The document discusses trauma radiography procedures and best practices. It outlines the different levels of trauma centers and describes specialized equipment used in trauma imaging. Key responsibilities of the radiographer are to perform diagnostic imaging quickly and accurately while prioritizing patient safety and ethical practices. Standard trauma projections are described for various body regions as well as considerations for patient positioning and immobilization.

1. Chapter 13 Trauma Radiography Heather Johnson, A.S., R.T. (R)

2. Trauma 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 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

5. Trauma 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

6. Introduction Trauma is defined as a sudden, unexpected, dramatic, forceful, or violent event Blunt, penetrating, explosive, and thermal forces are common causes of traumatic injuries

9. Introduction Trauma affects persons in all age ranges Radiographers in the emergency department (ED) must be prepared for a variety of procedures on patients in all age groups

11. Preliminary Considerations Specialized trauma imaging systems reduce the amount of time required to obtain diagnostic images One type provides greater flexibility in IR/CR maneuverability Another type scans the entire body in a few seconds

13. STATSCAN

16. Mobile radiography is often used for ED procedures

17. Preliminary Considerations Mobile fluoroscopy units, or C-arms, may be used in fracture reduction or foreign body localizations Immobilization devices are a necessity in trauma imaging Trauma patients often cannot hold the required position

18. Radiographer’s Role in Trauma Depends upon department protocol and staffing Primary responsibilities Perform quality diagnostic imaging procedures Practice ethical radiation protection Provide patient care

19. Radiographer’s Role in Trauma Patient level of consciousness changes are common in trauma

20. “ Best Practices” in Trauma Radiography Speed Efficiency in producing quality images in the shortest possible time Accuracy Optimum image quality, minimum repeats Quality Quality cannot be sacrificed for speed Do not use patient condition as an excuse for poor quality images

21. “ Best Practices” in Trauma Radiography Positioning Important not to aggravate patient’s condition when obtaining images Move tube and IR, instead of patient, whenever possible Practice standard precautions Expect to be exposed to body fluids in ED Do not touch a patient without gloves!

22. Disclaimer: The following three slides are gruesome.

26. “ Best Practices” in Trauma Radiography Anticipation Some injuries require follow-up procedures; knowing what to do increases appreciation for radiographer’s role in ED

27. “ Best Practices” in Trauma Radiography Attention to detail Pay careful attention to patient’s condition, which could change at any time Attention to ED protocol and scope of practice Know the protocol and scope of practice in your facility Professionalism Adhere to Code of Ethics

28. Radiographic Procedures in Trauma Slide

29. General Procedural Guidelines Slide

30. General Procedural Guidelines Patient preparation IR size SID ID markers Radiation protection Patient instructions Immobilization Documentation Image critique

31. Patient Preparation Use good communication skills with appropriate touch and eye contact Trauma often causes anxiety Check patient for potential artifacts Explain what you are removing and why Secure all personal effects using proper procedure for your facility

32. IR Size IR size for trauma procedures are the same as for routine procedures Use smallest IR that will demonstrate anatomy Collimate field size to anatomy of interest

33. SID SID is standardized as a part of procedural protocol When SID is not specified under a projection, 40 to 48  60 to 72  SID recommended for projections with increased OID

34. ID Markers Right or left side markers must be included on each image Other required ID markers must be in the blocker or elsewhere on the final image Markers used for penetrating trauma to identify entrance and exit wounds

36. Just Kidding…..

37. Radiation Protection Shield pediatric patients and patients of reproductive age Warn other staff of exposure when performing mobile imaging Other radiation protection measures Close collimation Optimum technique factors

38. Patient Instructions Explain and demonstrate positions, when possible Explain respiration instructions for patients who can cooperate Use short exposure times to eliminate possibility of imaging motion

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

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

43. Image Critique Criteria Image evaluation for trauma procedures is the same as for routine procedures Image quality is critical for an accurate diagnosis It is poor practice to accept lower quality images due to patient condition or difficulty of procedure

44. Trauma Projections

45. Lateral Cervical Spine Horizontal CR centered to midpoint of IR Pre-vertebral soft tissue must be visualized Image should demonstrate entire C-spine from sella turcica to top of T1 If all seven cervical vertebrae are not seen, then a swimmer’s view is required

46. Lateral Cervical Spine Patient and IR centered for trauma lateral of C-spine

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

48. Swimmer’s (cervicothoracic) Required if C7 and top of T1 not demonstrated on lateral C-spine Trauma usually requires dorsal decubitus position Patient supine without rotation Ask patient to raise arm opposite the x-ray tube over head Assist patient and provide support

49. Cervicothoracic Spine Relax shoulder closer to x-ray tube Vertical IR centered just above jugular notch Horizontal CR centered to C7-T1 interspace and midcoronal plane Use breathing technique if possible Blur ribs and lung markings to better demonstrate spine

50. Cervicothoracic Spine Image demonstrates lower cervical and upper thoracic vertebrae in profile between the shoulders

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

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

53. AP Axial Cervical Spine Patient is supine Usually immobilized with collar and spine board Place IR under spine board, if present, centered to C4 (Adam’s apple) Head and shoulders without rotation Ask patient to look straight ahead

54. AP Axial Cervical Spine CR directed 15 to 20 degrees cephalad to enter MSP at C4 Image demonstrates C3-T1 or T2, including all soft tissues If backboard is present, unavoidable artifacts may be seen

55. AP Axial Cervical Spine Patient and IR positioned for trauma AP axial C-spine

56. AP Axial Cervical Spine Trauma AP axial C-spine; complete dislocation at C2-C3

57. AP Axial Oblique Cervical Spine TRAUMA OBLIQUES Patient is supine Usually immobilized with collar and spine board Place IR under spine board (not bucky), if present, centered to C4 and adjacent mastoid process About 3  lateral to MSP

58. AP Axial Oblique Cervical Spine Head and shoulders without rotation Ask patient to look straight ahead CR has double angle 45 degrees lateromedially 15 to 20 degrees cephalic CR enters lateral to MSP at level of C4

59. AP Axial Oblique Cervical Spine CR exit should be in center of IR Image demonstrates side opposite CR C1-T1 or T2 bodies and disk spaces Intervertebral foramina open If backboard is present, unavoidable artifacts may be seen

60. AP Axial Oblique Cervical Spine Patient and IR positioned for trauma AP axial oblique C-spine

61. AP Axial Oblique Cervical Spine Trauma AP axial oblique C-spine

62. Thoracic and Lumbar Spine X-table laterals performed first Vertical grid and IR Top of IR 1.5  to 2  (3.8 to 5 cm) above shoulders for thoracic spine Centered to level of iliac crests for lumbar spine Have patient cross arms on anterior chest

63. Thoracic and Lumbar Spine CR horizontal Centered to spine and IR Breathing technique improves visualization of thoracic vertebrae Exposure made on suspended respiration for lumbar vertebrae

64. Thoracic and Lumbar Spine Thoracic image demonstrates T3 or T4 to L1 Lumbar image demonstrates T12 to sacrum Vertebral bodies and spinous processes in profile

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

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

67. Chest Supine position used if general survey image of chest desired Check for need to demonstrate air-fluid levels If air-fluid levels are suspected, use X-table lateral If patient’s condition permits, lateral decubitus position with patient lying on affected side will also show air-fluid levels

68. Trauma AP Chest Obtain help to lift patient for IR placement Top of IR placed about 1.5  to 2  above shoulders Arms abducted MCP parallel to IR Use maximum SID to reduce heart magnification

69. Trauma AP Chest Ensure chin extended out of anatomy of interest CR directed perpendicular to center of IR look for light field slightly above shoulders and on sides of chest, CW or LW Exposure made upon second full inhalation, if possible

71. Trauma AP Chest Image demonstrates lung fields in their entirety Minimal rotation and distortion present

74. Abdomen If transfer to x-ray table is not possible, obtain lift help for IR placement IR centered to MSP at level of iliac crests Check for possibility of fluid accumulation in abdominal cavity Affects exposure factors Requires close monitoring of patient for status change during procedures

75. Abdomen Mark entrance and exit wounds, if present Align shoulders and hips in same plane MCP parallel to table CR perpendicular to center of IR Image demonstrates entire abdomen with pubic symphysis visible at lower border

77. Pelvis Pelvic fractures have a high risk of hemorrhage – pay close attention to patient for status change Obtain lift help for IR placement if transfer to x-ray table is not possible IR centered 2  above pubic symphysis or 2  below ASIS MCP parallel to IR

78. Pelvis Lower limbs internally rotated only if possible Ensure arms are not in anatomy of interest CR perpendicular to center of IR Exposure made on suspended respiration Image demonstrates entire pelvis and proximal femora

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

81. Cranium Patients with head trauma are often referred to CT first When x-rays are ordered, a general survey requires AP and lateral projections Generally, the patient is supine Lateral projection uses dorsal decubitus position

82. Trauma Lateral Cranium Elevate head on radiolucent support Ensure C-spine injury has been ruled out

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

84. Trauma AP Cranium Check with physician to determine anatomy of interest AP projection demonstrates anterior cranium AP axial projection (Towne) demonstrates posterior cranium

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

86. Trauma AP Cranium Trauma AP cranium; note fracture line

87. Facial Bones Patients with facial bone injuries are often referred to CT first Anticipate profuse bleeding and use universal precautions

89. Upper and Lower Limbs Obtain lift help for IR placement Injured limbs should be lifted with support at both joints Lift only enough to place IR Two projections at 90 degrees from each other required Do not attempt to rotate severely injured limbs for true positions

92. Upper and Lower Limbs Long bones require demonstration of adjacent joints Take separate projections, if necessary Maximize patient safety and comfort by moving IR and CR, rather than injured limb

96. Other Imaging Procedures in Trauma Slide

97. Other Imaging in Trauma CT is extensively used in trauma patients Often, CT is modality of choice Angiography may be used for vascular injuries Contrast studies are often ordered for evaluation of urinary system Blunt abdominal trauma and suspected pelvic fractures often result in injury to urinary system

99. Time for the “good stuff”!