trauma radiography
TRANSCRIPT
Chapter 13Chapter 13Trauma RadiographyTrauma Radiography
Heather Johnson, A.S., R.T. (R)
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.
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
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
IntroductionIntroduction
Trauma is defined as a sudden, Trauma is defined as a sudden, unexpected, dramatic, forceful, or violent unexpected, dramatic, forceful, or violent eventevent
Blunt, penetrating, explosive, and thermalBlunt, penetrating, explosive, and thermal forces are common causes of traumatic forces are common causes of traumatic injuriesinjuries
IntroductionIntroduction
Trauma affects persons in all age rangesTrauma affects persons in all age ranges
Radiographers in the emergency Radiographers in the emergency department (ED) must be prepared for a department (ED) must be prepared for a variety of procedures on patients in all age variety of procedures on patients in all age groupsgroups
Preliminary ConsiderationsPreliminary Considerations
Specialized trauma imaging systems Specialized trauma imaging systems reduce the amount of time required to reduce the amount of time required to obtain diagnostic imagesobtain diagnostic images– One type provides greater flexibility in IR/CR One type provides greater flexibility in IR/CR
maneuverabilitymaneuverability– Another type scans the entire body in a few Another type scans the entire body in a few
secondsseconds
STATSCAN
Mobile radiography is often used for ED Mobile radiography is often used for ED proceduresprocedures
Preliminary ConsiderationsPreliminary Considerations
Mobile fluoroscopy units, or C-arms, may Mobile fluoroscopy units, or C-arms, may be used in fracture reduction or foreign be used in fracture reduction or foreign body localizationsbody localizations
Immobilization devices are a necessity in Immobilization devices are a necessity in trauma imagingtrauma imaging– Trauma patients often cannot hold the Trauma patients often cannot hold the
required positionrequired position
Radiographer’s Role in TraumaRadiographer’s Role in Trauma
Depends upon department protocol and Depends upon department protocol and staffingstaffing
Primary responsibilitiesPrimary responsibilities– Perform quality diagnostic imaging Perform quality diagnostic imaging
proceduresprocedures– Practice ethical radiation protectionPractice ethical radiation protection– Provide patient careProvide patient care
Radiographer’s Role in TraumaRadiographer’s Role in Trauma
Patient Patient level of consciousnesslevel of consciousness changes changes are common in traumaare common in trauma
““Best Practices” in Trauma Best Practices” in Trauma RadiographyRadiography
SpeedSpeed– Efficiency in producing quality images in the Efficiency in producing quality images 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 for Do not use patient condition as an excuse for
poor quality imagespoor quality images
““Best Practices” in Trauma Best Practices” in Trauma RadiographyRadiography
PositioningPositioning– Important not to aggravate patient’s condition Important not to 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 body fluids in EDExpect to be exposed to body fluids in ED– Do not touch a patient without gloves!Do not touch a patient without gloves!
Disclaimer:Disclaimer:The following three slides are The following three slides are
gruesome.gruesome.
““Best Practices” in Trauma Best Practices” in Trauma RadiographyRadiography
AnticipationAnticipation– Some injuries require follow-up procedures; Some injuries require follow-up procedures;
knowing what to do increases appreciation for knowing what to do increases appreciation for radiographer’s role in EDradiographer’s role in ED
““Best Practices” in Trauma Best Practices” in Trauma RadiographyRadiography
Attention to detailAttention to detail– Pay careful attention to patient’s condition, Pay careful attention to patient’s condition,
which could change at any timewhich could change at any time
Attention to ED protocol and scope of Attention to ED protocol and scope of practicepractice– Know the protocol and scope of practice in Know the protocol and scope of practice in
your facilityyour facility
ProfessionalismProfessionalism– Adhere to Code of EthicsAdhere to Code of Ethics
Radiographic Procedures in Radiographic Procedures in TraumaTrauma
Slide 28
General Procedural General Procedural GuidelinesGuidelines
Slide 29
General Procedural GuidelinesGeneral Procedural Guidelines
Patient preparationPatient preparation
IR sizeIR size
SIDSID
ID markersID markers
Radiation Radiation protectionprotection
Patient instructionsPatient instructions
ImmobilizationImmobilization
DocumentationDocumentation
Image critiqueImage critique
Patient PreparationPatient Preparation
Use good communication skills with Use good communication skills with appropriate touch and eye contactappropriate touch and eye contact– Trauma often causes anxietyTrauma often causes anxiety
Check patient for potential artifactsCheck patient for potential artifacts– Explain what you are removing and whyExplain what you are removing and why– Secure all personal effects using proper Secure all personal effects using proper
procedure for your facilityprocedure for your facility
IR SizeIR Size
IR size for trauma procedures are the IR size for trauma procedures are the same as for routine proceduressame as for routine procedures
Use smallest IR that will demonstrate Use smallest IR that will demonstrate anatomyanatomy
Collimate field size to anatomy of interestCollimate field size to anatomy of interest
SIDSID
SID is standardized as a part of procedural SID is standardized as a part of procedural protocolprotocol– When SID is not specified under a projection, When SID is not specified under a projection,
40 to 4840 to 48– 60 to 7260 to 72 SID recommended for projections SID recommended for projections
with increased OIDwith increased OID
ID MarkersID Markers
Right or left side markers must be included Right or left side markers must be included on each imageon each image
Other required ID markers must be in the Other required ID markers must be in the blocker or elsewhere on the final imageblocker or elsewhere on the final image
Markers used for penetrating trauma to Markers used for penetrating trauma to identify entrance and exit woundsidentify entrance and exit wounds
Just Kidding…..
Radiation ProtectionRadiation Protection
Shield pediatric patients and patients of Shield pediatric patients and patients of reproductive age reproductive age
Warn other staff of exposure when Warn other staff of exposure when performing mobile imagingperforming mobile imaging
Other radiation protection measuresOther radiation protection measures– Close collimation Close collimation – Optimum technique factors Optimum technique factors
Patient InstructionsPatient Instructions
Explain and demonstrate positions, when Explain and demonstrate positions, when possible possible
Explain respiration instructions for patients Explain respiration instructions for patients who can cooperatewho can cooperate
Use short exposure times to eliminate Use short exposure times to eliminate possibility of imaging motionpossibility of imaging motion
ImmobilizationImmobilization
Many ED patients arrive in some sort of Many ED patients arrive in some sort of immobilization deviceimmobilization device
Immobilization devices are Immobilization devices are notnot to be to be removed unless ordered by a physicianremoved unless ordered by a physician
Imaging procedures are often performed Imaging procedures are often performed without removal of the immobilizationwithout removal of the immobilization
Images are used to rule out injury and Images are used to rule out injury and show if it is safe to remove immobilizationshow if it is safe to remove immobilization
DocumentationDocumentation
Because deviation or adjustment of routine Because deviation or adjustment of routine procedures is often required to procedures is often required to accommodate a patient’s injury, accommodate a patient’s injury, documentation is importantdocumentation is important
Make sure that deviation from routine is Make sure that deviation from routine is still within your scope of practice!still within your scope of practice!
Document deviation (AP, X-table, etc.), Document deviation (AP, X-table, etc.), time, portabletime, portable
Image Critique CriteriaImage Critique Criteria
Image evaluation for trauma procedures is Image evaluation for trauma procedures is the same as for routine proceduresthe same as for routine procedures
Image quality is critical for an accurate Image quality is critical for an accurate diagnosisdiagnosis
It is poor practice to accept lower quality It is poor practice to accept lower quality images due to patient condition or difficulty images due to patient condition or difficulty of procedureof procedure
Trauma ProjectionsTrauma Projections
Lateral Cervical SpineLateral Cervical Spine
Horizontal CR centered to midpoint of IRHorizontal CR centered to midpoint of IR
Pre-vertebral soft tissue must be Pre-vertebral soft tissue must be visualizedvisualized
Image should demonstrate entire C-Image should demonstrate entire C-spine from sella turcica to top of T1spine from sella turcica to top of T1
– If all seven cervical vertebrae are not seen, If all seven cervical vertebrae are not seen, then a swimmer’s view is requiredthen a swimmer’s view is required
Lateral Cervical SpineLateral Cervical Spine
Patient and IR centered for trauma lateral of C-spinePatient and IR centered for trauma lateral of C-spine
Lateral Cervical SpineLateral Cervical Spine
Lateral projection of C-spine in dorsal decubitus position; dislocation of C3-C4; C7 not demonstrated, so Lateral projection of C-spine in dorsal decubitus position; dislocation of C3-C4; C7 not demonstrated, so swimmer’s view is neededswimmer’s view is needed
Swimmer’s (cervicothoracic)Swimmer’s (cervicothoracic)
Required if C7 and top of T1 not Required if C7 and top of T1 not demonstrated on lateral C-spinedemonstrated on lateral C-spine
Trauma usually requires dorsal decubitus Trauma usually requires dorsal decubitus positionposition
Patient supine without rotationPatient supine without rotation
Ask patient to raise arm opposite the x-ray Ask patient to raise arm opposite the x-ray tube over headtube over head– Assist patient and provide supportAssist patient and provide support
Cervicothoracic SpineCervicothoracic Spine
Relax shoulder closer to x-ray tubeRelax shoulder closer to x-ray tube
Vertical IR centered just above jugular Vertical IR centered just above jugular notchnotch
Horizontal CR centered to C7-T1 Horizontal CR centered to C7-T1 interspace and midcoronal planeinterspace and midcoronal plane
Use breathing technique if possibleUse breathing technique if possible– Blur ribs and lung markings to better Blur ribs and lung markings to better
demonstrate spinedemonstrate spine
Cervicothoracic SpineCervicothoracic Spine
Image demonstrates lower cervical and Image demonstrates lower cervical and upper thoracic vertebrae in profile between upper thoracic vertebrae in profile between the shouldersthe shoulders
Cervicothoracic SpineCervicothoracic Spine
Patient and IR positioned for trauma lateral projection of cervicothoracic vertebrae using Patient and IR positioned for trauma lateral projection of cervicothoracic vertebrae using dorsal decubitus positiondorsal decubitus position
Cervicothoracic SpineCervicothoracic Spine
Lateral projection, dorsal decubitus position of cervicothoracic vertebraeLateral projection, dorsal decubitus position of cervicothoracic vertebrae
AP Axial Cervical SpineAP Axial Cervical Spine
Patient is supinePatient is supine– Usually immobilized with collar and spine Usually immobilized with collar and spine
boardboard
Place IR under spine board, if present, Place IR under spine board, if present, centered to C4 (Adam’s apple)centered to C4 (Adam’s apple)
Head and shoulders without rotationHead and shoulders without rotation– Ask patient to look straight aheadAsk patient to look straight ahead
AP Axial Cervical SpineAP Axial Cervical Spine
CR directed 15 to 20 degrees cephalad to CR directed 15 to 20 degrees cephalad to enter MSP at C4enter MSP at C4
Image demonstrates C3-T1 or T2, Image demonstrates C3-T1 or T2, including all soft tissuesincluding all soft tissues– If backboard is present, unavoidable artifacts If backboard is present, unavoidable artifacts
may be seenmay be seen
AP Axial Cervical SpineAP Axial Cervical Spine
Patient and IR positioned for trauma AP axial C-spine
AP Axial Cervical SpineAP Axial Cervical Spine
Trauma AP axial C-spine; complete dislocation at C2-C3
AP Axial Oblique Cervical SpineAP Axial Oblique Cervical Spine
TRAUMA OBLIQUESTRAUMA OBLIQUES
Patient is supinePatient is supine– Usually immobilized with collar and spine Usually immobilized with collar and spine
boardboard
Place IR under spine board (not bucky), if Place IR under spine board (not bucky), if present, centered to C4 and adjacent present, centered to C4 and adjacent mastoid processmastoid process– About 3About 3 lateral to MSP lateral to MSP
AP Axial Oblique Cervical SpineAP Axial Oblique Cervical Spine
Head and shoulders without rotationHead and shoulders without rotation– Ask patient to look straight aheadAsk patient to look straight ahead
CR has double angleCR has double angle– 45 degrees lateromedially45 degrees lateromedially– 15 to 20 degrees cephalic15 to 20 degrees cephalic
CR enters lateral to MSP at level of C4CR enters lateral to MSP at level of C4
AP Axial Oblique Cervical SpineAP Axial Oblique Cervical Spine
CR exit should be in center of IRCR exit should be in center of IR
Image demonstrates side opposite CRImage demonstrates side opposite CR– C1-T1 or T2 bodies and disk spacesC1-T1 or T2 bodies and disk spaces– Intervertebral foramina openIntervertebral foramina open– If backboard is present, unavoidable artifacts If backboard is present, unavoidable artifacts
may be seenmay be seen
AP Axial Oblique Cervical SpineAP Axial Oblique Cervical Spine
Patient and IR positioned for trauma AP axial oblique C-spine
AP Axial Oblique Cervical SpineAP Axial Oblique Cervical Spine
Trauma AP axial oblique C-spine
Thoracic and Lumbar SpineThoracic and Lumbar Spine
X-table laterals performed firstX-table laterals performed first
Vertical grid and IRVertical grid and IR– Top of IR 1.5Top of IR 1.5 to 2 to 2 (3.8 to 5 cm) above (3.8 to 5 cm) above
shoulders for thoracic spineshoulders for thoracic spine– Centered to level of iliac crests for lumbar Centered to level of iliac crests for lumbar
spinespine
Have patient cross arms on anterior chestHave patient cross arms on anterior chest
Thoracic and Lumbar SpineThoracic and Lumbar Spine
CR horizontal CR horizontal – Centered to spine and IRCentered to spine and IR
Breathing technique improves visualization Breathing technique improves visualization of thoracic vertebraeof thoracic vertebrae
Exposure made on suspended respiration Exposure made on suspended respiration for lumbar vertebraefor lumbar vertebrae
Thoracic and Lumbar SpineThoracic and Lumbar Spine
Thoracic image demonstrates T3 or T4 to Thoracic image demonstrates T3 or T4 to L1L1
Lumbar image demonstrates T12 to Lumbar image demonstrates T12 to sacrumsacrum
Vertebral bodies and spinous processes in Vertebral bodies and spinous processes in profileprofile
Trauma Lateral Lumbar SpineTrauma Lateral Lumbar Spine
CR and IR positioned for trauma lateral projection of lumbar spine using dorsal decubitus position
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
ChestChest
Supine position used if general survey Supine position used if general survey image of chest desiredimage of chest desired
Check for need to demonstrate air-fluid Check for need to demonstrate air-fluid levelslevels– If air-fluid levels are suspected, use X-table If air-fluid levels are suspected, use X-table
laterallateral– If patient’s condition permits, lateral decubitus If patient’s condition permits, lateral decubitus
position with patient lying on affected side will position with patient lying on affected side will also show air-fluid levelsalso show air-fluid levels
Trauma AP ChestTrauma AP Chest
Obtain help to lift patient for IR placementObtain help to lift patient for IR placement– Top of IR placed about 1.5Top of IR placed about 1.5 to 2 to 2 above above
shouldersshoulders
Arms abductedArms abducted
MCP parallel to IRMCP parallel to IR
Use maximum SID to reduce heart Use maximum SID to reduce heart magnificationmagnification
Trauma AP ChestTrauma AP Chest
Ensure chin extended out of anatomy of Ensure chin extended out of anatomy of interestinterest
CR directed perpendicular to center of IRCR directed perpendicular to center of IR– look for light field slightly above shoulders and look for light field slightly above shoulders and
on sides of chest, CW or LWon sides of chest, CW or LW
Exposure made upon second full Exposure made upon second full inhalation, if possibleinhalation, if possible
Trauma AP ChestTrauma AP Chest
Image demonstrates lung fields in their Image demonstrates lung fields in their entiretyentirety– Minimal rotation and distortion presentMinimal rotation and distortion present
AbdomenAbdomen
If transfer to x-ray table is not possible, If transfer to x-ray table is not possible, obtain lift help for IR placementobtain lift help for IR placement
IR centered to MSP at level of iliac crestsIR centered to MSP at level of iliac crests
Check for possibility of fluid accumulation Check for possibility of fluid accumulation in abdominal cavityin abdominal cavity– Affects exposure factorsAffects exposure factors– Requires close monitoring of patient for status Requires close monitoring of patient for status
change during procedureschange during procedures
AbdomenAbdomen
Mark entrance and exit wounds, if presentMark entrance and exit wounds, if present
Align shoulders and hips in same planeAlign shoulders and hips in same plane
MCP parallel to tableMCP parallel to table
CR perpendicular to center of IRCR perpendicular to center of IR
Image demonstrates entire abdomen with Image demonstrates entire abdomen with pubic symphysis visible at lower borderpubic symphysis visible at lower border
PelvisPelvis
Pelvic fractures have a high risk of Pelvic fractures have a high risk of hemorrhage – pay close attention to hemorrhage – pay close attention to patient for status changepatient for status change
Obtain lift help for IR placement if transfer Obtain lift help for IR placement if transfer to x-ray table is not possibleto x-ray table is not possible
IR centered 2IR centered 2 above pubic symphysis or above pubic symphysis or 22 below ASIS below ASIS
MCP parallel to IRMCP parallel to IR
PelvisPelvis
Lower limbs internally rotated only if Lower limbs internally rotated only if possiblepossible
Ensure arms are not in anatomy of interestEnsure arms are not in anatomy of interest
CR perpendicular to center of IRCR perpendicular to center of IR
Exposure made on suspended respirationExposure made on suspended respiration
Image demonstrates entire pelvis and Image demonstrates entire pelvis and proximal femoraproximal femora
Trauma AP PelvisTrauma AP Pelvis
Trauma AP pelvis; note fracture of left ilium and separation of pubic bones
CraniumCranium
Patients with head trauma are often Patients with head trauma are often referred to CT firstreferred to CT first
When x-rays are ordered, a general When x-rays are ordered, a general survey requires AP and lateral projectionssurvey requires AP and lateral projections
Generally, the patient is supineGenerally, the patient is supine– Lateral projection uses dorsal decubitus Lateral projection uses dorsal decubitus
position position
Trauma Lateral CraniumTrauma Lateral Cranium
Elevate head on radiolucent supportElevate head on radiolucent support– Ensure C-spine injury has been ruled outEnsure C-spine injury has been ruled out
Trauma Lateral CraniumTrauma Lateral Cranium
Trauma lateral projection of cranium; note multiple fractures in frontal bone
Trauma AP Cranium Trauma AP Cranium
Check with physician to determine Check with physician to determine anatomy of interestanatomy of interest– AP projection demonstrates anterior craniumAP projection demonstrates anterior cranium– AP axial projection (Towne) demonstrates AP axial projection (Towne) demonstrates
posterior craniumposterior cranium
Trauma CraniumTrauma Cranium
Patient and IR positioned for trauma AP cranium
Patient and IR positioned for trauma AP axial cranium
Trauma AP CraniumTrauma AP Cranium
Trauma AP cranium; note fracture line
Facial BonesFacial Bones
Patients with facial bone injuries are often Patients with facial bone injuries are often referred to CT firstreferred to CT first
Anticipate profuse bleeding and use Anticipate profuse bleeding and use universal precautionsuniversal precautions
Upper and Lower LimbsUpper and Lower Limbs
Obtain lift help for IR placementObtain lift help for IR placement
Injured limbs should be lifted with support Injured limbs should be lifted with support atat both jointsboth joints– Lift only enough to place IRLift only enough to place IR
Two projections at 90 degrees from each Two projections at 90 degrees from each other requiredother required– Do not attempt to rotate severely injured limbs Do not attempt to rotate severely injured limbs
for true positionsfor true positions
Upper and Lower LimbsUpper and Lower Limbs
Long bones require demonstration of Long bones require demonstration of adjacent jointsadjacent joints– Take separate projections, if necessaryTake separate projections, if necessary
Maximize patient safety and comfort by Maximize patient safety and comfort by moving IR and CR, rather than injured limbmoving IR and CR, rather than injured limb
Other Imaging Procedures in Other Imaging Procedures in TraumaTrauma
Slide 96
Other Imaging in TraumaOther Imaging in Trauma
CT is extensively used in trauma patientsCT is extensively used in trauma patients– Often, CT is modality of choiceOften, CT is modality of choice
Angiography may be used for vascular Angiography may be used for vascular injuriesinjuriesContrast studies are often ordered for Contrast studies are often ordered for evaluation of urinary system evaluation of urinary system – Blunt abdominal trauma and suspected pelvic Blunt abdominal trauma and suspected pelvic
fractures often result in injury to urinary fractures often result in injury to urinary systemsystem
Time for the “good stuff”!Time for the “good stuff”!