Section J: Trauma. Section J: Trauma. Clinical/Diagnostic Problem. (Grade) Head

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1 J Hea J01. Hea injury (For chilren see Section L) Recommenation (Grae) S Not inicate [B] There is poor correlation between the presence of a skull fracture an a clinically significant hea injury. The only inications for skull x-rays in the setting of trauma are suspecte open or epresse skull fractures, if is not available an suspecte chil abuse. Section J: Trauma [A] is inicate in all patients with a severe hea injury (GCS <13). In patients with a minor hea injury (GCS an witnesse loss of consciousness or isorientation or efinite amnesia) is inicate to rule out an injury requiring neurosurgical intervention if there is: GCS <15 2 hours after the injury Suspecte open or epresse skull fracture Any sign of a basal skull fracture Two or more episoes of vomiting Age > 65 years To rule out any other clinically significant intracranial injury, the following aitional risk factors justify obtaining : Amnesia for before the impact lasting > 30 minutes Dangerous mechanism of injury (motor vehicle accient or fall from> 3 feet or 5 stairs or more). A Specialize [B] A shoul be performe with presentation of high energy transfer mechanism or if associate with any of the following: Displace mi-face fracture Basilar skull fracture with caroti canal involvement Focal neurological eficit Cervical vertebral boy or transverse foramen fracture Fracture at C1-C3 Clothesline type injury or seat belt abrasion with significant swelling/pain Altere mental status Face an orbits J02. Nasal trauma Specialize [B] may be inicate if requeste by a referral service to plan for management. nasal bones Not s are unreliable in iagnosing/characterizing nasal bone fractures an o not alter management. 1

2 Recommenation (Grae) J03. Blunt orbital trauma [A] is inicate when an orbital fracture or globe injury is suspecte. Orbits May be use if is not available. J04. Orbital trauma: penetrating injury [A] is inicate when an orbital fracture or globe in jury is suspecte. is also inicate when oes not show a foreign boy but one, which may not be metallic, is strongly suspecte, when multiple foreign boies are present, or when it is not certain whether a foreign boy is intraocular. orbits [A] is the only imaging require to exclue a metallic foreign boy. US [C] 0 US can also be use for raiolucent foreign boies or where is ifficult. J05. Mile thir facial injury Facial Bones facial bones [A] Patient cooperation is essential to obtain views of iagnostic quality. Consier elay if patient is uncooperative. Shoul be consiere in setting of abnormal, suspecte fracture, foreign boy, or hematoma, an acute iploplia. [C] Discuss with maxillofacial surgeon, who may request low ose at an early stage in management of complex injuries. Although plain x-rays have ha a historical role, with reformats provies superior evaluation an shoul be the imaging moality of choice when available. J06. Manibular trauma [A] with reformats shoul be performe where available for superior fracture etection. manible or OPG [C] Panoramic is not appropriate in uncooperative or multiply injure patients. shoul be performe when available. 2

3 J Cervical spine J07. Conscious patient with hea an/or facial injury only cervical spine Recommenation (Grae) only In an alert, stable patient is inicate only if there are the following risk factors: Age >65 years Dangerous mechanism of injury Parasthesias in the extremities or other neurological eficit Miline tenerness Inability to actively rotate the neck 45 to the right an the left Section J: Trauma If the is normal an there is persistent pain, flexion an extension views can be obtaine to assess possible ligament amage. J08. Unconscious patient with hea injury J09. Neck injury an pain with or without neurological eficit J10. Neck injury with pain but initially normal; suspecte ligamentous injury Cervical Spine Cervical Spine cervical spine Cervical Spine MRI cervical spine Cervical Spine MRI [A] Although is inicate in the specific circumstances outline above, ue to superior visualization of both bony an soft-tissue injury shoul be obtaine as a first line moality if available, an to further characterize injury shoul one be suspecte on. [A] is inicate to characterize both bony an soft-tissue injury. only if is not available. [A] is inicate to characterize both bony an soft-tissue injury. Specialize investigation [B] 0 May be valuable ize situations where is negative an a purely ligamentous injury is suspecte, or to further characterize injury alreay seen on. [B] only if is not reaily available. [A] shoul be performe to etect raiographically occult fracture. Specialize investigation [B] 0 MRI emonstrates ligamentous injuries better than. cervical spine Specialize investigation [B] Views taken in flexion an extension (consier fluoroscopy) as achieve by the patient with no assistance an uner meical supervision. 3

4 Recommenation (Grae) Thoracic an Lumbar Spine J11. Trauma without neurological eficit, with or without pain Imaging is not usually inicate in a conscious asymptomatic patient, who can be reliably examine. Imaging is inicate if there is a history of a significant mechanism such as a fall or a high-impact motor vehicle accient, if there is pain an/or tenerness or if the patient cannot be reliably evaluate. may also be inicate in situations when is not reaily available. Spine [A] Threshol to shoul be low when there is pain / tenerness, a significant mechanism of injury, the presence of other spinal fractures, or when it is not possible to clinically evaluate a patient. J12. Trauma: with neurological eficit, with or without pain [A] is inicate to further evaluate for injury with or without localizing signs. MRI [B] 0 MRI is inicate if there is concern about a cor injury not seen on, if a purely ligamentous injury is suspecte, or to further characterize injury alreay seen on. [C] Shoul be performe only when is unavailable. Regarless / MRI is essential. Pelvis an sacrum J13. Fall with pain Pelvis an Lateral Hip [B] is inicate as an initial imaging moality if a pelvic or femoral neck fracture is suspecte. [B] is inicate if shows no fracture but there is ongoing pain or inability to weight bear. may also be inicate to further characterize fractures seen on. NM NM bone scan shoul performe at least hours post-injury to maximize sensitivity. Upper limb J14. Shouler injury [B] is the appropriate initial imaging moality. J15. Elbow trauma [B] is the appropriate initial imaging moality. 4

5 J J16. Wrist injury: suspecte scaphoi fracture Recommenation (Grae) [A] is the appropriate initial imaging moality. If a scaphoi fracture is suspecte a scaphoi view shoul be requeste. Delaye (at least ten ays) is appropriate if there is a high suspicion of a schaphoi fracture but a normal initial. If a scaphoi fracture or other carpal fracture is suspecte an the is normal is appropriate for further evaluation. Section J: Trauma MRI 0 If a scaphoi fracture is suspecte an the is normal an early iagnosis is require, MRI is the preferre moality for further evaluation. NM If a scaphoi fracture is suspecte an the is normal an early iagnosis is require NM can be use for further evaluation but NM bone scan shoul performe at least hours post-injury to maximize sensitivity. Lower limb J17. Knee trauma: fall / blunt trauma is the appropriate initial imaging moality. It is inicate if any of the following risk factors are present: Age > 55 years Tenerness over the hea of the fibula Isolate tenerness of the patella Inability to flex to 90 Inability to weight bear 4 steps immeiately an in the ED J18. Acute ankle injury is the appropriate initial imaging moality. It is inicate if any of the following risk factors are present : inability to weight-bear four steps immeiately an in the emergency room, point tenerness over the meial malleolus, an/or the posterior ege an istal tip of the lateral malleolus. is inicate to rule out an occult fracture is there is: An ankle effusion in the setting of normal x-rays an combine effusion (anterior to posterior) of greater then 13mm with ongoing suspicion of fracture; Ongoing pain or inability to weight bear. MRI 0 MRI is inicate if there is a suspecte isolate soft-tissue injury, occult fracture not seen on, or to further characterize fractures seen on. J19. Foot injury only is the appropriate initial imaging moality. 5

6 Recommenation (Grae) J20. Stress fracture [B] This is the preferre initial imaging moality. [B] is inicate if there are ongoing symptoms an a negative. MRI [B] 0 MRI is the superior moality for etecting early unisplace stress fractures which may be occult on an. NM [B] NM stuies may be useful for further evaluation of a suspecte stress fracture not visible on. J21. Suspecte hip fracture [A] is the appropriate initial imaging moality. [B] is inicate if there is ongoing inability to weight bear an/or a high suspicion for fracture espite a negative. Imaging of a Foreign Boy MRI [B] 0 MRI is inicate for ongoing suspicion of hip fracture in the setting of a normal or, especially if a stress fracture is suspecte. NM [B] NM bone scan can be performe where MRI is unavailable or contrainicate. NM bone scan shoul performe at least hours post-injury to maximize sensitivity. J22. Soft tissue injury: raio-opaque foreign boy suspecte [A] is the appropriate initial imaging moality. US 0 US may be inicate if glass or woo foreign boy is suspecte an is normal. J23. Soft tissue injury: raiolucent foreign boy suspecte. US only if there is concern about associate bony abnormality. 0 US is the appropriate initial imaging moality if a raiolucent, soft-tissue foreign boy is suspecte. J24. Swallowe foreign boy (For chilren see L58) shoul be performe in conjunction with irect examination of the upper pharynx where most foreign boies loge. is most useful if the swallowe foreign boy is raio-opaque. (continue on next page) 6

7 J J24. Swallowe foreign boy (For chilren see L58) (continue) chest an abomen Recommenation (Grae) For a suspecte sharp or potentially poisonous foreign boy (e.g. battery), shoul cover the aeroigestive tract from the pharynx to the rectum. is inicate if is negative or if there is clinical suspicion of obstruction or perforation of a hollow viscous. Section J: Trauma Chest J25. Chest trauma: Minor, suspecte rib fracture C Unisplace rib fractures are ifficult to ientify an their iagnosis oes not alter management. However, ientification of rib fractures may be useful in orer to counsel patients on recovery. J26. Chest trauma: Moerate to severe C [A] C is inicate as an initial examination but shoul not elay if there are suspecte severe injuries such as a pneumothorax. Chest [A] with contrast is inicate in the setting of severe trauma or penetrating injury in a patient who is hemoynamically stable. Unstable patients may require immeiate surgery. A Chest A is inicate in the setting of suspecte traumatic aortic injury, or high energy transfer mechanism. J27. Suspecte esophageal or airway injury Contrast enhance with water soluble oral contrast can be inicate in the setting of suspecte esophageal or airway injury in consultation prior to esophageal enoscopy or bronchoscopy. Abomen (incluing kiney) J28. Blunt or stab injury (For chilren see L59) [A] with contrast is inicate in the setting of severe trauma or penetrating injury in a patient who is hemoynamically stable. Unstable patients may require immeiate surgery. Abominal supine an C erect [B] If is unavailable, supine abominal an erect C are inicate to iagnose free intra peritoneal air. Pelvic x-rays are inicate to iagnose pelvic fractures which may enote internal injuries. Cystogram only A cystogram may be inicate in patients with severe pelvic trauma with suspecte blaer or urethral injury. 7

8 Recommenation (Grae) J29. Renal trauma [A] is the best imaging moality to investigate patients with suspecte major renal injury. Aults with blunt renal trauma but only microscopic hematuria o not require imaging. US only 0 US may be use if is unavailable but is not as sensitive as for evaluating traumatic injury. 8

Rib Views Not indicated [A] d CXR is not sensitive for rib fractures and therapy is pain management with or without a demonstrated fracture.

$Rib Views Not indicated [A] d CXR is not sensitive for rib fractures and therapy is pain management with or without a demonstrated fracture.$ F F01. Non-specific chest pain (See also E01, E04, E05) ST elevation MI, Non-STEMI/ High Risk ACS, Non-High Risk ACS an ACPS Recommenation (Grae) Diagnostic Imaging shoul be guie by clinical assessment,