Trauma radiography involves specialized procedures to image patients with traumatic injuries. Trauma centers are classified by level depending on available resources and specialties. Level I centers have the most comprehensive services available 24/7. Radiographers in emergency departments must be prepared to perform a variety of trauma imaging procedures on patients of all ages using specialized equipment. Common trauma projections include lateral cervical spine, cervicothoracic, and thoracic and lumbar spine views. Quality, speed, accuracy and attention to detail are important principles for optimal trauma radiography.

1. Trauma Radiography

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

3. Trauma LevelsTrauma Levels
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

4. Trauma LevelsTrauma 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 injuries,
some stabilization before transfer

5. IntroductionIntroduction
Trauma is defined as a sudden,Trauma is defined as a sudden,
unexpected, dramatic, forceful, ordramatic, forceful, or violentviolentunexpected,
event
Blunt, penetrating,
event
Blunt, explosive, and thermaland thermalpenetrating, explosive,
forces are common causes of traumatictraumaticforces are common causes of
injuriesinjuries

6. IntroductionIntroduction
Trauma affects persons in all age rangesin all age rangesTrauma affects persons
Radiographers in the emergencyRadiographers in the emergency
department (ED) mustmust be prepared forbe prepared for aa
variety of procedures on patients in all age
department (ED)
variety of procedures on patients in all age
groupsgroups

7. Preliminary ConsiderationsPreliminary Considerations
Specialized trauma imaging systemsSpecialized trauma imaging systems
reduce the amount ofof time required totime required to
obtain diagnostic images
reduce the amount
obtain diagnostic images
– One type provides greaterOne type provides greater flexibility in IR/CRflexibility in IR/CR
maneuverabilitymaneuverability
– AnotherAnother type scans the entire body in a fewtype scans the entire body in a few
secondsseconds

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12. Mobile radiography is often used for EDis often used for EDMobile radiography
proceduresprocedures

13. Preliminary ConsiderationsPreliminary Considerations
Mobile fluoroscopy units, orunits, or C-arms,C-arms, maymay
be used in fracture reduction or foreign
Mobile fluoroscopy
be used in fracture reduction or foreign
body localizations
Immobilization devices are a necessity
localizations
Immobilization devices are a necessity in
body
in
trauma imagingtrauma imaging
– Trauma patients often cannotTrauma patients often cannot hold thehold the
required positionrequired position

14. Radiographer’s Role in TraumaRadiographer’s Role in Trauma
Depends upon departmentupon department protocol andprotocol andDepends
staffing
Primary responsibilities
staffing
Primary responsibilities
– Perform qualityPerform quality diagnostic imagingdiagnostic imaging
procedures
Practice ethical radiation protection
procedures
– Practice ethical radiation protection
– Provide patient careProvide patient care

15. Radiographer’s Role in TraumaRadiographer’s Role in Trauma
Patient level of consciousnessPatient level of consciousness changeschanges
are common in traumaare common in trauma

16. “Best Practices” in Trauma“Best Practices” in Trauma
RadiographyRadiography
SpeedSpeed
– Efficiency in producing qualityEfficiency in producing quality images in theimages in the
shortest possible timeshortest possible time
AccuracyAccuracy
– Optimum image quality, minimum repeatsOptimum image quality, minimum repeats
QualityQuality
– Quality cannot be sacrificed for speedQuality cannot be sacrificed for speed
– Do not use patient condition as an excuse forDo not use patient condition as an excuse for
poor quality imagespoor quality images

17. “Best Practices” in Trauma“Best Practices” in Trauma
RadiographyRadiography
PositioningPositioning
– ImportantImportant notnot to aggravate patient’s conditionto aggravate patient’s condition
when obtaining imageswhen obtaining images
– Move tube and IR, instead of patient,Move tube and IR, instead of patient,
whenever possiblewhenever possible
Practice standard precautionsPractice standard precautions
– Expect to be exposed to bodyExpect to be exposed to body fluidsfluids in EDin ED
– Do not touch a patient without gloves!Do not touch a patient without gloves!

18. Disclaimer:
The following three slides are
Disclaimer:
The following three slides are
gruesome.gruesome.

19. “Best Practices” in Trauma“Best Practices” in Trauma
RadiographyRadiography
AnticipationAnticipation
– Some injuriesSome injuries require follow-up procedures;require follow-up procedures;
knowing what to do increases appreciation forappreciation forknowing what to do increases
radiographer’s role in EDrole in EDradiographer’s

20. “Best Practices” in Trauma“Best Practices” in Trauma
RadiographyRadiography
Attention to detailAttention to detail
– Pay carefulPay careful attention to patient’s condition,attention to patient’s condition,
which could change at anyany timetimewhich could change at
Attention to ED protocol and scope ofand scope ofAttention to ED protocol
practicepractice
– Know the protocolKnow the protocol and scope ofand scope of practice inpractice in
your facilityfacilityyour
ProfessionalismProfessionalism
– Adhere to Code ofAdhere to Code of EthicsEthics

21. Radiographic Procedures inRadiographic Procedures in
TraumaTrauma
Slide 28

22. General ProceduralGeneral Procedural
GuidelinesGuidelines
Slide 29

23. General Procedural GuidelinesGeneral Procedural Guidelines
Patient preparationpreparationPatient
IR sizeIR size
SID
ID markers
SID
ID markers
Radiation
protection
Radiation
protection
Patient instructionsPatient instructions
Immobilization
Documentation
Immobilization
Documentation
Image critiqueImage critique

24. Patient PreparationPatient Preparation
Use good communication skills with
appropriate touch and eye contact
Use good communication skills with
appropriate touch and eye contact
– Trauma often causesTrauma often causes anxietyanxiety
Check patient forfor potential artifactspotential artifactsCheck patient
– Explain whatExplain what you are removing and whyyou are removing and why
– Secure all personalSecure all personal effectseffects using properusing proper
procedure for your facilityprocedure for your facility

25. IR SizeIR Size
IR size for trauma procedures are thetrauma procedures are theIR size for
same as for routine proceduresroutine proceduressame as for
Use smallest IR thatIR that will demonstratewill demonstrateUse smallest
anatomy
Collimate field size to anatomy of
anatomy
Collimate field size to anatomy interestof interest

26. SIDSID
SID is standardized as a parta part ofofSID is standardized as
procedural protocolprocedural protocol
– When SID is notWhen SID is not specified underspecified under a projection,a projection,
40 to 48′′40 to 48
– 60 to 72′′
60 to 72′′
′′ SID recommended forSID recommended for projectionsprojections
with increased OIDwith increased OID

27. ID MarkersID Markers
Right or left side markers must beRight or left side markers must be
included on each imageincluded on each image
Other required ID markersrequired ID markers mustmust be in thebe in the
blocker or elsewhere on the final image
Other
blocker or elsewhere on the final image
Markers used for penetrating trauma toused for penetrating trauma toMarkers
identify entrance and exit woundswoundsidentify entrance and exit

29. Just Kidding…..

30. Radiation ProtectionRadiation Protection
Shield pediatric patients and patientspatients and patients ofofShield pediatric
reproductive agereproductive age
Warn other staffstaff ofof exposure whenexposure when
performing mobile imaging
Warn other
performing mobile imaging
Other radiation protection measuresradiation protection measuresOther
– Close collimationClose collimation
– Optimum technique factorsOptimum technique factors

31. Patient InstructionsPatient Instructions
Explain and demonstrate positions, when
possible
Explain and demonstrate positions, when
possible
Explain respiration instructionsExplain respiration instructions forfor patientspatients
who can cooperatewho can cooperate
Use short exposure times to eliminateexposure times to eliminateUse short
possibility of imaging motionimaging motionpossibility of

32. ImmobilizationImmobilization
Many ED patientsED patients arrive in some sortarrive in some sort ofofMany
immobilization device
Immobilization devices are not
immobilization device
Immobilization devices are not to beto be
removed unless ordered by a physicianremoved unless ordered by a physician
Imaging procedures are often performedare often performed
without removal of the immobilization
Imaging procedures
without removal of the immobilization
Images are used to rule out injury andinjury and
show if it is safe to remove immobilization
Images are used to rule out
show if it is safe to remove immobilization

35. DocumentationDocumentation
Because deviation or adjustmentadjustment ofof
routine procedures is often required to
Because deviation or
routine procedures is often required to
accommodate a patient’s injury,injury,
documentation is important
accommodate a patient’s
documentation is important
Make sure that deviation from routine isdeviation from routine is
still within your scope of practice!
Make sure that
still within your scope of practice!
Document deviation (AP, X-table,deviation (AP, X-table, etc.),etc.),Document
time, portabletime, portable

36. Image Critique CriteriaImage Critique Criteria
Image evaluation for trauma procedures istrauma procedures is
the same as for routine procedures
Image evaluation for
the same as for routine procedures
Image quality is critical foris critical for an accuratean accurateImage quality
diagnosisdiagnosis
It is pooris poor practice to acceptpractice to accept lowerlower qualityqualityIt
images due to patient condition or difficultydifficultyimages due to patient condition or
of procedureof procedure

37. Trauma ProjectionsTrauma Projections

38. Lateral Cervical SpineCervical SpineLateral
Horizontal CR centered to midpoint ofof IRIRHorizontal CR centered to midpoint
Pre-vertebral soft tissue must betissue must bePre-vertebral soft
visualized
Image should demonstrate entire C-
visualized
Image should demonstrate entire C-
spine from sella turcica to top of T1T1spine from sella turcica to top of
– If allall seven cervicalseven cervical vertebrae are notvertebrae are not seen,seen,If
then a swimmer’s view is requiredthen a swimmer’s view is required

39. Lateral Cervical SpineCervical SpineLateral
Patient and IR centered for trauma lateral of C-spineand IR centered for trauma lateral of C-spinePatient

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

41. Swimmer’s (cervicothoracic)(cervicothoracic)Swimmer’s
Required if C7 and top of T1 notC7 and top of T1 not
demonstrated on lateral C-spine
Required if
demonstrated on lateral C-spine
Trauma usually requires dorsal decubitusrequires dorsal decubitusTrauma usually
positionposition
Patient supine withoutsupine without rotation
Ask patient to raise arm opposite the x-ray
rotation
Ask patient to raise arm opposite the x-ray
Patient
tube over headheadtube over
– Assist patientAssist patient and provide supportand provide support

42. Cervicothoracic SpineCervicothoracic Spine
Relax shouldershoulder closercloser to x-rayto x-ray tubetube
Vertical IR centered just above jugular
Relax
Vertical IR centered just above jugular
notchnotch
Horizontal CR centered to C7-T1Horizontal CR centered to C7-T1
interspace and midcoronal planeinterspace and midcoronal plane
Use breathing technique if possiblepossibleUse breathing technique if
– BlurBlur ribs and lung markings to betterribs and lung markings to better
demonstrate spinedemonstrate spine

43. Cervicothoracic SpineCervicothoracic Spine
Image demonstrates lower cervical andcervical and
upper thoracic vertebrae in profile
Image demonstrates lower
upper thoracic vertebrae in profile
between the shouldersbetween the shoulders

44. Cervicothoracic SpineCervicothoracic Spine
Patient and IR positioned for trauma lateral projection of
cervicothoracic vertebrae using dorsal decubitus position

45. Cervicothoracic SpineCervicothoracic Spine
Lateral projection, dorsal decubitus position of cervicothoracic
vertebrae

46. AP Axial CervicalCervical SpineSpineAP Axial
Patient is supineis supinePatient
– UsuallyUsually immobilized with collarimmobilized with collar and spineand spine
boardboard
Place IR under spine board,spine board, ifif present,present,
centered to C4 (Adam’s apple)
Place IR under
centered to C4 (Adam’s apple)
Head and shoulders without rotationwithout rotationHead and shoulders
– Ask patientAsk patient to lookto look straightstraight aheadahead

47. AP Axial CervicalCervical SpineSpineAP Axial
CR directed 15 to 20 degrees cephalad tocephalad toCR directed 15 to 20 degrees
enter MSP atMSP at C4
Image demonstrates C3-T1 or T2,
C4
Image demonstrates C3-T1 or T2,
enter
including all soft tissuestissuesincluding all soft
– IfIf backboard is present,backboard is present, unavoidable artifactsunavoidable artifacts
may be seenmay be seen

48. AP Axial CervicalCervical SpineSpineAP Axial
Patient and IR positioned for trauma AP axial C-spine

49. AP Axial CervicalCervical SpineSpineAP Axial
Trauma AP axial C-spine; complete dislocation at C2-C3

50. AP Axial Oblique Cervical SpineOblique Cervical SpineAP Axial
TRAUMA OBLIQUESTRAUMA OBLIQUES
Patient is supineis supinePatient
– UsuallyUsually immobilized with collarimmobilized with collar and spineand spine
boardboard
Place IR under spine board (notspine board (not bucky),bucky), ififPlace IR under
present, centered to C4 and adjacent
mastoid process
present, centered to C4 and adjacent
mastoid process
– AboutAbout 3′′3′′ laterallateral to MSPto MSP

51. AP Axial Oblique Cervical SpineOblique Cervical SpineAP Axial
Head and shoulders without rotationwithout rotationHead and shoulders
– Ask patientAsk patient to lookto look straightstraight aheadahead
CR has double angleCR has double angle
– 45 degrees45 degrees lateromediallylateromedially
– 15 to 20 degrees15 to 20 degrees cephaliccephalic
CR enters lateral to MSP at level of C4lateral to MSP at level of C4CR enters

52. AP Axial Oblique Cervical SpineOblique Cervical SpineAP Axial
CR exit should be in centershould be in center of IR
Image demonstrates side opposite CR
of IR
Image demonstrates side opposite CR
CR exit
– C1-T1 orC1-T1 or T2 bodies and disk spacesT2 bodies and disk spaces
– IntervertebralIntervertebral foramina openforamina open
– If backboard is present,If backboard is present, unavoidable artifactsunavoidable artifacts
may be seenmay be seen

53. AP Axial Oblique Cervical SpineOblique Cervical SpineAP Axial
Patient and IR positioned for trauma AP axial oblique C-spine

54. AP Axial Oblique Cervical SpineOblique Cervical SpineAP Axial
Trauma AP axial oblique C-spine

55. Thoracic and Lumbar SpineSpineThoracic and Lumbar
X-table laterals performed firstX-table laterals performed first
Vertical grid and IRVertical grid and IR
– Top ofTop of IR 1.5IR 1.5′′ to 2′′ to 2′′ (3.8 to 5 cm)′′ (3.8 to 5 cm) aboveabove
shoulders forfor thoracicthoracic spinespineshoulders
– Centered to level of iliacCentered to level of iliac crests forcrests for lumbarlumbar
spinespine
Have patient crosscross armsarms on anterioron anterior chestchestHave patient

56. Thoracic and Lumbar SpineSpineThoracic and Lumbar
CR horizontalCR horizontal
– Centered to spine and IR
Breathing technique improves
Centered to spine and IR
Breathing technique improves
visualization of thoracic vertebrae
Exposure made on suspended respiration
thoracic vertebrae
Exposure made on suspended respiration
visualization of
for lumbarlumbar vertebraevertebraefor

57. Thoracic and Lumbar SpineSpineThoracic and Lumbar
Thoracic image demonstrates T3 or T4 toT4 toThoracic image demonstrates T3 or
L1
Lumbar image demonstrates T12 to
L1
Lumbar image demonstrates T12 to
sacrum
Vertebral bodies and spinous processes
sacrum
Vertebral bodies and spinous inprocesses in
profileprofile

58. Trauma Lateral Lumbar SpineTrauma Lateral Lumbar Spine
CR and IR positioned for trauma lateral projection of lumbar spine using dorsal
decubitus position

59. Trauma Lateral Lumbar SpineTrauma Lateral Lumbar Spine
Lateral projection of thoracolumbar spine, dorsal decubitus position; note fracture
and dislocation of L2 and spine board artifacts

60. ChestChest
Supine position used if generalgeneral surveysurveySupine position used if
image of chestchest desireddesired
Check for need to demonstrate air-fluid
image of
Check for need to demonstrate air-fluid
levelslevels
– IfIf air-fluid levelsair-fluid levels are suspected,are suspected, use X-tableuse X-table
laterallateral
– IfIf patient’spatient’s condition permits, lateralcondition permits, lateral decubitusdecubitus
position with patient lying on affected side willposition with patient lying on affected side will
also show air-fluid levelsalso show air-fluid levels

61. Trauma AP ChestTrauma AP Chest
Obtain help to lift patientpatient forfor IR placementIR placementObtain help to lift
– Top ofTop of IR placed aboutIR placed about 1.51.5′′ to 2′′ to 2′′ above′′ above
shouldersshoulders
Arms abducted
MCP parallel to IR
Use maximum SID to reduce heart
abducted
MCP parallel to IR
Use maximum SID to reduce heart
magnification
Arms
magnification

62. Trauma AP ChestTrauma AP Chest
Ensure chin extended out ofof anatomyanatomy ofofEnsure chin extended out
interest
CR directed perpendicular to center of
interest
CR directed perpendicular to center IRof IR
– look forlook for lightlight field slightlyfield slightly above shoulders andabove shoulders and
on sides of chest, CW or LWLWon sides of chest, CW or
Exposure made upon second fullExposure made upon second full
inhalation, ifif possiblepossibleinhalation,

64. Trauma AP ChestTrauma AP Chest
Image demonstrates lung fields in theirin theirImage demonstrates lung fields
entiretyentirety
– MinimalMinimal rotation and distortion presentrotation and distortion present

67. AbdomenAbdomen
If transfertransfer to x-rayto x-ray table is not possible,table is not possible,
obtain lift help for IR placement
If
obtain lift help for IR placement
IR centered to MSP at level oflevel of iliaciliac crests
Check for possibility of fluid accumulation
crests
Check for possibility of fluid accumulation
in abdominal cavity
IR centered to MSP at
in abdominal cavity
– AffectsAffects exposure factorsexposure factors
– RequiresRequires close monitoring ofclose monitoring of patientpatient forfor statusstatus
change during procedureschange during procedures

68. AbdomenAbdomen
Mark entrance and exit wounds,entrance and exit wounds, ifif presentpresentMark
Align shoulders and hips in same planeAlign shoulders and hips in same plane
MCP parallel to tableMCP parallel to table
CR perpendicular to centerto center ofof IR
Image demonstrates entire abdomen with
IR
Image demonstrates entire abdomen with
CR perpendicular
pubic symphysis visible at lower borderborderpubic symphysis visible at lower

70. PelvisPelvis
Pelvic fractures have a high riskfractures have a high risk ofof
hemorrhage – pay close attention to
Pelvic
hemorrhage – pay close attention to
patient for statusstatus changechangepatient for
Obtain lift help for IR placement ifIR placement if transfertransferObtain lift help for
to x-ray table is not possiblepossible
IR centered 2′′ above pubic symphysis or
to x-ray table is not
IR centered 2′′ above pubic symphysis or
2′′ below ASIS2′′ below ASIS
MCP parallel to IRMCP parallel to IR

71. PelvisPelvis
Lower limbslimbs internally rotated only ifinternally rotated only ifLower
possible
Ensure arms are not in anatomy
possible
Ensure arms of interestinterestare not in anatomy of
CR perpendicular to centerto center ofof IR
Exposure made on suspended respiration
IR
Exposure made on suspended respiration
CR perpendicular
Image demonstrates entire pelvis and
proximal femora
Image demonstrates entire pelvis and
proximal femora

72. Trauma AP PelvisTrauma AP Pelvis
Trauma AP pelvis; note fracture of left ilium and separation of pubic bones

74. CraniumCranium
Patients with head trauma are oftenwith head trauma are often
referred to CT first
Patients
referred to CT first
When x-rays are ordered,When x-rays are ordered, a generala general
survey requires AP and lateral projectionssurvey requires AP and lateral projections
Generally, the patientthe patient is supineis supineGenerally,
– LateralLateral projection uses dorsalprojection uses dorsal decubitusdecubitus
positionposition

75. Trauma Lateral CraniumTrauma Lateral Cranium
Elevate head on radiolucent supportElevate head on radiolucent support
– Ensure C-spine injury hasEnsure C-spine injury has been ruled outbeen ruled out

76. Trauma Lateral CraniumTrauma Lateral Cranium
Trauma lateral projection of cranium; note multiple fractures in frontal bone

77. Trauma AP CraniumTrauma AP Cranium
Check with physician to determineCheck with physician to determine
anatomy of interestof interestanatomy
– AP projection demonstratesAP projection demonstrates anterioranterior craniumcranium
– AP axial projection (Towne) demonstratesAP axial projection (Towne) demonstrates
posterior craniumcraniumposterior

78. Trauma CraniumTrauma Cranium
Patient and IR positioned for
trauma AP cranium
Patient and IR positioned for
trauma AP axial cranium

79. Trauma AP CraniumTrauma AP Cranium
Trauma AP cranium; note fracture line

80. Facial BonesBonesFacial
Patients with facialwith facial bone injuriesbone injuries are oftenare oftenPatients
referred to CT first
Anticipate profuse bleeding and use
universal precautions
referred to CT first
Anticipate profuse bleeding and use
universal precautions

82. Upper and Lowerand Lower LimbsLimbsUpper
Obtain lift help forhelp for IR placementIR placement
Injured limbs should be lifted with support
Obtain lift
Injured limbs should be lifted with support
at both jointsat both joints
– LiftLift only enough to place IRonly enough to place IR
Two projections at 90 degrees from eachTwo projections at 90 degrees from each
other requiredother required
– Do not attempt to rotate severely injured limbsDo not attempt to rotate severely injured limbs
for true positionsfor true positions

85. Upper and Lowerand Lower LimbsLimbsUpper
Long bones require demonstration ofrequire demonstration of
adjacent joints
Long bones
adjacent joints
– Take separate projections,Take separate projections, ifif necessarynecessary
Maximize patient safetysafety and comfortand comfort byby
moving IR and CR, rather than injured
Maximize patient
moving IR and CR, rather than injured
limblimb

89. Other Imaging Procedures inOther Imaging Procedures in
TraumaTrauma
Slide 96

90. Other Imaging in TraumaOther Imaging in Trauma
CT is extensively used in trauma patientsextensively used in trauma patientsCT is
– Often,Often, CT isCT is modalitymodality ofof choicechoice
Angiography may be used for vascularvascularAngiography may be used for
injuries
Contrast
injuries
studies are often ordered forContrast studies are often ordered for
evaluation of urinary systemevaluation of urinary system
– BluntBlunt abdominalabdominal trauma and suspected pelvictrauma and suspected pelvic
fractures often resultoften result in injury to urinaryin injury to urinaryfractures
systemsystem

91. Time for the “good stuff”!the “good stuff”!Time for

99. Thankyou
Nitish Virmani