kuliah blok kegawatdaruratan_oktober 2010

PENCITRAAN PADA PENCITRAAN PADA KEADAAN GAWAT DARURAT KEADAAN GAWAT DARURAT (EMERGENCY RADIOLOGI(EMERGENCY RADIOLOGI

dr.Yanto Budiman , Sp.Rad, M.Kes

Bagian Radiologi FKUAJ/RSAJ

Head and faceCervical spineChestAbdomenExtremities

Head and Face Head and Face Skull FractureFacial FractureCerebral contusioEpidural HematomaSubdural HematomaSub Arachnoid HematomaCVD /Stroke

Skull FractureSkull FractureTipe Fracture :

◦Liniar◦Depressed◦Basal Clinical signs:rhinorrhoea,

otorrhoea, Battles’ sign (retro-auricular haematoma),Racoon Eyes

Facial Fracture-Maksilla Facial Fracture-Maksilla

Facial Fracture-Infra Facial Fracture-Infra Orbital Orbital

*

Tear drop sign

Facial Fracture-MandibullaFacial Fracture-Mandibulla

Cerebral ContusionCerebral ContusionRadiological features Non-contrast computed tomography (CT)

useful in the early posttraumatic period. Contusions are seen as multiple focal areas of

low or mixed attenuation intermixed with areas of increased density representing haemorrhage ( Salt & Pepper app)

True extent becomes apparent over time with progression of cell necrosis and oedema.

Magnetic resonance imaging (MRI) is the best modality for demonstration of oedema and contusion distribution.

Epidural HematomaEpidural HematomaRadiological featuresCT signs include a biconvex hyperdense

elliptical collection with a sharply defined edge. Mixed density suggests active bleeding.

The haematoma does not cross suture lines.May separate the venous sinuses/falx from

the skull; this is the only type of haemorrhage to do this.

Mass effect depends on the size of the haemorrhage and associated oedema.

Associated fracture line may be seen.

Subdural HematomaSubdural HematomaRadiological featuresCT shows a crescentic fluid collection

between the brain and inner skull. Concave inner margin with minimal brain substance displacement.

In the acute phase high density; in the subacute phase (2–4 weeks

post-injury) isodense to brain.in the chronic phase (4 weeks post-

injury) low density.

Subdural HematomaSubdural Hematoma

acute Sub acute Chronic

Subarachnoid hematomaSubarachnoid hematomaRadiological featuresNon-contrast CT is sensitive within 4–5

hours of onset.Look for acute haemorrhage (increased

density) in the cortical sulci, basal cisterns, Sylvian fissures, superior cerebellar cisterns and in the ventricles.

Older MRI macine is relatively less sensitive than CT Scan, but in modern MR Machine , using special sequences like GRE , FLAIR and DWI is comparable to CT Scan

Subarachnoid Subarachnoid HematomaHematoma

MRI FLAIR CT Scan

CVD /StrokeCVD /StrokeIschemic Stroke Haemorrhage Stroke

Non-contrast CT in the first instance.

CT is useful in detecting haemorrhage.

Hyperacute/ acute infarct may not visible at CT Scan till > 24 Hours.

Ischemic Ischemic StrokeStroke

Haemorrhage strokeHaemorrhage stroke

Cervical spine injuryCervical spine injuryClassified according to mechanism

of trauma:Flexion injuriesRotational injuriesExtension injuriesVertical compression injuries

Clay shovelers’ Clay shovelers’ fracturefracture

Tear drop fractureHangman Fracture

Comminuted compression fracture

Chest Chest RIB/STERNAL FRACTURE FLAIL CHEST PNEUMOTHORAX HAEMOTHORAX AORTIC RUPTURE DIAPHRAGMATIC RUPTURE/HERNIA FOREIGN BODY PNEUMONIAPULMONARY EDEMA

Rib/sternal fractureRib/sternal fractureConsider associated injuries:– Clavicle/1st or 2nd rib fractures suggest or indicate a significant force, often associated with great vessel, tracheo-bronchial or spinal injury.– Sternal injuries may be associated with myocardial contusion.– With lower rib fractures, abdominal visceral injury, such as liver, spleen or kidney, may occur.

Rib/sternal fracture (2)Rib/sternal fracture (2)Radiological featuresA PA/AP CXR/lateral / top lordotik /

oblique view are performed to assess for both complications and to identify any underlying fracture.

Preferebly 2 viewsSigns of secondary complications

may be evident – pneumothorax,haemothorax, pulmonary contusion, etc.

Flail ChestFlail ChestRadiological features:

● Multiple rib fractures.● Costochondral separation may not be evident.● Signs of secondary complications may be evident – pneumothorax,haemothorax, pulmonary contusion, etc

PneumothoraxPneumothoraxRadiological featuresA luscent area with no vascular

marking and Visceral pleural edge visible.

Mediastinal shift to contralateral affected side

A small pneumothorax may not be visualised on a standard inspiratory film.A expiratory film may be of benefit

HydroPneumothorax

HaemothoraxHaemothoraxAccumulation of blood within the pleural space following blunt or penetrating trauma.Radiological featuresBlunting of the costophrenic angles – seen with approximately 200 ml of blood.General increased opacification of the hemithorax is seen on a supine film.

HaemothoraxHaemothorax

Erect Film Supine Film

Aortic RuptureAortic Rupture

Aortic rupture

Diaphragmatic Diaphragmatic rupture/herniarupture/herniaRadiological features

● In the acute phase, unless there is visceral herniation, sensitivity is poor for all imaging modalities.● CXR:– Air filled or solid appearing viscus above the diaphragm.This may only be recognised following passage of an NG tube.– Other features include mediastinal shift away from the affected side, diaphragmatic elevation, apparent unilateral pleural thickening or suspiciousareas of atelectasis.● In the non-acute setting contrast studies may be useful.

Diaphragmatic rupture/hernia

Diaphragmatic Diaphragmatic rupture/herniarupture/hernia

Foreign body – Foreign body – Inhaled/ingested foreign Inhaled/ingested foreign

bodiesbodies

Pulmonary EdemaPulmonary Edema•Cardiac : Heart Failure•Non-Cardiac : renal failure, IV overload, ARDS, anaphylaxis, near drowning.

•Radiologic Features:•Alveolar edema :tiny nodular/acinar areas of increased opacity, frank consolidation, batwing appearance•Interstitial edema : appearance of Kerley lines

IntestitialPulmonary edema-heart failure

Alveolar pulmonary edema/ Bat Wing ( Butterfly ) apperances.

Non cardiac Pulmonary edema-ARDS

AbdomenAbdomen● ABDOMINAL AORTIC ANEURYSMS● OBSTRUCTION – LARGE BOWEL● OBSTRUCTION – SMALL BOWEL● PERFORATION ● TRAUMA – BLUNT ABDOMINALT RAUMA

Spleen, Hepatic, and pancreas

CT SCAN USG - FASTPlain Abdomen Film

Abdominal aortic Abdominal aortic aneurysmsaneurysms

Radiological features◦ Abdominal X-ray (AXR): Look for curvilinear

‘egg shell’ type calcification◦ Ultrasound (US) can accurately determine

size.Limited use in assessing rupture.◦ CT is accurate in assessing aneurysm

rupture as well as visualising adjacent structures.

(up)Ruptured aortic aneurysm. The arrowheads denote the breach in the wall of the aneurysm (A), with extensive associated retroperitonealhaemorrhage (H).

(Left)Calcification in the left lateral wall of an aortic aneurysm (arrowheads).

Obstruction-SBOObstruction-SBORadiologic Features: AXR (3pos.)

◦Dilated small bowel, multiple airfluid level

◦Bowel wall Thickening, “Herring Bone appearances”

◦Little gas in colon, especially rectumKey: disproportionate dilatation of

SB, bowel sound ↑Causes : Adhesions,Hernia, Volvulus,

Gallstone ileus,Intussusception

Mechanical Small Bowel Obstruction

Supine

Cross Table

Erect

Obstruction-LBOObstruction-LBORadiologic features

◦Dilated colon to point of obstruction◦Multiple air fluid level=Step Ladder◦“Herring Bone appearances”◦Little or no air in rectum/sigmoid◦Little or no gas in small bowel,

Ileocecal valve remains competent. Distended small bowel shows incompetent ileocecal valve

Large bowel Obstruction

PerforationPerforationPerforation of an air containing

hollow viscus will result in free intraperitoneal air

Radiological features◦CXR : free sub-diaphragmatic air

AXR : Left Lateral DecubitusAir will then outline the lateral edge of the liver

Perforation

pneumoperitonium

AXR , LLD position

BLUNT HEPATIC TRAUMABLUNT HEPATIC TRAUMAThe third most common organ injured in the

abdomen.

The need for surgery is determined by the size of the laceration, the amount of

hemoperitoneum, & the patient’s clinical status.

Ultrasound findings: - Laceration (right lobe > left lobe)

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- Intrahepatic hematoma: * Hyperechoic in the first 24 hours * Hypoechoic & sonolucent thereafter

- Subcapsular hematoma: * Unilateral, along the area of laceration * Anechoic, hypoechoic, septated

lenticular, or curvelinear (DD/ascitic fluid)

- Capsular disruption

- Intraperitoneal fluid

Ultrasound findingsUltrasound findings

A crescent-shaped hyperechoic collection along the right lateral aspect of the liver consistent with subcapsular hematoma.

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BLUNT HEPATIC TRAUMABLUNT HEPATIC TRAUMACT grading (blunt hepatic trauma)

Grade I Capsular avulsion, superficial laceration (s) (<1 cm deep),subcapsular haematoma (<1 cm thick), isolated periportal blood tracking

Grade II Parenchymal laceration (s) 1-3 cm deep, central/subcapsularhaematoma (s) 1-3 cm

Grade III Laceration (s) > 3 cm deep, central/subcapsular haematoma(s)> 3 cm

Grade IV Massive central/subcapsular haematoma (> 10 cm), lobartissue destruction (maceration) or devascularisation

Grade V Bilobar tissue destruction (maceration) or devascularisation

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BLUNT HEPATIC TRAUMABLUNT HEPATIC TRAUMA

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BLUNT HEPATIC TRAUMABLUNT HEPATIC TRAUMA

SUBACUTE SUBCAPSULAR SUBACUTE SUBCAPSULAR HAEMATOMA OF THE LIVERHAEMATOMA OF THE LIVER

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BLUNT HEPATIC TRAUMABLUNT HEPATIC TRAUMA

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Liver laceration with extravasation. Liver laceration with extravasation. An enhanced axial CT scan of the An enhanced axial CT scan of the upper abdomen shows a large laceration through the right lobe of the liver upper abdomen shows a large laceration through the right lobe of the liver (blue arrow), blood in the peritoneal cavity (black arrows) and active (blue arrow), blood in the peritoneal cavity (black arrows) and active extravasation of the intravenous contrast (red arrow). The stomach is extravasation of the intravenous contrast (red arrow). The stomach is labeled "S."labeled "S."

SPLENIC INJURYSPLENIC INJURYMost commonly injuredUltrasound findings: - Splenomegaly, with progressive enlargement - Irregular splenic border - Intrasplenic hematoma - Contusion (splenic inhomogeneity) - Subcapsular and pericapsular fluid collections - Free intraperitoneal blood (disappear 2-4 weeks) - Left pleural effusion - When the spleen returns to normal → small irregular foci /normal parenchyma

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SPLENIC INJURYSPLENIC INJURY

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SPLENIC INJURYSPLENIC INJURY

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HAEMOPERITONEUM (FRAGMENTED HAEMOPERITONEUM (FRAGMENTED SPLEEN)SPLEEN)

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BLUNT PANCREATIC INJURYBLUNT PANCREATIC INJURYCT grading (blunt pancreatic injury)

Grade I Minor contusion or laceration without duct injury

Grade II Major contusion or laceration without duct injury or tissue loss

Grade III Distal transection or parenchymal injury with duct injury

Grade IV Proximal transection (to the right of mesenteric vein) or parenchymal injury involving ampulla

Grade V Massive disruption of pancreatic head

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BLUNT PANCREATIC INJURYBLUNT PANCREATIC INJURY

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ExtremitiesExtremitiesTrauma : Plain X-Ray, CT Scan,

MRIRule of two (Plain X-Ray)

◦Two views◦Two joints◦Two sides

Clavicle fracture

Scapular Fracture

AC Separation

AP position

Lateral position

Galeazzi Fracture

Monteggia Fracture

Posterior hip dislocation

Left Acetabulum Fracture- CTScan 2D -3D

Left femoral neck Fracture

Shenton’s line

ANY QUESTIONS??ANY QUESTIONS??

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