Trauma Radiography Dos & Donts

Chan Lai Kuan KSKB JB

2/10/2010 CLK/ Melaka

Defination of Trauma
a sudden, unexpected, dramatic, forceful, or violent event  Trauma or injury refers to any body damage due to a physical impact or accident. accident.  Blunt, penetrating, explosive, and thermal forces are common causes of traumatic injuries  The degree of injury may range from mild to life and limb threatening. threatening.
 As
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Severity of Trauma

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Types of Trauma
Trauma

Major Trauma

Major trauma can be the result of many different dominate injuries, and is defined by an injury severity score (ISS) of greater than 15 on a scale of 75.
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The Injury Severity Score



(ISS) is an established medical score to assess ISS) trauma severity. It correlates with mortality, morbidity and hospitalization time after trauma. polytrauma. It is used to define the term polytrauma. A Polytrauma is defined as ISS >= 16.

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ISS Definition
Useful for decision of triage tool ??? Need further study on its application.

 

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Traumatic Injury
Classified by body part affect
    

Poly trauma Head injury Chest trauma Abdominal trauma Extremity trauma

      

Facial trauma Spinal injury Neck trauma Genitourinary trauma Pelvic trauma Soft tissue injury Violence and abuse

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No body is Spare
 Trauma

affect persons in all age ranges

 Radiographers

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

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Trauma Centers
 Many

types of facilities provide emergency medical care, ranging from major metropolitan medical center to small outpatient clinics in rural areas. areas. term Trauma Center signifies a specific level of emergency medical care as defined by the American College of Surgeons Commission on Trauma. Trauma.
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 The

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Alfred Hospital Melbourne

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Trauma Levels
 Level

I is the most comprehensive, usually a universityuniversity-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
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Trauma 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 stabilization before transfer
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injuries,

some

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Imaging System

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Imaging System


Preliminary Considerations
 

Trauma patients often cannot hold the required position Specialized trauma imaging systems reduce the amount of time required to obtain diagnostic images

One type provides greater flexibility in IR/CR maneuverability Another type scans the entire body in a few seconds (Statscan)
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STATSCAN

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Preliminary Considerations


Mobile radiography is often used for ED procedures


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Mobile fluoroscopy units, or CCarms, may be used in fracture reduction or foreign body localizations Immobilization devices are a necessity in trauma imaging CLK/ KT

EQUIPMENT / ACCESSORIES

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ACCESSORIES
Positioning pads Slider

Cassette holder Glider

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Radiographers Role in Trauma



Depends upon department protocol and staffing Primary responsibilities



 

Perform quality diagnostic imaging procedures Practice ethical radiation protection Provide patient care

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Radiographers Role in Trauma

Take Note

Patient level of consciousness changes are common in trauma

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Best Practices in Trauma Radiography



Speed


Efficiency in producing quality images in the shortest possible time Optimum image quality, minimum repeats Quality cannot be sacrificed for speed Do not use patient condition as an excuse for poor quality images

Accuracy


Quality
 

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Best Practices in Trauma Radiography



Anticipation


Patient condition may deteriorate and need extra attention. Routine practice may not be possible, modification in techniques and patient management is required. Some injuries require follow-up procedures; followknowing what to do increases appreciation for radiographers role in ED
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Best Practices in Trauma Radiography



Attention to detail


Pay careful attention to patients condition, which could change at any time Know the protocol and scope of practice in your facility

Attention to ED protocol and scope of practice



Professionalism


Adhere to Code of Ethics

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General Procedural Guidelines

        

Patient preparation IR size SID ID markers Radiation protection Patient instructions Immobilization Documentation Image critique
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Patient Preparation


Use good communication skills with appropriate touch and eye contact


Trauma often causes anxiety Explain what you are removing and why Secure all personal effects using proper procedure for your facility

Check patient for potential artifacts

 

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IR Size
 

IR size for trauma procedures are the same as for routine procedures Use smallest IR that will demonstrate anatomy

Collimation


Collimate field size to anatomy of interest

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SID


SID is standardized as a part of procedural protocol



When SID is not specified under a projection, 90cm to 100cm SID recommended for projections with increased OID 150cm to 180cm

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ID Markers
  

Right or left side markers must be included on each image Other required ID markers must be in the blocker or elsewhere on the final image Markers used for penetrating trauma to identify entrance and exit wounds

Bullet entrance - mark with opaque marker

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Radiation Protection


Shield pediatric patients and patients of reproductive age Warn other staff of exposure when performing mobile imaging Other radiation protection measures
 

Close collimation Optimum technique factors

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Patient Instructions


Explain and demonstrate positions, when possible Explain respiration instructions for patients who can cooperate

Exposure Time


Use short exposure times to eliminate possibility of imaging motion

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Immobilization
  

Many ED patients arrive in some sort of immobilization device Immobilization devices are not to be removed unless ordered by a physician Imaging procedures are often performed without removal of the immobilization

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

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Documentation


Because deviation or adjustment of routine procedures is often required to accommodate a patients injury, documentation is important Make sure that deviation from routine is still within your scope of practice. Document deviation (AP, X-table, etc.), time, Xportable

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Image Critique Criteria



Image evaluation for trauma procedures is the same as for routine procedures Image quality is critical for an accurate diagnosis It is poor practice to accept lower quality images due to patient condition or difficulty of procedure

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History Taking
Not just the work of the medical officer or the nurse  Extra information make task simplify  Mechanism of injury, time and also patients feeling  Look for signs and ask for symptoms - journey to successful radiography


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Basic Principles of Trauma Radiography



   

Positioning  Important not to aggravate patients condition when obtaining images  Move tube and IR, instead of patient, whenever possible Obtain two (2) projections 900 to each other. Cassette should be protected from body fluid to avoid cross infection. Use grid when it is possible. Avoid grid cut-off. cutGive clear explanation for alert patient to obtain cooperation.
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Basic Principles of Trauma Radiography



Practice standard precautions

 Expect

to be exposed to body fluids in ED  Do not touch a patient without gloves!



Stop bleeding 1st before performing the examination. Make sure wound is cover-up before x-ray. coverx-

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Basic Principles of Trauma Radiography

     

Do not moved @ minimum movement of patient. Do not turn patient by force to ideal position. Do not remove splint , bandage or cervical collar. Do not remove any object ( tube, clip) on the patient without permission from staff. Do not transfer patient onto the x-ray table if xspinal injury is suspected. Do no neglect radiation protection.
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Do not try to pull out the knife

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Basic Principles of Trauma Radiography

For cervical spine:  Do not moved patients head and cervical spine.  Perform Lateral projection 1st using horizontal beam  Excess and get cervical clearance before moving patient head for AP projection  Image should demonstrate C1 to C7.  Do not attempt a cervical examination if suspicious of severe injury go straight to do a CT.  CT C.Spine should include level of T5.
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For Cervical Spine:

Lateral Cervical Spine Lateral projection of Cspine in dorsal decubitus position; dislocation of position; C3-C4; C7 not demonstrated, so swimmers view is needed

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Inadequate diagnosis Image

what is important here is to inform the radiologist when you cannot achieve the diagnostic criteria for plain film interpretation without excessive repeat radiographs. Get alternative imaging modality
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For Cervical Spine:

Important fact: Do not attempt to pull down patients should to get image of C7 & and T1. Is contraindicated for trauma patient.

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Upper and Lower Limbs

 

Obtain lift help for IR placement Injured limbs should be lifted with support at both joints


Lift only enough to place IR

Two projections at 90 degrees from each other required

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Basic Principles of Trauma Radiography

Extremities (Upper & Lower limbs)

Do two projection two projections at 90 degrees from each  Long bones require demonstration of adjacent joints Take separate projections, if necessary .  Maximize patient safety and comfort by moving IR and CR, rather than injured limb  Handle injured part with care.  Injured limbs should be lifted with support at both CLK/ KT 2/10/2010 joints


Basic Principles of Trauma Radiography

Extremities


Do not force joint or injured part to ideal position.

Do not attempt to rotate severely injured limbs for true positions

Do not move fracture part or after surgery without assistant from other staffs (SN, MO, MA).

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Chest Radiography
Supine position used if general survey image of chest desired  Check for need to demonstrate air-fluid levels air If air-fluid levels are suspected, use X-table airXlateral If patients condition permits, lateral decubitus position with patient lying on affected side will also show air-fluid levels air

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CHEST RADIOGRAPH


The chest radiograph (CXR) is the initial radiographic study of choice in patients with thoracic blunt trauma. A chest radiograph is an important adjunct in the diagnosis of many conditions, including:
   

chest wall fractures, pneumothorax, hemothorax, and injuries to the heart and great vessels (e.g., enlarged cardiac silhouette, widened mediastinum).

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Chest Trauma

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Immediate Life Threatening Chest Injuries

   

Tension pneumothorax Massive haemothorax Open chest wound Cardiac tamponade (abnormal pressure caused by excessive fluid between the pericardium and the heart) Flail segment (unstable ribcage after multiple fractures of the ribs and sternum)
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RIB FRACTURES

CLAVICULAR FRACTURE

TENSION PNEUMOTHORAX

CARDIAC TEMPONADE

FLAIL CHEST

PNEUMOTHORAX

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Abdomen


 

If transfer to x-ray table is not possible, obtain xlift help for IR placement IR centered to MSP at level of iliac crests Check for possibility of fluid accumulation in abdominal cavity
 

Affects exposure factors Requires close monitoring of patient for status change during procedures

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Abdomen
 

Check LMP for female of reproductive age. If condition permit delay need to rule out pregnancy status. Ultrasound may be a better choice of imaging tool. Pay attention to internal bleeding if patient suffer blunt trauma, observe vital signs and listen to complain.
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Pelvis


Pelvic fractures have a high risk of hemorrhage pay close attention to patient for status change Obtain lift help for IR placement if transfer to x-ray table is not possible. Do not try to internal rotate the legs.

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Cranium
      

Patients with head trauma are often referred to CT When x-rays are ordered, a general survey xrequires AP and lateral projections Generally, the patient is supine . Erect will demonstrate air-fluid level. airPA should be projection of choice if condition permit. Lateral projection must be done 1st Only elevate head on radiolucent support after ensure C-spine injury has been ruled Cout
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Wrong Practice

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Facial Bones


Patients with facial bone injuries are often referred to CT first No point doing modification projections if images are not of high quality. Anticipate profuse bleeding and use universal precautions

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Other Imaging in Trauma

   

CT is extensively used in trauma patients



Often, CT is modality of choice

Angiography may be used for vascular injuries MRI is valuable in diagnosis of spinal injury Contrast studies are often ordered for evaluation of urinary system


Blunt abdominal trauma and suspected pelvic fractures often result in injury to urinary system

Ultrasound plays an important role to rule out internal bleeding, visceral organ rapture and vascular occlusion.
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Other Imaging in Trauma cont



Ultrasound, computerized tomography (CT) and magnetic resonance imaging(MRI) are utilized as diagnostic tools
List the indications for the use of ultrasound, CT and MRI.  Know the advantages of ultrasound verses CT verses MRI.


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ONE SIMPLE CONCEPT

Time is LIFE  Delay can mean difference in life and death  ED patient management relies mainly on Medical Imaging


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Conclusion
o o

Radiographer plays an extremely important role in the evaluation of patient with poly trauma The doctor depends on radiographs produced by the radiographer to make his/her decision Radiographers and the radiology department help make a difference in the patients quality of life and outcome. outcome. The very radiographs that you produce contribute to this outcome. outcome.
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LIVE UP TO THE CHALLLENGE

A challenge for the radiographer to produce good quality radiographs DESPITE ALL ODDS

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