understand Accurate for traumatic injuries

Presence or absence

Grading Associated injuries

Lefort fractures

Trauma: Now It’s Time for CT

Valuable

2D & 3D: easy to understand Accurate for traumatic injuries

Presence or absence

Grading Associated injuries

Thoracic aortic injury

“Tuna Auction” at Tsukiji Fish Market

Image credit: Japan-Guide.com

16-year-old man with blunt head injury Epidural hematoma with significant mass effect

24-year-old man with blunt head injury Diffuse axonal injury with subarachnoid hemorrhage

80-year-old woman with neck trauma Burst fracture of C5

50-year-old woman after MVC Thoracic aortic injury (pseudoaneurysm)

Blunt left diaphragmatic rupture

Trauma CT

Selective or “Pan scan”

Pan scan = scanning from head to pelvis in one shot Pre-contrast head CT

Post-contrast neck, chest, abdomen and pelvis

Ramathibodi Protocol

“Pan Scan”

Indication based on severity of trauma and initial evaluations (clinical exam + FAST)

Ramathibodi Protocol

20-year-old woman

Non-contrast Head

Post-contrast Neck Post-contrast Chest, Abdomen

20-year-old woman, motorcycle vs. car SDH, vitreous hemorrhage, tonsillar herniation Pulmonary contusions, pneumothorax Buttock hematoma with active contrast extravasation

40-year-old man, motorcycle vs. car SDH, thoracic aortic injury, T-shaped acetabular fracture

40-year-old man with multiple trauma. Pulmonary contusions with active contrast extravasation, intrapulmonary chest tube, para-cardiac mediastinal hematoma with active contrast extravasation, splenic laceration with active contrast extravasation

“Pan Scan”

Should it replace other imaging in the primary survey (CXR, PXR, FAST and selective CT)?

CXR PXR FAST

Selective CT

Pan scan CT V

“Pan Scan”

Caputo ND, et al. J Trauma Acute Care Surg 2014

Dilemma continues…

Awaiting REACT-2 Trial (after 2016)

Trauma Angioembolization

Hemorrhage is the major preventable cause of trauma deaths within the first 48 hours of admission

55%

Death from blood loss in acute phase

Sauaia A, et al. J Trauma 1995

Trauma Angioembolization

Prolonged hypotension increases late deaths and long-term disability

Bloody vicious cycle Coagulopathy

Acidosis Hypothermia

Trauma.lbg.ac.at

Trauma Angioembolization

Advancement in catheter embolization system allows embolization of small target vessels with accuracy and speed – replacing the need for surgery

Embolic Materials

Image credits: neurointervention.blogspot.com, birthmarks.us, sterileeye.com

GELFOAM

PVA

COIL

GLUE

32-year-old woman after MVC Hepatic artery pseudoaneurysm within laceration

Coiling of pseudoaneurysm

39-year-old man after MVC Thoracic aortic injury with stent-graft placement

Conclusions

Radiology is helpful in both Dx and Rx of trauma

CT is the workhorse for detection of life-threatening injuries (bleeding), grading and guiding Rx

Endovascular Rx is emerging as a valuable option for “damage control” in actively bleeding patients, and treating traumatic vascular injuries

THANK YOU FOR ���YOUR ATTENTION!