MDCT PROTOCOLS FOR POLYTRAUMA PATIENTS BCR 2017, Budapest Agenda - - PowerPoint PPT Presentation

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MDCT PROTOCOLS FOR POLYTRAUMA PATIENTS BCR 2017, Budapest Agenda - - PowerPoint PPT Presentation

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Andrs Palk Department of Radiology, University of Szeged, Hungary MDCT PROTOCOLS FOR POLYTRAUMA PATIENTS BCR 2017, Budapest Agenda Definition and significance Clinical implications Role of imaging Examination protocols

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András Palkó

Department of Radiology, University of Szeged, Hungary

MDCT PROTOCOLS FOR POLYTRAUMA PATIENTS

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BCR 2017, Budapest

Agenda

Definition and significance Clinical implications Role of imaging Examination protocols Challenges Conclusion

Department of Radiology, University of Szeged, Hungary 2

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BCR 2017, Budapest

Agenda

Definition and significance Clinical implications Role of imaging Examination protocols Challenges Conclusion

Department of Radiology, University of Szeged, Hungary 3

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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, LangenbecksArch Surg (2008) 393:825–831

Lecky FE et al, in: H.-C. Pape et al. (eds.), Damage Control Management in the Polytrauma Patient, Springer, 2010

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Significance

Injury is a global pandemic and the most frequent

cause of death < 45

5 Department of Radiology, University of Szeged, Hungary

http://www.cdc.gov/injury/wisqars. 2007

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External injury standardised death rates / 100 000 male

Department of Radiology, University of Szeged, Hungary 6

http://www.euro.who.int/eprise/main/WHO/InformationSources/Data/2005117

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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

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Patterns of injury and mortality in polytrauma

Department of Radiology, University of Szeged, Hungary 8

Lecky FE et al, in: H.-C. Pape et al. (eds.), Damage Control Management in the Polytrauma Patient, Springer, 2010

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Patterns of injury and mortality in polytrauma

Department of Radiology, University of Szeged, Hungary 9

Lecky FE et al, in: H.-C. Pape et al. (eds.), Damage Control Management in the Polytrauma Patient, Springer, 2010

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Agenda

Definition and significance Clinical implications Role of imaging Examination protocols Challenges Conclusion

Department of Radiology, University of Szeged, Hungary 10

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What is to be done

Patient requires a timely and effective management in

  • rder to avoid the deathly spiral of severe systemic

complications:

prolonged haemorrhagic shock systemic inflammatory response

syndrome (SIRS)

multiple organ dysfunction

syndrome (MODS)

Department of Radiology, University of Szeged, Hungary 11

  • F. Gebhard et al, Langenbecks Arch Surg (2008) 393:825–831
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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

12 Department of Radiology, University of Szeged, Hungary

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Injury Severity Score

ISS = A2 + B2 + C2, (A, B, C = the AIS scores of the

three most severely injured regions)

Severe > 15

13 Department of Radiology, University of Szeged, Hungary

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Injury Severity Score

14 Department of Radiology, University of Szeged, Hungary

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Dilemma

Selective nonsurgical management is safe and cost-

effective, 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 15

Soto JA, Anderson SW, Radiology: 265, 2012

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Diagnosis

16 Department of Radiology, University of Szeged, Hungary

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Agenda

Definition and significance Clinical implications Role of imaging Examination protocols Challenges Conclusion

Department of Radiology, University of Szeged, Hungary 17

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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

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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

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Diagnostic algorithm

(clinical examination, triage) Plain X-ray

abdomen and pelvis chest

Ultrasound – FAST + diagnostic Computed tomography

20 Department of Radiology, University of Szeged, Hungary

http://www.acr.org/Quality-Safety/Appropriateness-Criteria, 2012

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BCR 2017, Budapest Department of Radiology, University of Szeged, Hungary 21

Diagnostic algorithm

(clinical examination, triage) Plain X-ray

abdomen and pelvis chest

Ultrasound – FAST + diagnostic Computed tomography

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http://www.acr.org/Quality-Safety/Appropriateness-Criteria, 2012

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Why MDCT?

  • Fastest „single best” modality: simultaneous evaluation 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

22 Department of Radiology, University of Szeged, Hungary

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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

Department of Radiology, University of Szeged, Hungary 23

Standards of practice and guidance of trauma radiology in the severely injured patient (RCR)

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Agenda

Definition and significance Clinical implications Role of imaging Examination protocols Challenges Conclusion

Department of Radiology, University of Szeged, Hungary 24

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NON-CONTRAST PRIMARY SURVEY

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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

Department of Radiology, University of Szeged, Hungary 26

  • S. Nicolaou et al. / European Journal of Radiology 68 (2008) 398–408
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BCR 2017, Budapest 27 Department of Radiology, University of Szeged, Hungary

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COMPREHENSIVE POLYTRAUMA SCANNING

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Scanning protocol @ 64

  • Patient position:

supine, hands up/down

  • Scanning direction:

cephalocaudal

  • Tube voltage:

120 – 140 kVp w. AEC

  • Auto mA range:

100 – 700

  • Collimation :

0.625 – 1.25 mm

  • Pitch:

1.375

  • Primary reconstruction:

Slice thickness:

3/5 mm (+ 0,625 for 3D, MPR)

FOV:

adjusted to body habitus

Department of Radiology, University of Szeged, Hungary 30

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Contrast administration protocol - Iodine

Department of Radiology, University of Szeged, Hungary

Concentration:

350 – 400 mg/mL

Volume (extracellular enhancement):

80 – 150 mL

Flow (bolus geometry – vessels):

Biphasic

6 mL/sec + 4 mL/sec

Monophasic

2.5 – 4 mL/sec

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Contrast administration protocol – saline flush

Department of Radiology, University of Szeged, Hungary

Volume:

30 – 50 mL

Flow:

2,5 – 3 mL/sec

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Contrast administration protocol – scan delay

Department of Radiology, University of Szeged, Hungary

Single vs. double vs. triple phase Single phase delay:

Fixed (pt < 50) vs. bolus triggering (pt > 50) Angio / arterial bleeding:

18 sec or 90 HU @ aortic arch

General:

35 sec or 100 HU @ AA

Parenchymal organ / veins:

60 – 75 sec or 70 HU @ liver

Delayed scans:

3 – 5 min

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Pseudoaneurysm

Department of Radiology, University of Szeged, Hungary 34

Boscak AR et al, Radiology 268:79-88, 2013

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Active bleeding

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Contrast administration protocol – GI tract

Department of Radiology, University of Szeged, Hungary

None Oral only Rectal only Oral and rectal

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Contrast administration protocol – GI tract

Department of Radiology, University of Szeged, Hungary

None Oral only Rectal only Oral and rectal

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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

Department of Radiology, University of Szeged, Hungary 38

Nguyen D et al: AJR 2009; 192:3–10

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Photon starvation & beam hardening

Department of Radiology, University of Szeged, Hungary 39

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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

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BCR 2017, Budapest Dep artm ent

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Agenda

Definition and significance Clinical implications Role of imaging Examination protocols Challenges Conclusion

Department of Radiology, University of Szeged, Hungary 48

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Time restraints – the „golden hour”

Primary diagnostic evaluation is to be completed

within the shortest possible time frame

Time restraints:

stabilization + transfer + positioning scanning data manipulation/interpretation

Department of Radiology, University of Szeged, Hungary 49

  • S. Nicolaou et al. / European Journal of Radiology 68 (2008) 398–408
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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

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Diagnostic errors

Occurs in 2-40 % ”Contribution” of imaging (secondary-tertiary

survey)

Department of Radiology, University of Szeged, Hungary 51

  • S. Nicolaou et al. / European Journal of Radiology

68 (2008) 398–408

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Radiation dose

A lifetime excess cancer mortality risk of 0.08 %

is estimated in patients younger than 45 years

  • ld who undergo panscanning

Indiscriminate use of CT without obvious injuries

  • r a severe injury mechanism may not be

justified.

Department of Radiology, University of Szeged, Hungary 52

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Dose reduction

Automated exposure control and tube potential

selection software

Bearing devices removal Contiguous scanning (decreases DLP by 17 %)

Department of Radiology, University of Szeged, Hungary 53

Frellesen C et al: Eur Radiol (2014) 24:1725–1734

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BUT!!!!

We must not hold back a clearly indicated CT

examination because of excessive and disproportionate fear of radiation-induced cancer

Life-threatening injuries may be missed and

appropriate treatment may be delayed, potentially leading to a worse clinical outcome (“second risk of radiation”)

Department of Radiology, University of Szeged, Hungary 54

HendeeWR et al: Radiology 2012, 264(2):312–321

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Trauma and pregnancy - principles

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 third- trimester 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

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Agenda

Definition and significance Clinical implications Role of imaging Examination protocols Challenges Conclusion

Department of Radiology, University of Szeged, Hungary 56

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Acute polytrauma imaging algorithm

Department of Radiology, University of Szeged, Hungary 57

D Barron Orthopedics and Trauma, 2011, 25:2

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Take home…

Polytrauma patients require 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

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