Trauma and Foreign Body Radiography Chapter 13 Trauma and Foreign Body Radiography 2 24 2014 online ed.

Blunt trauma- physical trauma caused to body part by impact, injury What is trauma? Sudden, unexpected, dramatic, forceful, or violent event Common types: Blunt trauma- physical trauma caused to body part by impact, injury or physical attack Blunt Abdominal trauma- physical trauma to abdomen Penetrating trauma- when object pierces skin, enters tissue of body, creating an open wound Explosion Thermal forces- fire

Blunt Abdominal Trauma (BAT) 50% to 75 percent of all blunt trauma is blunt abdominal trauma- mostly car collisions due to rapid deceleration by steering wheel or dashboard

Immobilization Many ER pts arrive in immobilization devices Do not remove immobilization devices unless ordered by Dr.!!!! -perform exam with immobilization still in place 1st images - to rule out injury and show if safe to remove immobilization

Preliminary Considerations in Trauma Radiography Speed produce quality images in shortest possible time Accuracy Get it right the 1st time! Or minimal repeats Quality Quality cannot be sacrificed for speed Do not use pt condition as excuse for poor quality images!

Mobile fluoroscopy units C-arms may be used in instead of plain images for: Fx. reduction Or foreign body localizations

When Positioning- Do no harm! Important not to aggravate pt’s condition when obtaining images Provide immobilization support to reduce risk of motion Move tube and IR, instead of pt, whenever possible Expect to be exposed to body fluids Pay careful attention to pt’s condition- could change at any time!

Remember: Trauma often causes anxiety! Use good communication skills with appropriate touch and eye contact Explain and demonstrate positions, when possible Check pt for potential artifacts Explain what you are removing and why Secure all personal effects using proper procedure for your facility Use short exposure times --why?

SID When SID not specified for a projection, Merrill’s Atlas recommends 48 ? 60 to 72 SID recommended for projections with increased OID Why?

Radiation Protection Shield all pediatric pts and pts of reproductive age Unless it will compromise exam! Use tight collimation Optimum technique factors (high mA, low time)

If backboard is present, unavoidable artifacts may be seen

Crosstable Lateral Cervical Spine Perform 1st and check with physician before proceeding with other projections! Dorsal decubitus position, horizontal beam Shoulders relaxed Head -no rotation- ask pt to look straight ahead without moving head or neck Vertical IR placed at top of shoulder in holder

Lateral Cervicothoracic Spine (Swimmers) Required if C7 and top of T1 not demonstrated on lateral C-spine Trauma- usually Dorsal decubitus position Pt supine -no rotation Ask pt to raise arm opposite x-ray tube over head

Vertebrae in profile between shoulders Swimmer’s Demonstrates: lower cervical upper thoracic Vertebrae in profile between shoulders

AP Axial Cervical Spine Pt supine Usually immobilized with collar and spine board Place IR under spine board, if present, centered to C4 Head and shoulders - no rotation Ask pt to look straight ahead Do not rotate head

AP Axial Cervical Spine CR directed 15 - 20 degrees cephalad to enter MSP and C4 Image demonstrates C3-T1 or T2 Include all soft tissues

AP Axial Oblique Cervical Spine Head and shoulders without rotation Ask pt to look straight ahead Do not rotate head CR has double angle 45 degrees lateromedially 15 to 20 degrees which way? Use a grid?

AP Axial Oblique Cervical Spine Which projection? Which formina demonstrated? (RPO, Left)

Thoracic and Lumbar Spine Dorsal decubitus positions performed 1st Vertical grid IR Top of IR 1.5 to 2 above shoulders for thoracic spine Centered to level of iliac crests for lumbar spine Have pt cross arms on anterior chest

Trauma Lateral Lumbar Spine CR and IR positioned for trauma lateral projection of lumbar spine using dorsal decubitus position

Trauma AP Chest Pt. supine Obtain help to place cassette under pt. Top of IR placed about 1.5 to 2 above shoulders Arms abducted MCP parallel to IR Use maximum SID to reduce heart magnification

Trauma AP Chest (cont’d) Ensure chin extended out of anatomy of interest CR directed perpendicular to center of IR Enters pt at MSP at about 3 below jugular notch Exposure on 2nd full inhalation, if possible

Trauma AP Chest (cont’d) Image must demonstrate lung fields in their entirety Minimal rotation and distortion present Collapsed lung

Lateral Decubitus Chest X-ray If pt’s condition permits, position pt lying on affected side

Trauma Lateral Chest If air-fluid levels are suspected, use dorsal decubitus position

Penetrating wounds to Abdomen Stabbings, gunshots Mark entrance and exit wounds, if present Align shoulders and hips in same plane

Bullet Wound (IVP) Demonstrate entire abdomen Pubic symphysis must be visible at lower border

When the pt. arrives- If transfer to x-ray table not possible, obtain lifting help to place IR with grid directly under pt Monitor pt closely for status change during procedures!

Why take a Decubitus Abdomen? Rule out free air

Left (right would confuse free air with stomach gas) Which decub is this? Left (right would confuse free air with stomach gas)

Pelvis Pelvic fxs have high risk of hemorrhage – pay close attention to pt for status change! Obtain lift help for IR placement under pt if transfer to x-ray table is not possible IR centered 2 above pubic symphysis or 2 below ASIS

Pelvis (cont’d) Lower limbs usually not rotated internally 15 degrees in trauma cases Ensure arms not in anatomy of interest! Suspend respiration Demonstrate entire pelvis and prox. femora

Note: fracture of left ilium and separation of pubic bones Trauma AP Pelvis Note: fracture of left ilium and separation of pubic bones

Contrast studies Why is a study of the urinary system often ordered? Suspected pelvic fxs often result in injury to urinary system

Cranium Pts with head trauma are often referred to CT 1st Why? Much more information Standard x-ray routine AP and lateral Generally, pt. is supine

Trauma AP Cranium AP projection AP axial projection- (aka?) for anterior cranium AP axial projection- (aka?) Towne (for posterior cranium) Obtain lift help for IR placement if transfer to x-ray table is not possible C-spine injury should be ruled out first!

Trauma AP Cranium (cont’d) Check for rotation and tilt CR centered perpendicular - nasion IR is to center of CR

Trauma AP Cranium (cont’d) Demonstrates anterior cranium with petrous ridges filling orbits

Trauma AP Axial Cranium (Towne) CR angled how many degrees? 30 deg. Caud 2 - 2 ½ “ above glabella Demonstrates posterior cranium Foramen magnum in center

Trauma AP Axial Cranium (Towne) Check for rotation and tilt of head OML perpendicular to IR If IOML used, what must CR angle be changed to ? 37 degrees caudad!

Trauma Lateral Cranium Elevate head on radiolucent support C-spine injury ruled out 1st! Place vertical IR centered to cranium Make sure interpupillary line is perpendicular to IR and MSP is vertical Horizontal CR enters center of IR and pt at 2 above EAM dorsal decubitus position

Trauma Lateral Cranium Multiple fxs in frontal bone -2 gunshot wounds

Facial Bones Often referred to CT first Anticipate profuse bleeding and use universal precautions

Acanthioparietal Facial Bones Also known as? - Reverse waters Image demonstrates facial bones and maxillary sinuses Facial bones should be symmetric opaque right maxillary sinus – evidence of fx

Modified Waters- reverse For orbits and facial bones Leave Pt. “as is” on guerney or table Angle CR cephalic if necessary to accommodate for lack of pt cooperation flexing neck Normal modified waters Reverse modified waters with compensating angle

Alternate Water’s Method Do not angle pt’s head unless safe! Extend head so acanthiomeatal line is 30 deg to image receptor if pt. can cooperate

Upper and Lower Limbs Obtain lift help for IR placement Injured limbs should be lifted with support at both jts (Move IR and CR, not injured limb when possible!) Lift only enough to place IR Do not attempt to rotate severely injured limbs for true positions 2 projections at 90 degrees apart Must demonstrate both adjacent jts (Take 2 separate projections if need be)

Many projections can be reversed or modified Most trauma pts. arrive in supine position radiograph pt. as is! Move as little as possible

Reversing or Modifying Extremity Projections Obtain x-table lateral or decubitus images if pt. is unable to stand or rotate body part to desired position

Foot Trauma

Any alien object that enters body by puncture or natural orifice Foreign Body Any alien object that enters body by puncture or natural orifice May have to be surgically removed To localize radiographically- obtain 2 views at right angles to each other

Technical Considerations Why use small focal spot? Why must screens clean? How might exposure factors be adjusted to display soft tissue? Why is positioning crucial to determine depth of penetrating injury? Why is marking entry points for penetrating foreign objects helpful?

Radiographic Localization Techniques Penetrating foreign bodies (bullet) Direct CR through foreign body Obtain right angle views, PA or AP and lateral Indicate site of puncture wound Obtain additional projections as indicated by Dr.

Aspirated (in lungs) or Swallowed Objects Children- often do on purpose! Adults - usually accidental Mentally disturbed patients Compulsively swallow objects

Aspirated or Swallowed Objects cont’d Respiratory System Include entire neck and chest Digestive System Include neck, chest and abdomen

Aspirated Foreign Body

Swallowed Foreign Body Implied by absence of air