András Palkó Department of Radiology, University of Szeged, Hungary MDCT PROTOCOLS FOR POLYTRAUMA PATIENTS
BCR 2017, Budapest Agenda � Definition and significance � Clinical implications � Role of imaging � Examination protocols � Challenges � Conclusion Department of Radiology, University of Szeged, Hungary 2
BCR 2017, Budapest Agenda � Definition and significance � Clinical implications � Role of imaging � Examination protocols � Challenges � Conclusion Department of Radiology, University of Szeged, Hungary 3
BCR 2017, Budapest Definition � Etymology (Greek): poly (multiple) + trauma (wounds) � A significant injury in at least two out of the following six body regions: � Head, neck, and cervical spine � Face � Chest and thoracic spine � Abdomen and lumbar spine � Limbs and bony pelvis � External (skin) � Syndrome of multiple injuries of different anatomical regions with consecutive systemic reactions, which may lead to dysfunction of remote organs. F. Gebhard et al, LangenbecksArch Surg (2008) 393:825–831 Lecky FE et al, in: H.-C. Pape et al. (eds.), Damage Control Department of Radiology, University of Szeged, Hungary Management in the Polytrauma Patient, Springer, 2010 4
BCR 2017, Budapest Significance � Injury is a global pandemic and the most frequent cause of death < 45 http://www.cdc.gov/injury/wisqars. 2007 Department of Radiology, University of Szeged, Hungary 5
BCR 2017, Budapest External injury standardised death rates / 100 000 male http://www.euro.who.int/eprise/main/WHO/InformationSources/Data/2005117 Department of Radiology, University of Szeged, Hungary 6
BCR 2017, Budapest Mortality 1st peak • Within minutes (major vascular and CNS injuries) • Medical intervention is rarely successful 2nd peak • Within the first (“golden“) hour (intracranial bleeding, major chest/abdominal injury) • Primary focus of Advanced Trauma Life Support (ATLS) 3rd peak • After days/weeks Department of Radiology, University of Szeged, Hungary 7
BCR 2017, Budapest Patterns of injury and mortality in polytrauma Lecky FE et al, in: H.-C. Pape et al. (eds.), Damage Control Management in the Polytrauma Patient, Springer, 2010 Department of Radiology, University of Szeged, Hungary 8
BCR 2017, Budapest Patterns of injury and mortality in polytrauma Lecky FE et al, in: H.-C. Pape et al. (eds.), Damage Control Management in the Polytrauma Patient, Springer, 2010 Department of Radiology, University of Szeged, Hungary 9
BCR 2017, Budapest Agenda � Definition and significance � Clinical implications � Role of imaging � Examination protocols � Challenges � Conclusion Department of Radiology, University of Szeged, Hungary 10
BCR 2017, Budapest What is to be done � Patient requires a timely and effective management in order to avoid the deathly spiral of severe systemic complications: � prolonged haemorrhagic shock � systemic inflammatory response syndrome (SIRS) � multiple organ dysfunction syndrome (MODS) F. Gebhard et al, Langenbecks Arch Surg (2008) 393:825–831 Department of Radiology, University of Szeged, Hungary 11
BCR 2017, Budapest Abbreviated Injury Scale (AIS) Anatomy-based scoring system, considering injuries of all major body regions Minor 1 Moderate 2 Serious 3 Severe 4 Critical 5 Maximal (currently untreatable) 6 Department of Radiology, University of Szeged, Hungary 12
BCR 2017, Budapest Injury Severity Score � ISS = A 2 + B 2 + C 2 , (A, B, C = the AIS scores of the three most severely injured regions) � Severe > 15 13 Department of Radiology, University of Szeged, Hungary
BCR 2017, Budapest Injury Severity Score 14 Department of Radiology, University of Szeged, Hungary
BCR 2017, Budapest Dilemma � Selective nonsurgical management is safe and cost- effective, if the diagnosis is fast and accurate BUT � identification of serious pathology is challenging � may not manifest during the initial assessment � associated injuries may divert attention � clinical examination is notoriously unreliable Soto JA, Anderson SW, Radiology: 265, 2012 Department of Radiology, University of Szeged, Hungary 15
BCR 2017, Budapest Diagnosis Department of Radiology, University of Szeged, Hungary 16
BCR 2017, Budapest Agenda � Definition and significance � Clinical implications � Role of imaging � Examination protocols � Challenges � Conclusion Department of Radiology, University of Szeged, Hungary 17
BCR 2017, Budapest Role of imaging � To detect: � injuries + immediate and late complications � To provide the fastest possible diagnosis in order to start therapy ASAP to decrease mortality Department of Radiology, University of Szeged, Hungary 18
BCR 2017, Budapest Keep in mind � Triage (NISS, GCS, etc.) � Algor i thm and technique of imaging depend on haemodynamic stability and associated injuries � Timing: lifesaving interventions should not be impeded Department of Radiology, University of Szeged, Hungary 19
BCR 2017, Budapest Diagnostic algorithm � (clinical examination, triage) � Plain X-ray � abdomen and pelvis � c hest � Ultrasound – FAST + diagnostic � Computed tomography http://www.acr.org/Quality-Safety/Appropriateness-Criteria, 2012 Department of Radiology, University of Szeged, Hungary 20
BCR 2017, Budapest Diagnostic algorithm � (clinical examination, triage) � Plain X-ray � abdomen and pelvis � c hest � Ultrasound – FAST + diagnostic � Computed tomography http://www.acr.org/Quality-Safety/Appropriateness-Criteria, 2012 Department of Radiology, University of Szeged, Hungary 21 21
BCR 2017, Budapest Why MDCT? � Fastest „single best” modality: simultaneous evaluation of parenchymal organs – hollow viscerae – CNS – bones – vessels + extravasation, leakage – etc. – � Limitation: � lack of sensitivity in diagnosing mesenteric, hollow visceral and diaphragmatic injuries; � motion artefacts; � access to the patient Department of Radiology, University of Szeged, Hungary 22
BCR 2017, Budapest Indications of MDCT � Haemodynamic instability � Obvious severe injury on clinical assessment � Abdominal fluid by FAST � Suspicion of occult, severe injury by clinical examination Whole body MDCT is the default procedure of choice Standards of practice and guidance of trauma radiology in the severely injured patient (RCR) 23 Department of Radiology, University of Szeged, Hungary
BCR 2017, Budapest Agenda � Definition and significance � Clinical implications � Role of imaging � Examination protocols � Challenges � Conclusion Department of Radiology, University of Szeged, Hungary 24
NON-CONTRAST PRIMARY SURVEY
BCR 2017, Budapest Non-contrast primary survey � Haemodynamically instable patient � Scan directly: thigh to head – reconstruct 3-5 mm axials � Immediate monitor reading � A, B2, C � A – airway � B2 – breathing, brain � C – circulation / source of bleeding Transform the scanner room into Trauma Bay Zero S. Nicolaou et al. / European Journal of Radiology 68 (2008) 398–408 Department of Radiology, University of Szeged, Hungary 26
BCR 2017, Budapest Department of Radiology, University of Szeged, Hungary 27
BCR 2017, Budapest Department of Radiology, University of Szeged, Hungary 28
COMPREHENSIVE POLYTRAUMA SCANNING
BCR 2017, Budapest Scanning protocol @ 64 � Patient position: supine, hands up/down � Scanning direction: cephalocaudal � Tube voltage: 120 – 140 kVp w. AEC � Auto mA range: 100 – 700 � Collimation : 0.625 – 1.25 mm � Pitch: 1.375 � Primary reconstruction: � Slice thickness: 3/5 mm (+ 0,625 for 3D, MPR) � FOV: adjusted to body habitus Department of Radiology, University of Szeged, Hungary 30
BCR 2017, Budapest Contrast administration protocol - Iodine � Concentration: 350 – 400 mg/mL � Volume (extracellular enhancement): 80 – 150 mL � Flow (bolus geometry – vessels): � Biphasic 6 mL/sec + 4 mL/sec � Monophasic 2.5 – 4 mL/sec Department of Radiology, University of Szeged, Hungary 31
BCR 2017, Budapest Contrast administration protocol – saline flush � Volume: 30 – 50 mL � Flow: 2,5 – 3 mL/sec Department of Radiology, University of Szeged, Hungary 32
BCR 2017, Budapest Contrast administration protocol – scan delay � Single vs. double vs. triple phase � Single phase delay: � Fixed (pt < 50) vs. bolus triggering (pt > 50) � Angio / arterial bleeding: 18 sec or 90 HU @ aortic arch � General: 35 sec or 100 HU @ AA � Parenchymal organ / veins: 60 – 75 sec or 70 HU @ liver � Delayed scans: 3 – 5 min Department of Radiology, University of Szeged, Hungary 33
BCR 2017, Budapest Pseudoaneurysm Boscak AR et al, Radiology 268:79-88, 2013 Department of Radiology, University of Szeged, Hungary 34
BCR 2017, Budapest Active bleeding Department of Radiology, University of Szeged, Hungary 35
BCR 2017, Budapest Contrast administration protocol – GI tract � None � Oral only � Rectal only � Oral and rectal Department of Radiology, University of Szeged, Hungary 36
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