Improving quality of acute trauma care In Radiology

Dr R. NyabandaRadiologistKenyatta National Hospital19th April 2013

RADIOLOGY DEPARTMENT

VISIONTo be a world class centre of excellence in the provision of innovative diagnostic imaging and

interventional radiology services.MISSION

To provide specialized quality diagnostic imaging and interventional radiology services,

facilitate medical training, research and participate in national health planning and

policy.

JOINT COMMISSION INTERNATIONAL (JCI)ACCREDITATION STANDARDS FORHOSPITALSStandards Lists Version

trauma in radiology in severely injured patients

Management of Severely Injured Patients (SIPs)• The acute trauma setting is not the place for

disagreement about the patient. Immediate management decisions must be made by the designated trauma leader.

• The trauma team leader is an overall charge in acute care.

• Just as the trauma team leader must be an experienced consultant, there must be a consultant in Radiology in charge of trauma.

• Protol driven imaging and intervention must be available and delivered by experienced staff!

Location and Facilities• Just like in A&E, triaging of patients is very

important.• Imaging SIPs more accurately delineates the extent

of injury than clinical examination.• Imaging technique of choice is the one which is

definitive in trauma setting. In SIPs this is most often head to thigh CE-MDCT.

• The MDCT should be adjacent to emergency room.• Radiography must also be present in the emergency

room• The imaging environment requires all the life support

facilities available in the emergency room. This will include monitoring and gases.

Radiography• CXR-Chest radiograph must be obtained to

document the position of tubes and lines and to evaluate for pneumothorax or hemothorax and mediastinal abnormalities

• AXR or pelvic X Ray are usually irrelevant if patient is going in for CT.

• The British Orthopaedic Association and British Society of Spine Surgeons do not recommend plain films of the C-spine in a SIP and their standard of practice is CT.

• Cervical spinal injury precautions and pelvic binders should remain in place until the MDCT has been fully assessed

C6 #

Focused Abdominal Sonography in Trauma (FAST)FAST is used to demonstrate - intra-abdominal hemorrhage - Solid organ injuries- spleen, liver, kidney - Pericardial effusion

MDCTClear of the need for protocols must exist for

notifying the CT department urgent imaging and how the department will respond to ensure that the scanner is clear to receive the incoming injured patient.

IV assess right antecubital assess is preferred for contrast adminstration

Radiation dose should be considered

Polytrauma protocol MDCT is indicated when:There is hemodynamic instabilityThe mechanism of injury or representation

suggests that there may be occult severe injuries that cannot be excluded by clinical examination or plain films

If plain films suggest significant injury, such as pneumothorax, pelvic fractures

Obvious severe injury on clinical assessment

Interventional Radiology(IR)

• The role of IR in the SIP is to stop hemorrhage as quickly as possible

• The decision on whether a patient with traumatic hemorrhage undergoes endovascular treatment, open surgery, a combination of the two or non-operative management is typically a decision made by both the trauma team leader and interventional radiologist after consultation.

• Interventional treatment modalities include Balloon occlusion, transarterial embolization to stop hemorrhage.

MRIMRI is not indicated in the setting of acute

trauma care. However availability of clear protocols for the transfer of SIPs to MRI facilities after stabilizing the patient is recommended.

No Imaging !There may be circumstances where imaging

is inappropriate; for example, where a SIP is admitted with profound shock, is not responding to intravenous fluids and the site of bleeding is clear from the mechanism of injury and rapid assessment. Such patients may be best taken straight to theatre.

Quality IndicatorAll imaging should be discussed at debriefing

meetings and errors of protocol or facts discussed at discrepancy meetings

Radiologists should ensure they participate in ongoing audit and morbidity and mortality meetings of trauma services

Non-accidental injury

Note massive edema minimally hyper- dense subdural, extreme mass effect and herniation despite open fontanelle

ReferencesStandards of practice and guidance for trauma

radiology in severely injured patients. Operating Framework for the NHS in ENGLAND 2011/2012

Ann Osborn. Craniocerebral Trauma update 2010Emergency Radiology, Advanced trauma life

support ABCDE from a radiology point of view.

Emerg Radiol. 2007 July; 14(3): 135–141McGahan J P, Wang L, Richards J R. Focused

abdominal US for trauma. Radiographics. 2001;21:S191–S199. [PubMed]