Trauma Radiography Puteri Resort Melaka 2010

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Trauma Trauma RadiographyRadiographyDo’s & Don’tsDo’s & Don’ts

Chan Lai KuanChan Lai Kuan

KSKB JBKSKB JB

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Defination of TraumaDefination of Trauma

As a sudden, unexpected, dramatic, As a sudden, unexpected, dramatic, forceful, or violent event forceful, or violent event

Trauma or injury refers to any body Trauma or injury refers to any body damage due to a physical impact or damage due to a physical impact or accident.accident.

Blunt, penetrating, explosive, and Blunt, penetrating, explosive, and thermal forces are common causes thermal forces are common causes of traumatic injuriesof traumatic injuries

The degree of injury may range The degree of injury may range from mild to life and limb from mild to life and limb threatening.threatening.

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Severity of TraumaSeverity of Trauma

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

Types of TraumaTypes of Trauma

TraumaTrauma Major TraumaMajor Trauma

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The Injury Severity ScoreThe Injury Severity Score

((ISSISS) is an established medical score to ) is an established medical score to assess trauma severity. It correlates assess trauma severity. It correlates with mortality, morbidity and with mortality, morbidity and hospitalization time after trauma. It is hospitalization time after trauma. It is used to define the term used to define the term polytrauma..

A A Polytrauma is defined as ISS >= 16. is defined as ISS >= 16.

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ISS DefinitionISS Definition

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

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Traumatic InjuryTraumatic Injury

Poly trauma Head injuryHead injury Chest traumaChest trauma Abdominal traumaAbdominal trauma Extremity traumaExtremity trauma

Facial trauma Facial trauma Spinal injury Spinal injury Neck trauma Neck trauma Genitourinary Genitourinary

trauma trauma Pelvic trauma Pelvic trauma Soft tissue injury Soft tissue injury Violence and Violence and

abuseabuse

Classified by body part affectClassified by body part affect

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No body is SpareNo body is Spare Trauma affect persons in all Trauma affect persons in all

age rangesage ranges

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

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Trauma CentersTrauma Centers Many types of facilities provide Many types of facilities provide

emergency medical care, ranging emergency medical care, ranging from major metropolitan medical from major metropolitan medical center to small outpatient clinics in center to small outpatient clinics in rural areas. rural areas.

The term “Trauma Center” signifies The term “Trauma Center” signifies a specific level of emergency a specific level of emergency medical care as defined by the medical care as defined by the American College of Surgeons American College of Surgeons Commission on Trauma. Commission on Trauma.

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Alfred Hospital

Melbourne

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Trauma LevelsTrauma Levels Level I Level I

is the most comprehensive, is the most comprehensive, usually a university-based usually a university-based center, research facility, or large center, research facility, or large medical center, complete medical center, complete imaging capabilities 24 hours a imaging capabilities 24 hours a day, specialty physicians are day, specialty physicians are available on site 24 hours a day available on site 24 hours a day

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Trauma LevelsTrauma Levels

Level II Level II same as level one, but not a research same as level one, but not a research facility, may not have as many facility, may not have as many specialists specialists

Level III Level III no specialists, can stabilize patient no specialists, can stabilize patient for transport to a higher level center, for transport to a higher level center, may not have 24 hour imaging may not have 24 hour imaging

Level IV Level IV clinics, attend minor injuries, some clinics, attend minor injuries, some stabilization before transferstabilization before transfer

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Imaging SystemImaging System

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Imaging System Imaging System

Preliminary Considerations Preliminary Considerations Trauma patients often cannot hold the Trauma patients often cannot hold the

required positionrequired position Specialized trauma imaging systems reduce Specialized trauma imaging systems reduce

the amount of time required to obtain the amount of time required to obtain diagnostic images diagnostic images

One type provides greater flexibility One type provides greater flexibility in IR/CR maneuverability in IR/CR maneuverability

Another type scans the entire body in Another type scans the entire body in a few seconds (Statscan) a few seconds (Statscan)

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STATSCANSTATSCAN

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Preliminary Preliminary Considerations Considerations

Mobile fluoroscopy units, Mobile fluoroscopy units, or C-arms, may be used in or C-arms, may be used in fracture reduction or fracture reduction or foreign body localizationsforeign body localizations

Immobilization devices are Immobilization devices are a necessity in trauma a necessity in trauma imaging imaging

Mobile radiography is often used for Mobile radiography is often used for ED procedures ED procedures

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EQUIPMENT / ACCESSORIESEQUIPMENT / ACCESSORIES

Emergency trolley

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Slider

ACCESSORIESACCESSORIES

Cassette holder

Positioning pads

Glider

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Radiographer’s Role in Radiographer’s Role in Trauma Trauma

Depends upon department Depends upon department protocol and staffing protocol and staffing

Primary responsibilities Primary responsibilities Perform quality diagnostic imaging Perform quality diagnostic imaging

procedures procedures Practice ethical radiation Practice ethical radiation

protection protection Provide patient careProvide patient care

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Radiographer’s Role in Radiographer’s Role in TraumaTrauma

Patient level of consciousness changes are common in trauma

Take NoteTake Note

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Best Practices in Trauma Best Practices in Trauma RadiographyRadiography

Speed Speed Efficiency in producing quality images Efficiency in producing quality images

in the shortest possible time in the shortest possible time Accuracy Accuracy

Optimum image quality, minimum Optimum image quality, minimum repeats repeats

Quality Quality Quality cannot be sacrificed for speed Quality cannot be sacrificed for speed Do not use patient condition as an Do not use patient condition as an

excuse for poor quality imagesexcuse for poor quality images

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Anticipation Anticipation

Patient condition may deteriorate Patient condition may deteriorate and need extra attention.and need extra attention.

Routine practice may not be Routine practice may not be possible, modification in techniques possible, modification in techniques and patient management is required.and patient management is required.

Some injuries require follow-up Some injuries require follow-up procedures; knowing what to do procedures; knowing what to do increases appreciation for increases appreciation for radiographer’s role in EDradiographer’s role in ED

Best Practices in Trauma Best Practices in Trauma RadiographyRadiography

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Attention to detail Attention to detail Pay careful attention to patient’s Pay careful attention to patient’s

condition, which could change at any time condition, which could change at any time Attention to ED protocol and scope of Attention to ED protocol and scope of

practice practice Know the protocol and scope of practice Know the protocol and scope of practice

in your facility in your facility Professionalism Professionalism

Adhere to Code of EthicsAdhere to Code of Ethics

Best Practices in Trauma Best Practices in Trauma Radiography Radiography

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General Procedural General Procedural GuidelinesGuidelines

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

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Patient Preparation Patient Preparation

Use good communication skills Use good communication skills with appropriate touch and eye with appropriate touch and eye contact contact

Trauma often causes anxiety Trauma often causes anxiety Check patient for potential Check patient for potential

artifacts artifacts Explain what you are removing and Explain what you are removing and

why why Secure all personal effects using Secure all personal effects using

proper procedure for your facilityproper procedure for your facility

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IR Size IR Size IR size for trauma procedures are the IR size for trauma procedures are the

same as for routine procedures same as for routine procedures Use smallest IR that will demonstrate Use smallest IR that will demonstrate

anatomy anatomy

Collimate field size to anatomy of Collimate field size to anatomy of interest interest

Collimation Collimation

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SID SID

SID is standardized as a part of SID is standardized as a part of procedural protocol procedural protocol

When SID is not specified under a When SID is not specified under a projection, 90cm to 100cmprojection, 90cm to 100cm

SID recommended for projections SID recommended for projections with increased OID 150cm to 180cmwith increased OID 150cm to 180cm

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ID MarkersID Markers Right or left side markers must be Right or left side markers must be

included on each image included on each image Other required ID markers must be Other required ID markers must be

in the blocker or elsewhere on the in the blocker or elsewhere on the final image final image

Markers used for penetrating trauma Markers used for penetrating trauma to identify entrance and exit wounds to identify entrance and exit wounds

Bullet entrance - mark with opaque marker

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Radiation ProtectionRadiation Protection

Shield pediatric patients and Shield pediatric patients and patients of reproductive age patients of reproductive age

Warn other staff of exposure when Warn other staff of exposure when performing mobile imaging performing mobile imaging

Other radiation protection Other radiation protection measures measures

Close collimation Close collimation

Optimum technique factorsOptimum technique factors

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Patient InstructionsPatient Instructions Explain and demonstrate positions, Explain and demonstrate positions,

when possible when possible Explain respiration instructions for Explain respiration instructions for

patients who can cooperate patients who can cooperate

Exposure TimeExposure Time

Use short exposure times to Use short exposure times to eliminate possibility of imaging eliminate possibility of imaging motion motion

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Immobilization Immobilization Many ED patients arrive in some Many ED patients arrive in some

sort of immobilization device sort of immobilization device Immobilization devices are not to Immobilization devices are not to

be removed unless ordered by a be removed unless ordered by a physician physician

Imaging procedures are often Imaging procedures are often performed without removal of the performed without removal of the immobilization immobilization

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

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Documentation Documentation

Because deviation or adjustment of Because deviation or adjustment of routine procedures is often routine procedures is often required to accommodate a required to accommodate a patient’s injury, documentation is patient’s injury, documentation is important important

Make sure that deviation from Make sure that deviation from routine is still within your scope of routine is still within your scope of practice.practice.

Document deviation (AP, X-table, Document deviation (AP, X-table, etc.), time, portableetc.), time, portable

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Image Critique Criteria Image Critique Criteria

Image evaluation for trauma Image evaluation for trauma procedures is the same as for procedures is the same as for routine procedures routine procedures

Image quality is critical for an Image quality is critical for an accurate diagnosis accurate diagnosis

It is poor practice to accept lower It is poor practice to accept lower quality images due to patient quality images due to patient condition or difficulty of procedurecondition or difficulty of procedure

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History TakingHistory Taking

Not just the work of the medical Not just the work of the medical officer or the nurseofficer or the nurse

Extra information make task simplifyExtra information make task simplify Mechanism of injury, time and also Mechanism of injury, time and also

patient’s feelingpatient’s feeling Look for signs and ask for Look for signs and ask for

symptomssymptoms

- journey to successful radiography- journey to successful radiography

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Positioning Positioning Important not to aggravate patient’s Important not to aggravate patient’s

condition when obtaining images condition when obtaining images Move tube and IR, instead of patient, Move tube and IR, instead of patient,

whenever possiblewhenever possible Obtain two (2) projections 90Obtain two (2) projections 900 0 to each to each

other.other. Cassette should be protected from body Cassette should be protected from body

fluid to avoid cross infection.fluid to avoid cross infection. Use grid when it is possible. Avoid grid Use grid when it is possible. Avoid grid

cut-off. cut-off. Give clear explanation for alert patient to Give clear explanation for alert patient to

obtain cooperation.obtain cooperation.

Basic Principles of Trauma Basic Principles of Trauma Radiography Radiography

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Practice standard precautions Practice standard precautions Expect to be exposed to body fluids in Expect to be exposed to body fluids in ED ED

Do not touch a patient without gloves!Do not touch a patient without gloves! Stop bleeding 1Stop bleeding 1stst before performing before performing

the examination.the examination. Make sure wound is cover-up before Make sure wound is cover-up before

x-ray. x-ray.


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Do not moved @ minimum movement Do not moved @ minimum movement of patient.of patient.

Do not turn patient by force to ideal Do not turn patient by force to ideal position.position.

Do not remove splint , bandage or Do not remove splint , bandage or cervical collar.cervical collar.

Do not remove any object ( tube, clip) Do not remove any object ( tube, clip) on the patient without permission from on the patient without permission from staff. staff.

Do not transfer patient onto the x-ray Do not transfer patient onto the x-ray table if spinal injury is suspected.table if spinal injury is suspected.

Do no neglect radiation protection.Do no neglect radiation protection.


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Do not try to pull out the Do not try to pull out the knifeknife

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For cervical spine:For cervical spine: Do not moved patient’s head and cervical Do not moved patient’s head and cervical

spine.spine. Perform Lateral projection 1Perform Lateral projection 1stst using using

horizontal beamhorizontal beam Excess and get cervical clearance before Excess and get cervical clearance before

moving patient head for AP projectionmoving patient head for AP projection Image should demonstrate C1 to C7.Image should demonstrate C1 to C7. Do not attempt a cervical examination if Do not attempt a cervical examination if

suspicious of severe injury – go straight suspicious of severe injury – go straight to do a CT. to do a CT.

CT C.Spine should include level of T5.CT C.Spine should include level of T5.


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Lateral Cervical Spine Lateral projection of Lateral Cervical Spine Lateral projection of C-spine in dorsal decubitus position; C-spine in dorsal decubitus position; dislocation of C3-C4; C7 not demonstrated, dislocation of C3-C4; C7 not demonstrated, so swimmer’s view is needed so swimmer’s view is needed

For Cervical Spine:For Cervical Spine:

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Inadequate diagnosis Inadequate diagnosis ImageImage

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:For Cervical Spine:

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

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Upper and Lower Limbs Upper and Lower Limbs

Obtain lift help for IR placement Obtain lift help for IR placement Injured limbs should be lifted with Injured limbs should be lifted with

support at both joints support at both joints Lift only enough to place IR Lift only enough to place IR

Two projections at 90 degrees Two projections at 90 degrees from each other required from each other required

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Extremities (Upper & Lower limbs)Extremities (Upper & Lower limbs) Do two projection two projections at 90 degrees Do two projection two projections at 90 degrees

from eachfrom each Long bones require demonstration of adjacent Long bones require demonstration of adjacent

jointsjoints Take separate projections, if necessary .Take separate projections, if necessary . Maximize patient safety and comfort by moving Maximize patient safety and comfort by moving

IR and CR, rather than injured limbIR and CR, rather than injured limb Handle injured part with care. Handle injured part with care. Injured limbs should be lifted with support at Injured limbs should be lifted with support at

both joints both joints Lift only enough to place IR Lift only enough to place IR


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ExtremitiesExtremities Do not force joint or injured part to Do not force joint or injured part to

ideal position.ideal position. Do not attempt to rotate severely Do not attempt to rotate severely

injured limbs for true positionsinjured limbs for true positions Do not move fracture part or after Do not move fracture part or after

surgery without assistant from other surgery without assistant from other staffs (SN, MO, MA).staffs (SN, MO, MA).


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Chest RadiographyChest Radiography Supine position used if general survey Supine position used if general survey

image of chest desired image of chest desired Check for need to demonstrate air-fluid Check for need to demonstrate air-fluid

levels levels If air-fluid levels are suspected, use X-If air-fluid levels are suspected, use X-

table lateral table lateral If patient’s condition permits, lateral If patient’s condition permits, lateral

decubitus position with patient lying on decubitus position with patient lying on affected side will also show air-fluid levels affected side will also show air-fluid levels

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CHEST RADIOGRAPHCHEST RADIOGRAPH The chest radiograph (CXR) is the The chest radiograph (CXR) is the

initial radiographic study of choice in initial radiographic study of choice in patients with thoracic blunt trauma. patients with thoracic blunt trauma.

A chest radiograph is an important A chest radiograph is an important adjunct in the diagnosis of many adjunct in the diagnosis of many conditions, including: conditions, including: chest wall fractures, chest wall fractures, pneumothorax, pneumothorax, hemothorax, hemothorax, and injuries to the heart and great vessels and injuries to the heart and great vessels

(e.g., enlarged cardiac silhouette, widened (e.g., enlarged cardiac silhouette, widened mediastinum). mediastinum).

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Chest TraumaChest Trauma

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Immediate Life Threatening Immediate Life Threatening Chest InjuriesChest Injuries

Tension pneumothoraxTension pneumothorax Massive haemothoraxMassive haemothorax Open chest woundOpen chest wound Cardiac tamponade (abnormal pressure Cardiac tamponade (abnormal pressure

caused by excessive fluid between the caused by excessive fluid between the pericardium and the heart)pericardium and the heart)

Flail segment (unstable ribcage after Flail segment (unstable ribcage after multiple fractures of the ribs and multiple fractures of the ribs and sternum)sternum)

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RIB FRACTURESRIB FRACTURESCLAVICULAR CLAVICULAR FRACTUREFRACTURE

CARDIAC CARDIAC TEMPONADETEMPONADE FLAIL CHESTFLAIL CHEST PNEUMOTHORAXPNEUMOTHORAX

TENSION TENSION PNEUMOTHORAXPNEUMOTHORAX

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Abdomen Abdomen

If transfer to x-ray table is not If transfer to x-ray table is not possible, obtain lift help for IR possible, obtain lift help for IR placement placement

IR centered to MSP at level of iliac IR centered to MSP at level of iliac crests crests

Check for possibility of fluid Check for possibility of fluid accumulation in abdominal cavity accumulation in abdominal cavity

Affects exposure factors Affects exposure factors Requires close monitoring of patient Requires close monitoring of patient

for status change during proceduresfor status change during procedures

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Abdomen Abdomen

Check LMP for female of Check LMP for female of reproductive age.reproductive age.

If condition permit delay – need to If condition permit delay – need to rule out pregnancy status.rule out pregnancy status.

Ultrasound may be a better choice Ultrasound may be a better choice of imaging tool.of imaging tool.

Pay attention to internal bleeding if Pay attention to internal bleeding if patient suffer blunt trauma, observe patient suffer blunt trauma, observe vital signs and listen to complain.vital signs and listen to complain.

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Pelvis Pelvis Pelvic fractures have a high risk of Pelvic fractures have a high risk of

hemorrhage – pay close attention to hemorrhage – pay close attention to patient for status change patient for status change

Obtain lift help for IR placement if Obtain lift help for IR placement if transfer to x-ray table is not possible.transfer to x-ray table is not possible.

Do not try to internal rotate the legs. Do not try to internal rotate the legs.

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Cranium Cranium Patients with head trauma are often Patients with head trauma are often

referred to CTreferred to CT When x-rays are ordered, a general When x-rays are ordered, a general

survey requires AP and lateral survey requires AP and lateral projections projections

Generally, the patient is supine . Generally, the patient is supine . Erect will demonstrate air-fluid level.Erect will demonstrate air-fluid level. PA should be projection of choice if PA should be projection of choice if

condition permit.condition permit. Lateral projection must be done 1Lateral projection must be done 1stst Only elevate head on radiolucent Only elevate head on radiolucent

support after ensure C-spine injury support after ensure C-spine injury has been ruled out has been ruled out

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Wrong PracticeWrong Practice

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Facial Bones Facial Bones

Patients with facial bone injuries Patients with facial bone injuries are often referred to CT first are often referred to CT first

No point doing modification No point doing modification projections if images are not of projections if images are not of high quality. high quality.

Anticipate profuse bleeding and Anticipate profuse bleeding and use universal precautions use universal precautions

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Other Imaging in Other Imaging in Trauma Trauma

CT is extensively used in trauma patients CT is extensively used in trauma patients Often, CT is modality of choice Often, CT is modality of choice

Angiography may be used for vascular Angiography may be used for vascular injuries injuries

MRI is valuable in diagnosis of spinal MRI is valuable in diagnosis of spinal injuryinjury

Contrast studies are often ordered for Contrast studies are often ordered for evaluation of urinary system evaluation of urinary system

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

Ultrasound plays an important role to Ultrasound plays an important role to rule out internal bleeding, visceral rule out internal bleeding, visceral organ rapture and vascular occlusion.organ rapture and vascular occlusion.

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

ultrasound, CT and MRI.ultrasound, CT and MRI. Know the advantages of ultrasound Know the advantages of ultrasound

verses CT verses MRI.verses CT verses MRI.

Other Imaging in Other Imaging in Trauma cont’ Trauma cont’

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ONE SIMPLE CONCEPTONE SIMPLE CONCEPTONE SIMPLE CONCEPTONE SIMPLE CONCEPT Time is LIFETime is LIFE Delay can mean difference in life Delay can mean difference in life

and deathand death ED patient management relies ED patient management relies

mainly on Medical Imagingmainly on Medical Imaging

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ConclusionConclusion

o Radiographer plays an extremely Radiographer plays an extremely important role in the evaluation of patient important role in the evaluation of patient with poly traumawith poly trauma

o The doctor depends on radiographs The doctor depends on radiographs produced by the radiographer to make produced by the radiographer to make his/her decisionhis/her decision

Radiographers and the radiology Radiographers and the radiology department help make a difference in the department help make a difference in the patients’ quality of life and outcome.patients’ quality of life and outcome.

The very radiographs that you produce The very radiographs that you produce contribute to this outcome.contribute to this outcome.

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LIVE UP TO THE CHALLLENGELIVE UP TO THE CHALLLENGE

A challenge for the A challenge for the radiographer to produce good radiographer to produce good quality radiographsquality radiographs DESPITE DESPITE

ALL ODDSALL ODDS

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Trauma Radiography Puteri Resort Melaka 2010