Pediatric emergencies. Emergent Neuroimaging Acute chest (non-trauma) Acute abdomen (non-trauma) Sports injuries (trauma) Highlights/Trends Polytrauma
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1 Department of Clinical Radiology, Munich University Hospital Pediatric emergencies Emergent Neuroimaging Acute chest (non-trauma) Acute abdomen (non-trauma) Sports injuries (trauma) Highlights/Trends Polytrauma
2 Department of Clinical Radiology, Munich University Hospital ESER European Society of Emergency Radiology proudly meeting DRK 94. Dt. Röntgenkongress 2013, Hamburg PD DR ULRICH LINSENMAIER, München
3 DRG meets ESER II Radiologische Bildgebung beim Polytrauma Interventionelle Radiologie bei Polytrauma Priv. Doz. Dr. Uli Linsenmaier Institut für Diagnostische und Interventionelle Radiologie Kliniken München Pasing & Perlach KMPP, Munich Associate Professor of Radiology, LMU Munich President European Society of Emergency Radiology ESER
4 Ziel Patientenselektion Organverletzungen: Milz, Leber, Niere Gefäßverletzungen, Beckenblutungen Technik, Ergebnisse
5 Introduction Acute radiology interventions allow in carefully selected patients Bleeding control Embolization of vascular bleeding sites Embolization of parenchyma organ injuries
6 IR Therapy and Mortality Immediate death: sec. min. Early death: hrs. Late death: weeks
7 Acute Radiological Interventions only early MDCT diagnosis enables acute IR indications for IR treatment only with trauma team recognize operative therapy alternatives define time limit for IR treatment IR angio suite accessible 24hrs * 7days IR personnel available more combined OR/interventional suites
8 Acute Radiological Interventions II Advantages (over open surgical treatment), lesser soft tissue trauma, reduced contamination If successful, lesser anesthetics, diminished blood loss, shorter procedure time IR can support surgical procedures: bleeding control, balloon occlusion McArthur C, Marin M, 2004
9 Patient Selection Class I: remain hemodynamically unstable undergo FAST and CXR, primary OR Class II: marginally stable, probably requiring surgery, undergo MDCT, eligible for emergency IR treatment Class III: hemodynamically stable undergo MDCT, eligible for IR treatment R.F.Dondeliger Eur Radiol (2002)
10 Accessible Vascular Territories Supraaortic arteries: ECA, ICA, VA Subclavian, axillary arteries Pelvic arteries: CIA, IIA, EIA Lumbal and intercostal arteries Mesentery arteries: SMA, Celiac,IMA Upper / lower extremity arteries Venous bleeding sites pelvis/cava
11 Therapy Options Embolization (coils, particles) Stents, covered stents Balloon occlusion (temporary) Surgery combined interventions
12 Vascular injuries
13 Vascular Injuries II Avulsion cut-off AV fistual Traumatic false aneurysm
14 Vascular Injuries III Spasm Intramural hematoma Intima tear / dissection
15 Vascular Injuries IV Bleeding Retraction, occlusion Thrombosis, occlusion
16 Aortic injuries
17 25 yo after roll over by tractor Case # 1 serial rib fractures hemidiaphragmatic injury mediastinal enlargement pneumothorax
18 Traumatic AI
19 Endovascular stent repair completed within 55 min after admission
20 hemodynamically stable TAA completely excluded
21 Aortic injuries
22 69 yo MVA TAI w active hemorrhage Case # 2
23 involvement of AA, renal arteries right RA from false lumen celiac trunk, SMA, left RA from true lumen
24 endovascular stent repair DSA guided control over left brachial artery access
25 hemodynamically stable TA dissection completely covered
26 Supraaortic injuries
27 S.p. penetrating injury Bleeding from IMA Case # 7
28
29 coiling distal and proximal of bleeding site hemodynamically stable
30 Supraaortic injuries
31 33 yo MVA active mediastinal hemorrhage subclavian artery? Case # 3
32
33 false aneurysm of right subclavian artery involvement of int mammarian, vertebral arteries
34
35
36 Supraaortic injuries
37 37 yo male S.p. stabbing to left ear Case # 8
38 Case #
39 Case # left auricular hematoma soft tissue air collection pseudoaneurysm w unclear feeding from ECA / ICA
40
41
42 traumatic pseudoaneurysm AV fistula A. occipital artery >> IJV, vertebral vein successful primary occlusion w 3 microcoils
43 Pelvic injuries
44 33 yo s.p. fall type c pelvic fx Case # 4
45
46 CT guided temporary balloon occlusion combined with pelvic clamp Linsenmaier U., Rofo 2003; CT-guided aortic balloon occlusion ( )
47 Pelvic injuries
48 53 yo s.p. roll over by truck complex pelvic fx Case # 5 Department of Clinical Radiology, Munich University Hospital massive pelvic hemorrhage
49 Department of Clinical Radiology, Munich University Hospital temporary balloon occlusion of internal iliac artery C-clamp Linsenmaier U.Rieger J., Rofo 1999; Temporary balloon occlusion
50 Pelvic injuries
51 68yo bleeding from right external iliac artery Case 6
52 covered stent 8x37 mm bleeding control, pt remained stable
53
54 Organ injuries
55 Organ Injuries I Hematoma, subcapsular o parenchyma Laceration, w capsular tear Laceration, w vascular injury (segmental, hilar) << active bleeding << pseudoaneurysm Devascularization, partial or complete Shattered organ
56 IR Results Organ Injuries Organ injury only: 16-26% intervention rate Active bleeding: % intervention rate
57 Liver injuries
58 S.p. MVA CT grade IV liver injury Case # 9
59 coiling of right hepatic artery hemodynamically stable
60
61 Splenic injuries
62 36 yo S.p. MVA CT grade III splenic Case # 10
63
64 coiling and rebleeding additional temporary balloon occlusion
65
66 hemodynamically stable preserved organ function
67
68 esults-splenic Artery Embolization: / 221 (75%) Non-OP therapy possible 11 / 41 (27%) EMBO failed 10 / 124 (8%) Non-EMBO failed H.E.Smith, J Trauma. 2006
69 Conclusion emergency IR techniques balloon occlusion w embolization (aorta, pelvis) covered stenting (aorta, pelvis) delayed techniques embolization of vascular bleeding sites embolization of parenchyma organ injuries
70 Conclusion Emergency interventions with potential Endovascular stent repair for TAI Covered stent repair for arterial injury Temporary balloon occlusion for mass bleedings
71 Problems to consider.. false-negative angiograms: do not relay on DSA findings only Clinical examination, laboratory findings: are not reliable Consider rebleeding, when arterial pressure increased again vasoconstriction ceased after endogeneous thrombolysis after coagulopathy
72
73 Department of Clinical Radiology, Munich University Hospital Pediatric emergencies Emergent Neuroimaging Acute chest (non-trauma) Acute abdomen (non-trauma) Sports injuries (trauma) Highlights/Trends Polytrauma
74 Trends in use of CT in the ED Department of Clinical Radiology, Munich University Hospital (from 1995 to 2007) Exponential rise of the CT use in the ED 6-fold increase of the number of ED visits w CT 5-fold increase of the percentage of ED visit w CT continuous increase in the older population Nat Hospital Ambulatory Medical Care Survey > or visits / year evaluated 1995 to 2007 Larson DB et al. (2011). Radiology. 258:
75 Numbers of ED visits with CT from 1995 to exponential growth annual growth rate 16.0% doubling time 4.7 years Larson DB et al. (2011). Radiology. 258:
76 Trends in the ED Department of Clinical Radiology, Munich University Hospital MDCT improves patient triage and door-to-treatment times MDCT is the most important diagnostic tool for ED physicians MDCT: 1 out of 5 ED patients receive a CT MDCT use increased 330% (since 1995) largest increase: pts older than 79 (9.1% in 1996 to 29.1% in 2007). MDCT: Correlation between with drop in hospital admissions and shift away from expensive ICU admissions. Nat Hospital Ambulatory Medical Care Survey > or visits / year evaluated 1995 to 2007 Larson DB et al. (2011). Radiology. 258:
77 Department of Clinical Radiology, Munich University Hospital Danke Dr. Michael Krötz Dr. Mojtaba Sadeghi PD Dr. Johannes Rieger PD Dr. Markus Körner PD Dr. Dr. Stefan Wirth Institut für Klinische Radiologie Klinikum der Universität München, Innenstadt Ludwig-Maximilians-Universität, München
78 Department of Clinical Radiology, Munich University Hospital Pediatric emergencies Emergent Neuroimaging Acute chest (non-trauma) Acute abdomen (non-trauma) Sports injuries (trauma) Highlights/Trends Polytrauma
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