Geoff Orme-EvansJune 14, 2021

Blunt Trauma Radiological Workup

Focused patient history and workup

• 54-year-old man with a history of diabetes who presented via air care from scene s/p rollover MVC with prolonged extraction. 2 uPRBCs en route.

• Initial GCS 15 in trauma bay but tachycardic and hypotensive (SBP ~80s).

• LUE and LLE deformities.

• +FAST.

• Satting 100% on non-rebreather but intubated because planned OR for diaphragmatic hernia on portable CXR.

• Became acutely hypotensive (50s SBP) with faint pulses and taken to OR for emergent laparotomy.

• CT scans were deferred in the acute, hemodynamically unstable phase

List of imaging studies

• Initial

• FAST—free fluid in abdomen

• Portable CXR

• Portable XR AP

• Post-op #1

• Portable CXR x2

Rib Fractures

Raised L hemidiaphragm with pneumoperitoneum

Pulmonary Contusion L lung base

Fracture

Chest tube

Diffuse Interstitial edema

Bonus: Laps

ETT

8 hours later,worsened bilateral edema

Patient treatment or outcome

• CT Chest and AP confirmed other injuries

• MSK imaging for LUE and LLE (including femoral) fractures, and operative repairs

• Ex Lap #2, Ortho surgery #1

• MRI with diffuse fat emboli and possible diffuse axonal injury. Opens eyes but no purposeful movements.

• Multiple infections, including LUE possible myositis, empyema with fungus, abdominal with enterococcus, etc.

• Tracheostomy

• Remains hospitalized ~1 month

Imaging discussion

• Consideration starts prior to arrival• Key: Mechanism

Imaging discussion

• ACR Appropriateness Criteria: Polytrauma, blunt, hemodynamically unstable, initial imaging

Imaging discussion

Cost of choices

• Choosing Wisely• Avoid CT pan scans, head CT for minor injuries

• Possible* costs here:• Chest X-ray 1 view

• Uninsured/out-of-network: $478• In-network: $264

• Pelvis X-ray 1 or 2 views• Uninsured/out-of-network: $413• In-network: $172

• CT Chest with contrast• Uninsured/out-of-network: $4568• In-network: $1844

*From FairHealthConsumer.org, for Chapel Hill, NC, including related costs (Hospital, outpatient).Costs much lower without the “related costs.”

Imaging discussion

• Approach to chest X-ray: “RIP MA ABCDE”

• Technical:• Rotation

• Inspiration

• Penetration

• Magnification

• Angulation

• Other:

• ABCDE: Airway, Breathing, Cardiac, Disability, Everything Else

Imaging discussion

• Secondary imaging when stable:• Know what you’re looking for, but….

CTHead, C-Spine, Chest, A/P…

UNC Top Three

• Trauma workup begins prior to arrival:• Team and unit prep

• Mechanism

• Blunt trauma initial imaging with significant injury OR high-risk mechanism, stable or not:• FAST

• Chest and abdomen/pelvis X-rays

• Time!

References

• American College of Radiology. 2021 ACR Appropriateness Criteria.

• ChoosingWisely.org. Accessed June 11, 2021.

• FairHealthConsumer.org. Accessed June 11, 2021.

• Herring W. 2016. Learning Radiology: Recognizing the Basics. 3rd ed. Philadelphia, PA: Elsevier; 2016.

• Legome E. Initial evaluation and management of blunt thoracic trauma in adults. Up to Date. Updated May 21, 2021. Accessed June 10, 2021.

• Raja A, Zane RD. Initial management of trauma in adults. Up to Date. Updated October 13, 2020. Accessed June 10, 2021.