FACTT: Focused Assessment with Computed Tomography in Trauma.

Global Partner Exhibit Uploads for 2015 ARRS Annual Meeting April 19-24, 2015.

Gaspar Alberto Motta Ramírez,
MD.
radbody2013@yahoo.com.mx

FACTT:
Focused Assessment
with Computed Tomography in Trauma.
Gaspar Alberto Motta Ramírez, MD.
radbody2013@yahoo.com.mx

The “Total Body” Trauma ScanThe “Total Body” Trauma Scan
FACTT: Focused Assessment with Computed Tomography in Trauma.
First described in 2001 ASER (RSNA 2002) and first reported
by the MGH Emergency Imaging
Made possible with advent of helical scanning and
significantly improved with MDCT
Permits rapid imaging of the head, spine, chest abdomen and
pelvis in the multiple trauma patient; continued on to include
Excellent multiplanar and volumetric reformations for
evaluation of complex injuries

IMMEDIATE TOTAL-BODYIMMEDIATE TOTAL-BODY
COMPUTED TOMOGRAPHYCOMPUTED TOMOGRAPHY
WHOLE BODYWHOLE BODY
COMPUTED TOMOGRAPHY (WBCT)COMPUTED TOMOGRAPHY (WBCT)
The “Total Body” TraumaThe “Total Body” Trauma
ScanScan
FACTT:
Focused Assessment
with Computed Tomography in
Trauma.

Immediate recognition of life-threatening conditions and
injuries is the key to trauma management.
Trauma management incorporating FACTT enhances a
rapid response to life-threatening problems and enables a
comprehensive assessment of the severity of each relevant
injury.
Due to its speed and accuracy, FACTT during primary
trauma survey supports rapid decision-making and may
increase survival.
Kanz et al.
Journal of Trauma Management & Outcomes 2010, 4:4
http://www.traumamanagement.org/content/4/1/4

Patients with missed injuries tend to be more
severely injured with initial neurologic
compromise.
The majority of missed injuries are potentially
avoidable with repeat clinical assessments and a
high index of suspicion.
Buduhan G, McRitchie DI. Missed injuries in patients with multiple trauma.
J Trauma. 2000;49:600–605.

Trauma care creates a “perfect storm” for medical errors:
unstable patients,
incomplete histories,
time-critical decisions,
concurrent tasks,
involvement of many disciplines, and
often junior personnel working after-hours in busy emergency
departments,
interhospital transfers, particularly unstable patients who died during
or soon after transport
Gruen RL, Jurkovich GJ, McIntyre LK, Foy HM, Maier
RV.
Patterns of errors contributing to trauma mortality: lessons
learned from 2,594 deaths.
Ann Surg 2006;244: 371–380.

Buduhan G, McRitchie DI. Missed injuries in patients with multiple trauma.
J Trauma. 2000;49:600–605.

Patients exposed to high velocity injuries
are subject to a large pattern of lesions
ranging from neurologic injuries,
cervicofacial, thoracic, abdominal, spine
and so on.

ESSENTIAL, BASIC CONCEPT
MECHANISM OF TRAUMA
1. BLUNT
2. PENETRATING
The polytrauma patient,
initial management
and decision making

ESSENTIAL, BASIC CONCEPT
MECHANISM OF TRAUMA
1. BLUNT
2. PENETRATING

México City

In México, as in the world, traumatic injury is
the principal cause of death in people younger
than 45 years and a leading cause of mortality,
morbidity, and permanent disability.
TRAUMA
Instituto Nacional de Estadística, Geografía e Informática. Estadísticas sociodemográficas 1990-2005.
México: INEGI;2007.

The trauma is an urgent clinical-
surgical condition difficult to
assess due to the various
possibilities of injury that warrant
a multidisciplinary specialized
treatment.
Motta-Ramírez GA, Cabello PR.
Evaluación por ultrasonografía del trauma cerrado de abdomen en la sala de urgencias. Revisión de la literatura.
Rev Sanid Milit Mex. 1999;53:387-391

We have many qualified people providing care to injured patients. Most of them have
remarkable stories of success in improving trauma care, many times despite having
markedly restricted resources.
The Essential Trauma Care (ETC) Project is looking forwards to formally reaching
this goal. It represents a collaborative effort of the WHO and the International
Society of Surgery, along with stakeholders in different countries included in
México.
The ETC Project aims to define minimal, reasonable and affordable standards for
trauma care services worldwide. Furthermore, it seeks to define the resources needed
to ensure the availability of such services, for almost every injured person. Finally, it
seeks to establish constant efforts to promote the planning and organization required,
to effectively accomplish this task in every country.Global Partner Exhibit Uploads for 2015 ARRS Annual Meeting April 19-24, 2015.

Selection of axial images, that
defines clavicular fracture,
fractures of the 1st & 5th right
costal arch, subluxation of both
first costochondral arches and the
fractures of 2nd, 3rd
, 5th and 6th
left costal arches - FLAIL CHEST.
Also defines the bilateral subcutaneous emphysema and pneumothorax left
hidden, unnoticed clinically, radiologically suspected, and CT confirms

Successful management of emergency patients with multiple trauma in
the hospital depends on the immediate diagnosis and rapid treatment of
the most life-threatening injuries.
In order to reduce the time spent in the resuscitation room, an in-
hospital algorithm was developed in an interdisciplinary team approach
with respect to local structures that include FACTT (Focused
Assessment with Computed Tomography in Trauma).

Male, 25 years, with blunt trauma toracoabdominopélvico by runover. The axial images show
pneumocephalus, subarachnoid bleeding, fracture of the base of the skull, rib fractures,
hemothorax, pneumomediastinum, & multifragmentary dorsal vertebra fracture.

We have a work in progress. The aim of the study was to analyse
whether this algorithm affects the interval between hospital admission
and the completion of diagnostic procedures and the start of life-saving
interventions. All consecutive trauma patients are included.
The times between hospital admission and the end of the diagnostic
procedures (ultrasound, chest X-ray and FACTT), and between
hospital admission and the start of life-saving interventions were
registered and in-hospital mortality analysed.

Male, 60 years, with blunt abdominal trauma and abdominal mass. Note the changes in
the left abdominal wall. It was a POSTRAUMATIC RECTUS SHEATH
HEMATOMA (RSH).

Rectus sheath hematoma (RSH) is the result of bleeding into the rectus sheath from
damage to the superior or inferior epigastric arteries or their branches or from a direct
tear of the rectus muscle. The emergency physician should be familiar with rectus
sheath hematoma because it can mimic almost any abdominal condition. While usually
a self-limiting entity, rectus sheath hematoma can cause hypovolemic shock following
sufficient expansion, with associated mortality.

The mechanism, the time of day, the number of body parts
injured, the type of injuries, and resulting surgical or
radiological interventions were recorded. Also recorded was
the time from the FACTT examination to the formal report.
Where applicable, the consultant-verified reports were cross-
referenced with the out-of-hours registrar reports to assess
for discrepancies.

LESION RENAL TRAUMATICA
DERECHA GRADO IV.
Simple
phase
Arterial phase
Venosous
phase
Eliminatory phase
LEFT RENAL TRAUMATIC INJURY GRADE II
RENALRENAL
TRAUMATRAUMA

Incidence and prevalence of vascular
injury are related to several social and
cultural factors.
High-speed transportation, urban crime,
high level of industrialization, and new
diagnostic or therapeutic methods have all
contributed to increase the prevalence of
these types of injuries.
Santacruz-Torres A, Díaz-de León RF, Rosas-Cabral A.
Trauma vascular: 25 años de experiencia en Aguascalientes, México. Cir Ciruj 2008;76:367-372

POSTRAUMATIC HEMOTHORAX

Hall FM.
Evaluation of a single-pass continuous whole-body 16-MDCT protocol for patients with polytrauma.
AJR 2009; 192:3–10.
Use of single-pass continuous whole-body MDCT
protocols can significantly decrease examination
time for patients with polytrauma and improve
image quality compared with a conventional serial
scan protocol.
Monophasic injection with highly concentrated
contrast medium can reduce injection flow rate
and should therefore be preferred to a biphasic
injection technique.

RIGHT RENAL TRAUMATIC INJURY GRADE IV
RENALRENAL
TRAUMATRAUMA

SPLENIC LACERATIONSPLENIC LACERATION
Blunt abdominal trauma with perisplenic hematoma,
capsular disruption and parenchymal splenic laceration
involving the hilum: GRADE IVA

Why a total body trauma scan?
• Location of fatal injuries
• – 40% from head injuries
• – 25% from chest injuries
• – 10% from abdominal injuries
• – 20% related to spine trauma
• FACTT, “Total Body” MDCT scan
• – Scan from vertex of head through pelvis can evaluate
• for injuries in these four areas in a quick 2-4 minute
• single acquisition CT scan
• – Not for everyone; indicated for the polytrauma patient

FACTT, Scan Protocols
• Recommendation: 16 slice or greater MDCT scanner
• Use IV contrast material for chest, abdomen, pelvis
• Routine oral contrast not needed today
– Triple contrast (oral, colon, IV) for penetrating injuries
• If suspected carotid/vertebral injury, scan head/neck
with IV contrast after non-contrast head scan
• Continue scan as a run-off for lower extremity injury
• Delayed scan for positive parenchymal organ injury
• CT cystogram for suspected bladder rupture

We are evaluating the time from admission to the trauma
room until completion of head CT scan without contrast was;
the entire contrast-enhanced MDCT study, including pilot
scan and contrast application, a total scanning time with MPR
calculation of the spine and bony pelvis and if a relevant life-
threatening complication due to CT scanning during primary
trauma survey was observed.
We have already performed
whole-body MSCT in the
resuscitation periods without
prior ultrasound and chest X-
rays, which resulted in an interval
from admission up to completion
of the CT of 25±10 min.

Complete diagnostic imaging can be performed within 30 min after
trauma room admission by using MDCT.
During the primary survey, treatment of the patient is interrupted just for
the few minutes of the CT scan and contrast application. An adequate
survey of injuries can be achieved earlier and a targeted therapy can be
initiated ahead of time.
Integration of MDCT scanners in the primary trauma survey provides a
high standard of imaging in a very short time without endangering the
patient. When dealing with multiple casualties, MDCT could be used
also as an accurate and time-efficient means of hospital triage to
diagnose and prioritize patients and to plan further surgical interventions
and intensive care.
Der Unfallchirurg 2004;107(10):937-944.

Emergency Radiology 1999;6:61-69.
Emergency room

Insights Imaging 2014;5:403–405

Emergency Radiology 1999;6:61-69.
And, as I have already
pointed out, where is the
sub-specialist
radiologist, …… he is
where he is required: To
the ER

“Our emergency room dream”

In major trauma it is essential to immediately recognize and treat life-
threatening problems and conditions.
Most trauma protocols reserve the use of computed tomography for
the secondary survey, as patients cannot be attended to during the
examination and must be transferred from the emergency room to the
CT suite.
The relevant reduction in the scanning time of multidetector computed
tomography (MDCT) or multislice computed tomography (MSCT)
justifies its use as the major diagnostic adjunct for primary trauma
survey and initial resuscitation.
According to our ATLS®-based trauma algorithm, the multidetector
scanner situated in the emergency department is utilized immediately
after the correction of respiratory problems to detect causes of
bleeding or intracranial hematomas.
Der Unfallchirurg 2004;107(10):937-944.

The SEQUENTIAL TRAUMA SCORE developed is the
first sequential score that provides a prognosis of patients
with blunt major trauma at several points in time, with
every additional piece of information the precision
increases. Based on easy available routine data the medical
team has a simple, useful tool to identify patients at high
risk and to predict the prognosis of an individual patient
with major trauma very early, quickly and precisely.
Eur J Med Res (2010) 15: 185-195

Advances in the technology of computed tomography (CT) have
markedly altered the management of blunt trauma.
The most dramatic example is the evolution of nonoperative
management of solid organ injuries diagnosed by CT.
CT angiography (CTA) has supplanted invasive diagnostic
angiography, allowing rapid diagnosis of injuries, such as pelvic
arterial bleeding requiring embolization and aortic transection
requiring
operative or stent repair.
Tillou A et al. Is the Use of Pan-Computed Tomography for Blunt Trauma
Justified? A Prospective Evaluation. J Trauma. 2009;67: 779–787

In addition, CT has improved the care of patients by rapidly
characterizing multiple injuries so that priorities of management and
timing of operations can be established with more precise information.
Finally, the recognition that many injuries are initially occult has often
required admission of patients for observation.
With the pressure for bed availability in most trauma centers, the
liberal use of CT can rapidly identify or exclude occult injury to better
select patients for inpatient observation or early discharge.
Tillou A et al. Is the Use of Pan-Computed Tomography for Blunt Trauma
Justified? A Prospective Evaluation. J Trauma. 2009;67: 779–787

Heidelberg treatment algorithm
for emergency patients admitted
to the resuscitation room of
surgical emergency department.
Bernhard M et al. Introduction of a
treatment algorithm can improve the early
management of emergency patients in
the resuscitation room. Resuscitation
2007;73, 362—373.
FACTT
FAST, CXR

Moving from head to toe, we can accept
that cranial CT is currently the best
available screening method in the
emergency setting, irrespective of formal
proof of its sensitivity and specificity.
It quickly reveals the most common and
surgically important traumatic pathologies
such as skull fractures, intracranial
and intracerebral bleeds, contusions and
edema.
Stengel D et al Primary pan-CT for blunt multiple trauma:
can the hole be better than its parts?
Injury, Int. J. Care Injured (2009) 40S4, S36– S46.

Trauma care has significantly benefited from, and has been changed by,
the introduction of CT scanning. It is more than prudent to transfer this
principle to the primary trauma survey, and the idea of triaging
patients to single-pass full-body CT (pan-CT) perfectly fits these
prerequisites.
In 1998, Leidner and colleagues reported their experience with this
diagnostic tool, performed on 111 trauma patients admitted to the
Oskarshamn Hospital (Sweden) between 1991 and 1995.
Leidner B, Adiels M,Aspelin P, Gullstrand P et al.
Standardized CT examination of the multitraumatized patient.
Eur Radiol. 1998 8(9):1630−1638.

Patients should be promptly referred for whole
body computed tomography (WBCT), FACTT if
clinically indicated, to facilitate early detection of
serious injuries within one centre with a full range
of trauma specialists.
Adiotomre A, Chopra A, Kirwadi S, Kotnis N.
Results from the first year as a major trauma radiology unit in the UK .
Clinical Radiology 2014;69:812-821.

Sierink JC, Saltzherr, Reitsma TPJ B, VanDelden, Luitse OM J. S. K. and. Goslings JC.
Systematic review and meta-analysis of immediate total-body computed tomography compared with selective
radiological imaging of injured patients. British Journal of Surgery 2012; 99(Suppl 1): 52–58.
“showed differences in time in the ER in favour of
immediate total-body CT, FACTT during the
primary trauma survey compared with
conventional radiographic imaging supplemented
with selective
CT”.

Hilbert and co-workers described a decrease in
mortality rate from 15 to 8.6 % after introduction
of a clinical algorithm using immediate total body
CT, FACTT in the clinical care of seriously
injured patients.
Hilbert P, zur Nieden K, Hofmann GO, Hoeller I, Koch R, Stuttmann R.
New aspects in the emergency room management of critically injured patients: a multi-slice CT-oriented care
algorithm. Injury 2007; 38: 552–558.

Integration in training programs of
the indispensable diagnostic radiologist
skills throughout their role in the
evaluation of patients with trauma.
«…....precisely
is in the night shift, which often
we acquire more knowledge and
experiences. "

Diligent and careful
review of all studies
at all times and at all
times.

Highlights the potential use of FAST as a screening
diagnostic tool that could prevent unnecessary
radiation exposure and minimize cost of care in a
significant number of trauma patients.
Focused Assessment with Sonography in Trauma and abdominal
Computed Tomography utilization in adult trauma patients:
trends over the last decade.trends over the last decade.
Emergency Medicine International
Volume 2013, Article ID 678380, 7 pages
http://dx.doi.org/10.1155/2013/678380
Motta-Ramírez GA, Cabello PR.
Evaluación por ultrasonografía del trauma cerrado de abdomen en la sala de urgencias. Revisión
de la literatura. Rev Sanid Milit Mex. 1999;53:387-391.
2008:
http://es.slideshare.net/betomotta/radiologia-y-trauma-presentation
http://es.slideshare.net/betomotta/sensibilidad-y-especificidad-del-ultrasonido-fast-en-la-deteccin-
de-lquido-libre-en-trauma-abdominal
2010:
radiologiavirtual.org/rv/prog_preliminar_c_trauma_2010.html
2012:
http://es.slideshare.net/betomotta/trauma-20-noviembre-2012

Based on our early experiences, nearly one-third of patients
who undergo a FACTT scan for suspected polytrauma, will
have no acute injury at WBCT.
One-fifth of patients in our study required emergency
surgical or radiological intervention for acute injuries found
on FACTT.

And, as I have already pointed out, where is the
radiologist, …… he is where he is required: To the
FIELD….FASTFAST

Team work
.
Teamwork
A team of surgical specialists will be more efficient during this phase
than the care of one single general surgeon.
Teamwork remains the key to a successful polytraumatized patient's
care.

FACTT: Focused Assessment with Computed Tomography in Trauma.

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FACTT: Focused Assessment with Computed Tomography in Trauma.