MDCT PROTOCOLS FOR POLYTRAUMA PATIENTS

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1 András Palkó Department of Radiology, University of Szeged, Hungary MDCT PROTOCOLS FOR POLYTRAUMA PATIENTS

2 Agenda Definition and significance Clinical implications Roleof imaging Examination protocols Challenges Conclusion Department of Radiology, University of Szeged, Hungary 2

3 Agenda Definition and significance Clinical implications Roleof imaging Examination protocols Challenges Conclusion Department of Radiology, University of Szeged, Hungary 3

4 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, Langenbecks Arch Surg(2008) 393: Lecky FE et al, in: H.-C. Papeet al. (eds.), Damage Control Management in the Polytrauma Patient, Springer, 2010 Department of Radiology, University of Szeged, Hungary 4

Significance Injury is a global pandemic and the most frequent cause of death < 45

5 Significance Injury is a global pandemic and the most frequent cause of death < Department of Radiology, University of Szeged, Hungary 5

6 External injury standardised death rates / male BCR 2017, Budapest Department of Radiology, University of Szeged, Hungary 6

Mortality 1st peak Within minutes (major vascular and CNS injuries) Medical intervention is rarely successful 2nd peak Within the first ( golden ) hour (intracranial

7 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

8 Patterns of injury and mortality in polytrauma LeckyFE et al, in: H.-C. Papeet al. (eds.), Damage Control Management in the Polytrauma Patient, Springer, 2010 Department of Radiology, University of Szeged, Hungary 8

9 Patterns of injury and mortality in polytrauma LeckyFE et al, in: H.-C. Papeet al. (eds.), Damage Control Management in the Polytrauma Patient, Springer, 2010 Department of Radiology, University of Szeged, Hungary 9

10 Agenda Definition and significance Clinical implications Roleof imaging Examination protocols Challenges Conclusion Department of Radiology, University of Szeged, Hungary 10

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

11 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: Department of Radiology, University of Szeged, Hungary 11

12 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

13 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 Department of Radiology, University of Szeged, Hungary 13

14 Injury Severity Score Department of Radiology, University of Szeged, Hungary 14

Dilemma Selective nonsurgical management is safe and costeffective, if the diagnosis is fast and accurate BUT identification of serious pathology is challenging may not manifest during the initial

15 Dilemma Selective nonsurgical management is safe and costeffective, 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 Department of Radiology, University of Szeged, Hungary Soto JA, Anderson SW, Radiology: 265,

16 Diagnosis Department of Radiology, University of Szeged, Hungary 16

17 Agenda Definition and significance Clinical implications Roleof imaging Examination protocols Challenges Conclusion Department of Radiology, University of Szeged, Hungary 17

18 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

19 Keep in mind Triage (NISS, GCS, etc.) Algorithm 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

20 Diagnostic algorithm (clinical examination, triage) Plain X-ray abdomen and pelvis chest Ultrasound FAST + diagnostic Computed tomography Department of Radiology, University of Szeged, Hungary 20

21 Diagnostic algorithm (clinical examination, triage) Plain X-ray abdomen and pelvis chest Ultrasound FAST + diagnostic Computed tomography Department of Radiology, University of Szeged, Hungary 21

viscerae CNS bones vessels + extravasation, leakage etc.

22 Why MDCT? Fastest singlebest modality: simultaneousevaluation 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

23 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) Department of Radiology, University of Szeged, Hungary 23

24 Agenda Definition and significance Clinical implications Roleof imaging Examination protocols Challenges Conclusion Department of Radiology, University of Szeged, Hungary 24

25 NON-CONTRAST PRIMARY SURVEY

26 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) Department of Radiology, University of Szeged, Hungary 26

27 Department of Radiology, University of Szeged, Hungary 27

28 Department of Radiology, University of Szeged, Hungary 28

29 COMPREHENSIVE POLYTRAUMA SCANNING

30 Scanning 64 Patient position: supine, hands up/down Scanning direction: cephalocaudal Tube voltage: kvpw. AEC Auto ma range: Collimation : mm Pitch: Primary reconstruction: Slice thickness: FOV: 3/5 mm (+ 0,625 for 3D, MPR) adjusted to body habitus Department of Radiology, University of Szeged, Hungary 30

31 Contrast administration protocol - Iodine BCR 2017, Budapest Concentration: mg/ml Volume (extracellular enhancement): Flow (bolus geometry vessels): ml Biphasic Monophasic 6 ml/sec + 4 ml/sec ml/sec Department of Radiology, University of Szeged, Hungary 31

32 Contrast administration protocol saline flush BCR 2017, Budapest Volume: Flow: ml 2,5 3 ml/sec Department of Radiology, University of Szeged, Hungary 32

33 Contrast administration protocol scan delay Single vs. double vs. triple phase Single phase delay: Fixed (pt< 50) vs. bolus triggering (pt> 50) BCR 2017, Budapest Angio/ arterial bleeding: General: Parenchymal organ / veins: Delayed scans: 18 sec or 90 aortic arch 35 sec or 100 AA sec or 70 liver 3 5 min Department of Radiology, University of Szeged, Hungary 33

34 Pseudoaneurysm Boscak AR et al, Radiology 268:79-88, 2013 Department of Radiology, University of Szeged, Hungary 34

35 BCR 2017, Budapest Active bleeding Department of Radiology, University of Szeged, Hungary 35

36 Contrast administration protocol GI tract BCR 2017, Budapest None Oral only Rectal only Oral and rectal Department of Radiology, University of Szeged, Hungary 36

37 Contrast administration protocol GI tract BCR 2017, Budapest None Oral only Rectal only Oral and rectal Department of Radiology, University of Szeged, Hungary 37

38 Single pass vs segmental WBCT WBCT should cover head, C spine, chest, abdomen and pelvis Single pass: Pro: no time lost by arm repositioning Con: arm causes beam hardening and photon starvation artefacts Segmental: Pro: allows for changing arm position Con: repositioning is time consuming Nguyen D et al: AJR 2009; 192:3 10 Department of Radiology, University of Szeged, Hungary 38

39 Photon starvation & beam hardening BCR 2017, Budapest Department of Radiology, University of Szeged, Hungary 39

40 CT protocol as we do it Plain head, neck arms down Plain and CE (arterial + venous) chest, abdomen and pelvis arms up Iodine: 100 ml (+ saline flush), 350 mg/ml, 4 ml/sec, 18/60 sec delay or bolus triggering delayed scan if necessary no GI contrast Routine scanning protocol The examination is supervised by the radiologist allows for real-time adaptation Department of Radiology, University of Szeged, Hungary 40

41 Dep artm ent of Radi olog y, Univ ersit y of Szeg ed, Hun gary 41

42 Dep artm ent of Radi olog y, Univ ersit y of Szeg ed, Hun gary 42

43 Dep artm ent of Radi olog y, Univ ersit y of Szeg ed, Hun gary 43

44 Dep artm ent of Radi olog y, Univ ersit y of Szeg ed, Hun gary 44

45 Dep artm ent of Radi olog y, Univ ersit y of Szeg ed, Hun gary 45

46 Dep artm ent of Radi olog y, Univ ersit y of Szeg ed, Hun gary 46

47 Dep artm ent of Radi olog y, Univ ersit y of Szeg ed, Hun gary 47

48 Agenda Definition and significance Clinical implications Roleof imaging Examination protocols Challenges Conclusion Department of Radiology, University of Szeged, Hungary 48

Time restraints the golden hour Primary diagnostic evaluation is to be completed within the shortest possibletime frame Time restraints: stabilization + transfer +

49 Time restraints the golden hour Primary diagnostic evaluation is to be completed within the shortest possibletime frame Time restraints: stabilization + transfer + positioning scanning data manipulation/interpretation S. Nicolaou et al. / European Journal of Radiology 68 (2008) Department of Radiology, University of Szeged, Hungary 49

50 Time restraints wet reading Closely monitor the examination Report all significant findings immediately Finalize report when time allows Department of Radiology, University of Szeged, Hungary 50

51 Diagnostic errors Occurs in 2-40 % Contribution of imaging (secondary-tertiary survey) S. Nicolaou et al. / European Journal of Radiology 68 (2008) Department of Radiology, University of Szeged, Hungary 51

52 Radiation dose A lifetime excess cancer mortality risk of 0.08% is estimated in patients younger than 45 years old who undergo panscanning Indiscriminate use of CT without obvious injuries or a severe injury mechanism maynot be justified. Department of Radiology, University of Szeged, Hungary 52

53 Dose reduction Automated exposure control and tube potential selection software Bearing devices removal Contiguous scanning (decreases DLP by 17 %) Frellesen C et al: Eur Radiol (2014) 24: Department of Radiology, University of Szeged, Hungary 53

BUT!!!! Wemust nothold backa clearly indicated CT examination because of excessive and disproportionate fear of radiation-induced cancer Life-threatening injuriesmay be missed and appropriate

54 BUT!!!! Wemust nothold backa clearly indicated CT examination because of excessive and disproportionate fear of radiation-induced cancer Life-threatening injuriesmay be missed and appropriate treatment may be delayed, potentially leading to a worse clinical outcome ( second risk of radiation ) Hendee WR et al: Radiology 2012, 264(2): Department of Radiology, University of Szeged, Hungary 54

55 Trauma and pregnancy - principles BCR 2017, Budapest Any female patient in childbearing age must be considered pregnant until proved otherwise There is no foetal survival without maternal survival (the possible exception is thirdtrimester trauma with poor prognosis for the mother caesarean section may be necessary to save the foetus) In lifesaving trauma care one should not hesitate to perform the needed tests Department of Radiology, University of Szeged, Hungary 55

56 Agenda Definition and significance Clinical implications Roleof imaging Examination protocols Challenges Conclusion Department of Radiology, University of Szeged, Hungary 56

57 Acute polytrauma imaging algorithm BCR 2017, Budapest Department of Radiology, University of Szeged, Hungary D Barron Orthopedics and Trauma, 2011, 25:2 57

58 Take home Polytraumapatientsrequire fast and appropriate treatment to reduce morbidity/mortality Diagnostic imaging is the most accurate tool for reliable diagnosis CT is the single best diagnostic modality in polytrauma Department of Radiology, University of Szeged, Hungary 58

59 Department of Radiology, University of Szeged, Hungary BCR 2017, Budapest

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