Trauma Radiography


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Trauma Radiography

  1. 1. Chapter 13 Trauma Radiography Heather Johnson, A.S., R.T. (R)
  2. 2. Trauma Centers <ul><li>Many types of facilities provide emergency medical care, ranging from major metropolitan medical center to small outpatient clinics in rural areas. </li></ul><ul><li>The term “Trauma Center” signifies a specific level of emergency medical care as defined by the American College of Surgeons Commission on Trauma. </li></ul>
  3. 3. Trauma Levels <ul><li>Level I = is the most comprehensive, usually a university-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 </li></ul>
  4. 5. Trauma Levels <ul><li>Level II = same as level one, but not a research facility, may not have as many specialists </li></ul><ul><li>Level III = no specialists, can stabilize patient for transport to a higher level center, may not have 24 hour imaging </li></ul><ul><li>Level IV = clinics, attend minor injuries, some stabilization before transfer </li></ul>
  5. 6. Introduction <ul><li>Trauma is defined as a sudden, unexpected, dramatic, forceful, or violent event </li></ul><ul><li>Blunt, penetrating, explosive, and thermal forces are common causes of traumatic injuries </li></ul>
  6. 9. Introduction <ul><li>Trauma affects persons in all age ranges </li></ul><ul><li>Radiographers in the emergency department (ED) must be prepared for a variety of procedures on patients in all age groups </li></ul>
  7. 11. Preliminary Considerations <ul><li>Specialized trauma imaging systems reduce the amount of time required to obtain diagnostic images </li></ul><ul><ul><li>One type provides greater flexibility in IR/CR maneuverability </li></ul></ul><ul><ul><li>Another type scans the entire body in a few seconds </li></ul></ul>
  8. 13. STATSCAN
  9. 16. <ul><li>Mobile radiography is often used for ED procedures </li></ul>
  10. 17. Preliminary Considerations <ul><li>Mobile fluoroscopy units, or C-arms, may be used in fracture reduction or foreign body localizations </li></ul><ul><li>Immobilization devices are a necessity in trauma imaging </li></ul><ul><ul><li>Trauma patients often cannot hold the required position </li></ul></ul>
  11. 18. Radiographer’s Role in Trauma <ul><li>Depends upon department protocol and staffing </li></ul><ul><li>Primary responsibilities </li></ul><ul><ul><li>Perform quality diagnostic imaging procedures </li></ul></ul><ul><ul><li>Practice ethical radiation protection </li></ul></ul><ul><ul><li>Provide patient care </li></ul></ul>
  12. 19. Radiographer’s Role in Trauma <ul><li>Patient level of consciousness changes are common in trauma </li></ul>
  13. 20. “ Best Practices” in Trauma Radiography <ul><li>Speed </li></ul><ul><ul><li>Efficiency in producing quality images in the shortest possible time </li></ul></ul><ul><li>Accuracy </li></ul><ul><ul><li>Optimum image quality, minimum repeats </li></ul></ul><ul><li>Quality </li></ul><ul><ul><li>Quality cannot be sacrificed for speed </li></ul></ul><ul><ul><li>Do not use patient condition as an excuse for poor quality images </li></ul></ul>
  14. 21. “ Best Practices” in Trauma Radiography <ul><li>Positioning </li></ul><ul><ul><li>Important not to aggravate patient’s condition when obtaining images </li></ul></ul><ul><ul><li>Move tube and IR, instead of patient, whenever possible </li></ul></ul><ul><li>Practice standard precautions </li></ul><ul><ul><li>Expect to be exposed to body fluids in ED </li></ul></ul><ul><ul><li>Do not touch a patient without gloves! </li></ul></ul>
  15. 22. Disclaimer: The following three slides are gruesome.
  16. 26. “ Best Practices” in Trauma Radiography <ul><li>Anticipation </li></ul><ul><ul><li>Some injuries require follow-up procedures; knowing what to do increases appreciation for radiographer’s role in ED </li></ul></ul>
  17. 27. “ Best Practices” in Trauma Radiography <ul><li>Attention to detail </li></ul><ul><ul><li>Pay careful attention to patient’s condition, which could change at any time </li></ul></ul><ul><li>Attention to ED protocol and scope of practice </li></ul><ul><ul><li>Know the protocol and scope of practice in your facility </li></ul></ul><ul><li>Professionalism </li></ul><ul><ul><li>Adhere to Code of Ethics </li></ul></ul>
  18. 28. Radiographic Procedures in Trauma Slide
  19. 29. General Procedural Guidelines Slide
  20. 30. General Procedural Guidelines <ul><li>Patient preparation </li></ul><ul><li>IR size </li></ul><ul><li>SID </li></ul><ul><li>ID markers </li></ul><ul><li>Radiation protection </li></ul><ul><li>Patient instructions </li></ul><ul><li>Immobilization </li></ul><ul><li>Documentation </li></ul><ul><li>Image critique </li></ul>
  21. 31. Patient Preparation <ul><li>Use good communication skills with appropriate touch and eye contact </li></ul><ul><ul><li>Trauma often causes anxiety </li></ul></ul><ul><li>Check patient for potential artifacts </li></ul><ul><ul><li>Explain what you are removing and why </li></ul></ul><ul><ul><li>Secure all personal effects using proper procedure for your facility </li></ul></ul>
  22. 32. IR Size <ul><li>IR size for trauma procedures are the same as for routine procedures </li></ul><ul><li>Use smallest IR that will demonstrate anatomy </li></ul><ul><li>Collimate field size to anatomy of interest </li></ul>
  23. 33. SID <ul><li>SID is standardized as a part of procedural protocol </li></ul><ul><ul><li>When SID is not specified under a projection, 40 to 48  </li></ul></ul><ul><ul><li>60 to 72  SID recommended for projections with increased OID </li></ul></ul>
  24. 34. ID Markers <ul><li>Right or left side markers must be included on each image </li></ul><ul><li>Other required ID markers must be in the blocker or elsewhere on the final image </li></ul><ul><li>Markers used for penetrating trauma to identify entrance and exit wounds </li></ul>
  25. 36. Just Kidding…..
  26. 37. Radiation Protection <ul><li>Shield pediatric patients and patients of reproductive age </li></ul><ul><li>Warn other staff of exposure when performing mobile imaging </li></ul><ul><li>Other radiation protection measures </li></ul><ul><ul><li>Close collimation </li></ul></ul><ul><ul><li>Optimum technique factors </li></ul></ul>
  27. 38. Patient Instructions <ul><li>Explain and demonstrate positions, when possible </li></ul><ul><li>Explain respiration instructions for patients who can cooperate </li></ul><ul><li>Use short exposure times to eliminate possibility of imaging motion </li></ul>
  28. 39. Immobilization <ul><li>Many ED patients arrive in some sort of immobilization device </li></ul><ul><li>Immobilization devices are not to be removed unless ordered by a physician </li></ul><ul><li>Imaging procedures are often performed without removal of the immobilization </li></ul><ul><li>Images are used to rule out injury and show if it is safe to remove immobilization </li></ul>
  29. 42. Documentation <ul><li>Because deviation or adjustment of routine procedures is often required to accommodate a patient’s injury, documentation is important </li></ul><ul><li>Make sure that deviation from routine is still within your scope of practice! </li></ul><ul><li>Document deviation (AP, X-table, etc.), time, portable </li></ul>
  30. 43. Image Critique Criteria <ul><li>Image evaluation for trauma procedures is the same as for routine procedures </li></ul><ul><li>Image quality is critical for an accurate diagnosis </li></ul><ul><li>It is poor practice to accept lower quality images due to patient condition or difficulty of procedure </li></ul>
  31. 44. Trauma Projections
  32. 45. Lateral Cervical Spine <ul><li>Horizontal CR centered to midpoint of IR </li></ul><ul><li>Pre-vertebral soft tissue must be visualized </li></ul><ul><li>Image should demonstrate entire C-spine from sella turcica to top of T1 </li></ul><ul><ul><li>If all seven cervical vertebrae are not seen, then a swimmer’s view is required </li></ul></ul>
  33. 46. Lateral Cervical Spine <ul><li>Patient and IR centered for trauma lateral of C-spine </li></ul>
  34. 47. Lateral Cervical Spine Lateral projection of C-spine in dorsal decubitus position; dislocation of C3-C4; C7 not demonstrated, so swimmer’s view is needed
  35. 48. Swimmer’s (cervicothoracic) <ul><li>Required if C7 and top of T1 not demonstrated on lateral C-spine </li></ul><ul><li>Trauma usually requires dorsal decubitus position </li></ul><ul><li>Patient supine without rotation </li></ul><ul><li>Ask patient to raise arm opposite the x-ray tube over head </li></ul><ul><ul><li>Assist patient and provide support </li></ul></ul>
  36. 49. Cervicothoracic Spine <ul><li>Relax shoulder closer to x-ray tube </li></ul><ul><li>Vertical IR centered just above jugular notch </li></ul><ul><li>Horizontal CR centered to C7-T1 interspace and midcoronal plane </li></ul><ul><li>Use breathing technique if possible </li></ul><ul><ul><li>Blur ribs and lung markings to better demonstrate spine </li></ul></ul>
  37. 50. Cervicothoracic Spine <ul><li>Image demonstrates lower cervical and upper thoracic vertebrae in profile between the shoulders </li></ul>
  38. 51. Cervicothoracic Spine Patient and IR positioned for trauma lateral projection of cervicothoracic vertebrae using dorsal decubitus position
  39. 52. Cervicothoracic Spine Lateral projection, dorsal decubitus position of cervicothoracic vertebrae
  40. 53. AP Axial Cervical Spine <ul><li>Patient is supine </li></ul><ul><ul><li>Usually immobilized with collar and spine board </li></ul></ul><ul><li>Place IR under spine board, if present, centered to C4 (Adam’s apple) </li></ul><ul><li>Head and shoulders without rotation </li></ul><ul><ul><li>Ask patient to look straight ahead </li></ul></ul>
  41. 54. AP Axial Cervical Spine <ul><li>CR directed 15 to 20 degrees cephalad to enter MSP at C4 </li></ul><ul><li>Image demonstrates C3-T1 or T2, including all soft tissues </li></ul><ul><ul><li>If backboard is present, unavoidable artifacts may be seen </li></ul></ul>
  42. 55. AP Axial Cervical Spine Patient and IR positioned for trauma AP axial C-spine
  43. 56. AP Axial Cervical Spine Trauma AP axial C-spine; complete dislocation at C2-C3
  44. 57. AP Axial Oblique Cervical Spine <ul><li>TRAUMA OBLIQUES </li></ul><ul><li>Patient is supine </li></ul><ul><ul><li>Usually immobilized with collar and spine board </li></ul></ul><ul><li>Place IR under spine board (not bucky), if present, centered to C4 and adjacent mastoid process </li></ul><ul><ul><li>About 3  lateral to MSP </li></ul></ul>
  45. 58. AP Axial Oblique Cervical Spine <ul><li>Head and shoulders without rotation </li></ul><ul><ul><li>Ask patient to look straight ahead </li></ul></ul><ul><li>CR has double angle </li></ul><ul><ul><li>45 degrees lateromedially </li></ul></ul><ul><ul><li>15 to 20 degrees cephalic </li></ul></ul><ul><li>CR enters lateral to MSP at level of C4 </li></ul>
  46. 59. AP Axial Oblique Cervical Spine <ul><li>CR exit should be in center of IR </li></ul><ul><li>Image demonstrates side opposite CR </li></ul><ul><ul><li>C1-T1 or T2 bodies and disk spaces </li></ul></ul><ul><ul><li>Intervertebral foramina open </li></ul></ul><ul><ul><li>If backboard is present, unavoidable artifacts may be seen </li></ul></ul>
  47. 60. AP Axial Oblique Cervical Spine Patient and IR positioned for trauma AP axial oblique C-spine
  48. 61. AP Axial Oblique Cervical Spine Trauma AP axial oblique C-spine
  49. 62. Thoracic and Lumbar Spine <ul><li>X-table laterals performed first </li></ul><ul><li>Vertical grid and IR </li></ul><ul><ul><li>Top of IR 1.5  to 2  (3.8 to 5 cm) above shoulders for thoracic spine </li></ul></ul><ul><ul><li>Centered to level of iliac crests for lumbar spine </li></ul></ul><ul><li>Have patient cross arms on anterior chest </li></ul>
  50. 63. Thoracic and Lumbar Spine <ul><li>CR horizontal </li></ul><ul><ul><li>Centered to spine and IR </li></ul></ul><ul><li>Breathing technique improves visualization of thoracic vertebrae </li></ul><ul><li>Exposure made on suspended respiration for lumbar vertebrae </li></ul>
  51. 64. Thoracic and Lumbar Spine <ul><li>Thoracic image demonstrates T3 or T4 to L1 </li></ul><ul><li>Lumbar image demonstrates T12 to sacrum </li></ul><ul><li>Vertebral bodies and spinous processes in profile </li></ul>
  52. 65. Trauma Lateral Lumbar Spine CR and IR positioned for trauma lateral projection of lumbar spine using dorsal decubitus position
  53. 66. Trauma Lateral Lumbar Spine Lateral projection of thoracolumbar spine, dorsal decubitus position; note fracture and dislocation of L2 and spine board artifacts
  54. 67. Chest <ul><li>Supine position used if general survey image of chest desired </li></ul><ul><li>Check for need to demonstrate air-fluid levels </li></ul><ul><ul><li>If air-fluid levels are suspected, use X-table lateral </li></ul></ul><ul><ul><li>If patient’s condition permits, lateral decubitus position with patient lying on affected side will also show air-fluid levels </li></ul></ul>
  55. 68. Trauma AP Chest <ul><li>Obtain help to lift patient for IR placement </li></ul><ul><ul><li>Top of IR placed about 1.5  to 2  above shoulders </li></ul></ul><ul><li>Arms abducted </li></ul><ul><li>MCP parallel to IR </li></ul><ul><li>Use maximum SID to reduce heart magnification </li></ul>
  56. 69. Trauma AP Chest <ul><li>Ensure chin extended out of anatomy of interest </li></ul><ul><li>CR directed perpendicular to center of IR </li></ul><ul><ul><li>look for light field slightly above shoulders and on sides of chest, CW or LW </li></ul></ul><ul><li>Exposure made upon second full inhalation, if possible </li></ul>
  57. 71. Trauma AP Chest <ul><li>Image demonstrates lung fields in their entirety </li></ul><ul><ul><li>Minimal rotation and distortion present </li></ul></ul>
  58. 74. Abdomen <ul><li>If transfer to x-ray table is not possible, obtain lift help for IR placement </li></ul><ul><li>IR centered to MSP at level of iliac crests </li></ul><ul><li>Check for possibility of fluid accumulation in abdominal cavity </li></ul><ul><ul><li>Affects exposure factors </li></ul></ul><ul><ul><li>Requires close monitoring of patient for status change during procedures </li></ul></ul>
  59. 75. Abdomen <ul><li>Mark entrance and exit wounds, if present </li></ul><ul><li>Align shoulders and hips in same plane </li></ul><ul><li>MCP parallel to table </li></ul><ul><li>CR perpendicular to center of IR </li></ul><ul><li>Image demonstrates entire abdomen with pubic symphysis visible at lower border </li></ul>
  60. 77. Pelvis <ul><li>Pelvic fractures have a high risk of hemorrhage – pay close attention to patient for status change </li></ul><ul><li>Obtain lift help for IR placement if transfer to x-ray table is not possible </li></ul><ul><li>IR centered 2  above pubic symphysis or 2  below ASIS </li></ul><ul><li>MCP parallel to IR </li></ul>
  61. 78. Pelvis <ul><li>Lower limbs internally rotated only if possible </li></ul><ul><li>Ensure arms are not in anatomy of interest </li></ul><ul><li>CR perpendicular to center of IR </li></ul><ul><li>Exposure made on suspended respiration </li></ul><ul><li>Image demonstrates entire pelvis and proximal femora </li></ul>
  62. 79. Trauma AP Pelvis Trauma AP pelvis; note fracture of left ilium and separation of pubic bones
  63. 81. Cranium <ul><li>Patients with head trauma are often referred to CT first </li></ul><ul><li>When x-rays are ordered, a general survey requires AP and lateral projections </li></ul><ul><li>Generally, the patient is supine </li></ul><ul><ul><li>Lateral projection uses dorsal decubitus position </li></ul></ul>
  64. 82. Trauma Lateral Cranium <ul><li>Elevate head on radiolucent support </li></ul><ul><ul><li>Ensure C-spine injury has been ruled out </li></ul></ul>
  65. 83. Trauma Lateral Cranium Trauma lateral projection of cranium; note multiple fractures in frontal bone
  66. 84. Trauma AP Cranium <ul><li>Check with physician to determine anatomy of interest </li></ul><ul><ul><li>AP projection demonstrates anterior cranium </li></ul></ul><ul><ul><li>AP axial projection (Towne) demonstrates posterior cranium </li></ul></ul>
  67. 85. Trauma Cranium Patient and IR positioned for trauma AP cranium Patient and IR positioned for trauma AP axial cranium
  68. 86. Trauma AP Cranium Trauma AP cranium; note fracture line
  69. 87. Facial Bones <ul><li>Patients with facial bone injuries are often referred to CT first </li></ul><ul><li>Anticipate profuse bleeding and use universal precautions </li></ul>
  70. 89. Upper and Lower Limbs <ul><li>Obtain lift help for IR placement </li></ul><ul><li>Injured limbs should be lifted with support at both joints </li></ul><ul><ul><li>Lift only enough to place IR </li></ul></ul><ul><li>Two projections at 90 degrees from each other required </li></ul><ul><ul><li>Do not attempt to rotate severely injured limbs for true positions </li></ul></ul>
  71. 92. Upper and Lower Limbs <ul><li>Long bones require demonstration of adjacent joints </li></ul><ul><ul><li>Take separate projections, if necessary </li></ul></ul><ul><li>Maximize patient safety and comfort by moving IR and CR, rather than injured limb </li></ul>
  72. 96. Other Imaging Procedures in Trauma Slide
  73. 97. Other Imaging in Trauma <ul><li>CT is extensively used in trauma patients </li></ul><ul><ul><li>Often, CT is modality of choice </li></ul></ul><ul><li>Angiography may be used for vascular injuries </li></ul><ul><li>Contrast studies are often ordered for evaluation of urinary system </li></ul><ul><ul><li>Blunt abdominal trauma and suspected pelvic fractures often result in injury to urinary system </li></ul></ul>
  74. 99. Time for the “good stuff”!