Trauma Resuscitation — Imaging Considerations — Clinical Pathway: Emergency

Trauma Resuscitation Clinical Pathway — Emergency Department

Imaging Considerations

Initial imaging directed by Trauma and ED Resuscitation Team, which reviews need for advanced imaging with the appropriate consultants.

  Indications Comments
Plain Films
  • Chest
    • Based on mechanism of injury
    • Stable multisystem trauma
    • Evaluation of penetrating injury (trace bullet path)
  • Chest X-ray (CXR) can be helpful in picking up early signs of major vascular injury in chest (shearing force w/fall, motor-vehicle collision [MVC])
  • Pelvis
    • Based on MOI, clinical findings
  
  • Extremity
    • As clinically indicated in stable patients, one view
  
Head CT without Contrast
  • Abnormal mental status
  • Concern for intracranial hypertension
  • Lateralizing cranial nerve, motor findings
  • Penetrating trauma
  • ED Acute Head Trauma Pathway
  • Add temporal bone windows if concern for basilar skull fractures
  • Add orbits, facial bones as clinically indicated
  • Consider adding CT of C1, C2 in young children
    • Specify in HCT order
    • Replaces odontoid view, which is challenging to obtain in young kids
Neck Imaging
  • Assume C-spine injury in patients w/ blunt multisystem trauma, altered level of consciousness, significant blunt injury above clavicle
  • 3 View
    • Initial images: lateral, AP, odontoid
  • CT C1,C2
    • If unable to obtain adequate odontoid after 2 attempts
    • Consider adding in patients < 2 yrs who require Head CT
  • Obtain 3 view or 2 view with CT C1, C2 (young kids, requiring head CT)
  • Flexion, extension
  • Consider in alert, cooperative patients with normal 3 view and normal neuro exam, with significant pain
  • MRI
    • Abnormal mental status, exam, persistent neck pain
  • Used to delineate ligamentous injury, generally occurs after admission
Abdominal Pelvic CT with IV Contrast
  • Hemodynamic instability from suspected intra-abdominal injury
  • Abdominal CT is associated with significant radiation
  • Oral contrast does not increase diagnostic accuracy and may cause delay
  • Hollow viscous injuries may be missed on initial CT scan
  • Penetrating wound to the abdomen/torso
  • In hemodynamically stable patients:
    • Significant abdominal pain, tenderness
    • Bruising, Seatbelt sign, handle bar bruising
    • Child abuse suspected
    • Significant mechanism of injury
    • Distracting injuries prevent adequate PE
    • Gross Hematuria, down trending HCT
    • Elevated LFT AST > 200, ALT > 125, Pancreatic enzyme elevation
    • EFAST Ultrasound with Intraperitoneal fluid
  • Patients less likely to require further abdominal imaging
    • Glasgow coma scale ≥ 14
    • No evidence of the following:
      • Abdominal wall trauma or seat belt sign
      • Abdominal tenderness
      • Complaints of abdominal pain
      • Vomiting
      • Thoracic wall trauma
      • Decreased breath sounds
  • For patients with concern for non-accidental trauma; could have lower threshold for further imaging
  • ED Physical Abuse Clinical Pathway
Thoracic CT with IV Contrast
  • Concern for cardiac or great vessel injury
  • Aortic injury
    • Diminished/Absent peripheral pulses
    • Wide mediastinum on X-ray
    • Left hemothorax
  • Penetrating trauma to the chest
  • Major chest trauma is uncommon in pediatric patients
  • Bedside ultrasound is useful for detecting pericardial fluid
CT Angiography
  • Consider CTA Neck
    • Concern for blunt cerebrovascular injury
    • Base of skull fracture w/involvement of carotid canal or involvement of petrous temporal bone
    • Cervical spine fracture
    • Neurological exam findings not explained by neuroimaging
    • Horner syndrome
    • Le Fort II or III fracture pattern
    • Neck soft-tissue injury (seatbelt sign, hanging)
    • Posterior oropharyngeal injury
    • Scalp degloving
  • Consider CTA Chest
    • Concern for major vascular chest injury
    • Penetrating trauma
    • Deceleration injuries/Shearing forces (Fall, MVC)
  • Consider CTA Extremity
    • Concern for vascular extremity injury
    • Penetrating trauma
    • Abnormal ankle-brachial index, diminished pulses
    • Bony injury (open fx, dislocation, penetration) proximal to penetrating wound
  • CXR findings of high concern, which may require further imaging:
    • Wide mediastinum
    • Obliteration of the aortic knob
    • Deviation of the trachea to the right
    • Depression of left mainstem bronchus
    • Elevation of right mainstem bronchus
    • Obliteration of space b/w pulmonary artery and the aorta (obscure aortopulmonary window)
    • Deviation of esophagus (NG) to the right
    • Widened paratracheal stripe
    • Widened paraspinal interfaces
    • Presence of a pleural or apical cap
    • Left hemothorax
    • Fractures of the first or second rib or scapula
    • Hard signs of vascular extremity injury that may require emergent operative repair and angiography (should not delay definitive management, directed by Ortho and Trauma):
      • Pulsatile bleeding, expanding hematoma, absent distal pulses, cold/pale limb, palpable thrill, audible bruit
CT Extremity
  • High-Risk Fracture Types
    • Proximal tibia epiphyseal fractures
      • (Tibial plateau)-salter harris III, IV
    • Distal femoral physeal fractures
      • (Evaluate intra-articular extension, operative planning)
    • Medial epicondyle fracture (with elbow dislocation can get displaced medial epicondyle within ulnohumeral joint)
    • Unstable ankle fractures
  • As directed by orthopedics
Interventional Radiology Embolization
  • Solid-organ injuries (alternative to surgical intervention)
    • Liver
    • Spleen
    • Kidney
  • Pelvic Injuries
  • As clinically indicated

Reference

Holmes JF, Lillis K, Monroe D, et al. Identifying children at very low risk of clinically important blunt abdominal injuries. Ann Emerg Med 2013; 62:107