Trauma Imaging Protocols

Trauma Imaging Protocols - Code Red First Scans

• eFAST (Extended Focused Assessment with Sonography for Trauma)

  • Views: Pericardial (subxiphoid), RUQ (hepatorenal), LUQ (splenorenal), Pelvic (suprapubic), Anterior thoracic (lung sliding).
  • Detects: Free fluid (pericardial, pleural, peritoneal, pelvic), pneumothorax.
  • 📌 Mnemonic (FAST views): "Right Upper, Left Upper, Pelvic, Cardiac" (RUQ, LUQ, Pelvic, Subxiphoid).

  ⭐ eFAST: High specificity (95-100%) for intraperitoneal free fluid (detects ≥100-200 ml).

• Chest X-ray (CXR - AP Supine)

  • Assess: Lines/tubes, pneumothorax, hemothorax, widened mediastinum (>8 cm), rib fractures, pulmonary contusion.

• Pelvis X-ray (AP View)

  • Indications: Pelvic pain/instability, altered sensorium, distracting injury.
  • Look for: Fractures (e.g., pubic rami, SI joint disruption), malalignment.

• Other Portable X-rays (if CT delayed/unavailable)

  • C-spine: Lateral view (must see C7-T1).
  • Extremities: Based on clinical findings for suspected fractures.

Trauma Imaging Protocols - Pan-Scan Power Play

• Whole-Body CT (WBCT) / Pan-Scan: Rapid, comprehensive CT for major trauma.
• Indications:
  • High-energy trauma (e.g., fall >5m, RTC >60km/hr)
  • Multiple injuries (≥2 body regions)
  • Altered sensorium (GCS <13)
  • Unstable but transient responder to resuscitation
  • Specific injury patterns (e.g., seatbelt sign)
• Protocol Components:
  • NCCT Head & C-spine
  • CECT Chest (arterial phase)
  • CECT Abdomen & Pelvis (portal venous phase; consider arterial for active bleed, delayed for urothelial injury)
• Advantages: Rapid assessment, ↓ time to diagnosis, potential improved survival in select polytrauma.
• Disadvantages: Radiation (effective dose ~10-25 mSv), contrast risks (CIN, allergic reaction), potential over-investigation.

⭐ WBCT is associated with a survival benefit in patients with severe trauma (Injury Severity Score ISS > 15).

Trauma Imaging Protocols - Injury Zone Imaging

• Head Trauma:
  • NCCT Head: Key for EDH, SDH, SAH, IVH, contusions, DAI signs.
  • CT Angio/Venography: Indicated for suspected vascular injury (e.g., dissection, occlusion with specific fracture patterns like skull base #, penetrating trauma).
• Spine Trauma:
  • CT C-spine, T-spine, L-spine: Indications based on NEXUS/Canadian C-Spine rules (CCR) 📌.
  • MRI: For neurological deficit unexplained by CT, suspected ligamentous injury, spinal cord injury (SCI), epidural hematoma.
  • Cervical Spine Clearance Algorithm:

• Thoracic Trauma:
  • Beyond initial CECT chest: CT Aortogram for suspected traumatic aortic injury (mediastinal hematoma, abnormal aortic contour, intimal flap).
• Abdominal/Pelvic Trauma:
  • Triple Contrast CT (oral, rectal, IV): Consider for suspected bowel/hollow viscus injury (less common now).
  • CT Cystography (direct contrast instillation): For suspected bladder rupture.

⭐ The most common site of traumatic aortic injury is the aortic isthmus, typically just distal to the origin of the left subclavian artery.

Trauma Imaging Protocols - Special Cases & Safety

• Contrast Media in Trauma:
  • IV iodinated contrast for CECT: assess solid organ/vascular injury, active bleeding.
  • Risks: Contrast-Induced Nephropathy (CIN), allergic reactions (premedicate if prior history), manage extravasation.
• Pediatric Trauma Imaging:
  • Adhere to Image Gently & ALARA principles.
  • Prioritize USS/MRI; use age/weight-adjusted CT protocols (↓kVp, ↓mAs); consider focused CT.

  ⭐ In pediatric trauma, the 'Image Gently' campaign emphasizes dose reduction strategies without compromising diagnostic quality.

• Pregnant Trauma Patients:
  • Maternal life is priority; shield fetus when possible.
  • USS/MRI preferred; CT justified if benefits outweigh risks; counsel patient.
  • Fetal radiation effects: dose/gestation-dependent (threshold >50-100 mGy).
• Radiation Safety:
  • Justification (is scan necessary?) & Optimization (ALARA - as low as reasonably achievable).
  • Awareness of cumulative radiation dose.

High‑Yield Points - ⚡ Biggest Takeaways

• ABCDE approach dictates trauma imaging priorities.
• eFAST is key for initial assessment of hemoperitoneum and pneumothorax in unstable patients.
• Whole-Body CT (WBCT) is preferred for stable polytrauma patients.
• CT C-spine is superior to X-ray; use NEXUS/Canadian C-Spine Rule for clearance.
• CECT is essential for organ/vascular injury and detecting active bleeding.
• X-rays remain useful for extremity fractures and initial chest/pelvis views.
• Rapid imaging protocols are crucial for timely intervention.