multiorgan trauma - warszawski uniwersytet...

MULTIORGAN TRAUMAMichał Kozub

TRAUMATIC INJURIES

• Trauma is defined as a sudden, unexpected, dramatic, forceful, or violent event

• Blunt, penetrating, explosive, and thermal forces are common causes of traumatic injuries

TRAUMATIC INJURIES

• Trauma is responsible for 100,000 – 180,000 deaths annually in the United States and is the leading cause of death among those who are 1–44 years old

• The financial burden is estimated to be around $300 billion per year. Blunt trauma accounts for 70% of trauma cases, more than two-thirds of which are caused by motor vehicle collisions.

TRAUMATIC INJURIES

• Trauma patients are at risk for shock, coagulopathy, acidosis and multi–organ system failure, and their treatment is a race against time.

• In 2007, over 180 000 people died of trauma and abdominal injuries contributed to a large number of these deaths.

TRAUMATIC INJURIES

• The most common causes of trauma are motor vehicle collisions, falls from height, assaults and sports accidents.

• Three basic mechanisms explain the damage to the abdominal organs: deceleration, external compression, and crushing injuries.

Computed tomography whole body imaging in multi-trauma: 7 years experience

Sampson, M.A. et al.

Clinical Radiology , Volume 61 , Issue 4 , 365 - 369

TRAUMATIC INJURIES

• Rapid deceleration generates shear forces that create movement of adjacent structures in opposite directions, causing tears at the points of fixation, such as vascular pedicles and mesenteric attachments.

• In crushing injuries, massive forces crush the abdominal contents between the abdominal wall and the spine or bones of the chest wall.

• Extreme external compression may cause a sudden increase in intraabdominal/intracranial pressure, possibly resulting in rupture of hollow viscera.

IMMOBILIZATION IN THE PREHOSPITAL SETTING Cervical Collars

Full-Body Spine Immobilizers

TRAUMA SCAN - CT PROTOCOL

• non-contrast head,

• cervical spine: cranio-cervical and cervico-thoracic junctions

• oral / intravenouscontrast-enhancedthoracic, abdomen and pelvis) after initial triageand a standard trauma series of radiographs(chest, lateral C-spine and pelvis).

CT PROTOCOL

• Imaging of head trauma / neuroimaging in Traumatic Brain Imaging

• Imaging of spinal trauma

• Imaging of chest trauma

• Imaging of abdominal and pelvic injuries

IMAGING OF HEAD TRAUMA

•Head trauma is the leading cause of death in people under the age of 30

•Males have 2-3 x frequency of brain injury than females

•Due mainly to motor vehicle accidents and assaults

CLASSIFICATION OF TBI - TRAUMATIC BRAIN INJURY

• Primary• Injury to scalp, skull fracture

• Surface contusion/laceration

• Intracranial hematoma

• Diffuse axonal injury, diffuse vascular injury

• Secondary• Hypoxia-ischemia, swelling/edema, raised intracranial pressure

• Meningitis/abscess

• The presence of a skull fracture increases the risk of having a posttraumatic intracranial lesion.

• However, the absence of a skull fracture does not exclude a brain injury, which is particularly true in pediatric patients due to the capacity of the skull to bend.

• NO ROLE FOR PLAIN FILMS IN ACUTE HEAD TRAUMA

BONE FRACTURES

• CT without contrast is the modality of choice in acute trauma (fast, available, sensitive to acute subarachnoid hemorrhage and skull fractures)

• MRI is useful in non-acute head trauma (higher sensitivity than CT for cortical contusions, diffuse axonal injury, posterior fossa abnormalities)

APPROACH TO CT BRAIN

• Look at the scout film: Fracture of upper cervical spine or skull

• Look for brain asymmetry

• Look at sulci, Sylvian fissure and cisterns to exclude subarachnoid hemorrhage

• Change windows to look for subdural collection

• Look at bone windows to see fractures

• Determine if mass is intraaxial (in the brain) or extraaxial(outside)

SCALP INJURY

• Cephalohematoma: blood between the bone and periosteum - can not cross the suture lines.

• Subgaleal hematoma: blood between the periosteum and aponeurosis - can cross the suture lines.

EXTRAAXIAL FLUID COLLECTIONS

• Subarachnoid hemorrhage(SAH)

• Subdural hematoma(SDH)

• Epidural hematoma

• Intraventricular hemorrhage

SUBARACHNOID HEMORRAGE

• Can originate from direct vessel injury, contused cortex or intraventricular hemorrhage

• Look in the interpeduncular cistern and Sylvian fissure

• Usually focal (but diffuse from aneurysm)

• Can lead to communicating hydrocephalus

SUBDURAL HEMATOMA

• Occurs between the dura and arachnoid

• Can cross the sutures but not the dural reflections

• Due to disruption of the bridging cortical veins

• Hypodense(hyperacute, chronic), isodense(subacute), hyperdense(acute)

SUBDURAL HEMATOMA

SUBDURAL HEMATOMA

• Acute SDH with thickness > 10 mm or midline shift > 5mm should be evacuated

• Patient in coma with a decrease in GCS by >2 points with a SDH should undergo surgical evacuation

EPIDURAL HEMATOMA

• Located between the skull and periosteum

• Due to laceration of the middle meningeal artery or dural veins

• Common with fractures (in 80-95%)

• Can cross dural reflections but is limited by suture lines

• Lentiform shape (but concave shape in SDH)

EPIDURAL HEMATOMA

Lentiform shape

EPIDURAL HEMATOMA

• EDH > 30 cm3 should be evacuated

• EDH < 30 cm3 and <15 mm thickness and < 5 mm midline shift and GCS >8 may be managed nonoperativelywith serial CT

INTRAVENTRICULAR HEMORRHAGE

• Most commonly due to rupture of subependymalvessels

• Can occur from reflux of SAH or contiguous extension of an intracerebral hemorrhage

• Look for blood-cerebrospinal fluid level in occipital horns

INTRA-AXIAL INJURY

• Surface contusion/laceration

• Intraparenchymalhematoma

• White matter shearing injury/diffuse axonal injury

• Post-traumatic infarction

• Brainstem injury

CONTUSION/LACERATIONS

• Most common source of traumatic SAH

• Contusion: must involve the superficial gray matter

• Laceration: contusion + tear of pia-arachnoid

• Hemorrhage present ½ cases and occur at right angles to the cortical surface

• Located near the irregular bony contours: poles of frontal lobes, temporal lobes, inferior cerebellar hemispheres

CONTUSION/LACERATIONSinvolve the superficial gray matterFocal collections of blood that most commonly arise

from shear-strain injury to intraparenchymal vessels.

Usually located in the frontotemporal white matter or

basal ganglia

DIFFUSE AXONAL INJURY

• Rarely detected on CT ( 20% of

DAI lesions are hemorrhagic)

• MRI: T1, T2, T2 GRE, SWI (follow

up after 24h)

BRAIN HERNIATIONS

• Supratentorial herniation

• Uncal (transtentorial)

• Central

• Cingulate (subfalcine/transfalcine)

• Transcalvarial

• Tectal (posterior)

• Infratentorial herniation

• Upward (upward cerebellar or upwardtranstentorial)

• Tonsillar (downward cerebellar)

SUBFALCIAL HERNIATION

• Subfalcial: displacement of the cingulate gyrus under the free edge of the falx along with the pericallosal arteries.

• Can lead to anterior cerebral artery infarction

Midline shift is measured in millimeters, as the perpendicular distance between a midline structure (usually the septum pellucidum) and a line designated the midline.

UNCAL HERNIATION

• Displacement of the medial temporal lobe through the tentorial notch

• Displacement of the midbrain

• Effacement of the suprasellarcistern

• Displacement of the contralateral cerebral peduncle against the tentorium

• Widening of the ipsilateral cerebello pontine angle

• Compression of the posterior cerebral artery

TONSILLAR HERNIATION

• Inferior displacement of the cerebellar tonsils through the foramen magnum

• Can lead to posterior cerebellar artery infarction

IMAGING OF CERVICAL SPINE TRAUMA

• Spinal cord injury (SCI) is a significant cause of disability

• The majority (81%) are males and the average age is relatively young at 32.8 years.

• Approximately half the spinal cord injuries occur from motor vehicle crashes. Falls from >10 feet


• 85% of SCI (spinal cord injuries) arisefrom fracture or dislocation in vertebralcolumn

• 15% of SCIWORA (spinal cord injurywhithout radiological abnormality)

• Risk factors:• Congenital spinal stenosis

• Preexisting spondylosis

• Prolapse of intervertebral disc


• Spinal cord compression (bonefragments, hernation, hematoma, preexisting degenerative spinal disease)

• Intramedullary lesions:

• Edema

• Early ischemia

• Hematomyelia

• Contusive hemorrage

• Cord laceration/transection

• MRI is the method of choiceSubacute post-traumatic ascending myelopathy after T12 burst fracture in a 32-year-old male: case report and surgical result of cervical durotomyJian Zhang, Huili Wang, Haiying Liu & Guangshun Wang

IMAGING OF SPINAL TRAUMA

• Single detector CT scan has a sensitivity of 98% for fracture with a specificity of 93%

• With the new generation of 16 and up to 64 detector scanners, it is likely that CT today is more accurate and more cost effective

• CT is being used for screening cervical spine in high-risk patients, particularly if CT is also to be used to evaluate the subjects head

• Radiography remains appropriate in low-risk subjects, as well as in those situations where CT is not available.

FLEXION INJURIES

• The most common fracture mechanism in cervical injuries is hyperflexion.

• Anterior subluxation occurs when the posterior ligaments rupture.

http://www.radiologyassistant.nl/en/p49021535146c5/spine-cervical-injury.html

FLEXION INJURIES• Simple Wedge( compression) fracture

is the result of a pure flexion injury. The posterior ligaments remain intact. Anterior wedging of 3mm or more suggests fracture.

• Usually involves the upper endplate.

• Flexion teardrop fracture is the result of extreme flection with axial loading. It is unstable and is associated with a high incidence of cord damage.

HANGMAN' S FRACTURE - IS THE MOST COMMON CERVICAL SPINE FRACTURE.

• Traumatic Spondylolisthesis of C2

• Most common form of this injury results from extension combined with axial loading

• The full force of acute hyperextension of the head on the neck is transmitted through the pedicles of C2 onto the apophyseal joints. The weakest points in this chain are the interarticular segments of the pedicle. Thus, the arch of C2 is fractured anterior to the inferior facet.

HANGMAN' S FRACTURE - IS THE MOST COMMON CERVICAL SPINE FRACTURE.

• Hangman fracture is a bilateral fracture through the pars interarticularis of C2

• The pars interarticularis is found between the superior and inferior articular processes of C2

• Spinal cord damage is uncommon, despite frequent significant fracture displacement, due to the wide spinal canal at this level

http://www.radiologyassistant.nl/en/p49021535146c5/spine-cervical-injury.html#i49046c13e752d

ODONTOID FRACTURES.

• Odontoid or dens-fractures are very common.They are seen in elderly, but also frequently in children due to the relatively large head-to-spine ratio.

• The most common type of odontoid fracture, which is type II through the base of the odontoid.

• Classification of dens fractures (Anderson and DAlonso ) - based upon the location of the fracture site with respect to the dens

CLASSIFICATION OF DENS FRACTURES ANDERSON AND D’ALONSO

• Type I: Avulsion of the tip of the dens where it is attached to C1.This is a rare fracture.It is stable, since the fracture line is above the transverse ligament.

• Type II: Through the base of the dens.Most common fracture.Always unstable and poor healing.

• Type III: Fracture through the body of the axis and sometimes facets.Can be unstable, but has a better prognosis than type II due to better healing of the fracture which runs through the metaphyseal bone of the body of C2.

IMAGING OF CHEST TRAUMA

• Lung trauma

• Pulmonary contusions

• Pulmonary lacerations

• Traumatic lung herniation

• Torsion of the lung

• Pneumothorax

• Haemothorax

• Haemopneumothorax

• Tracheobronchial injuries

• Mediastinal

• Pneumomediastinum

• Mediastinal haematoma

• Aortic injury

• Oesophageal injuries

• Thoracic duct trauma

• Cardiac trauma

IMAGING OF CHEST TRAUMA

• Skeletal trauma

• Rib fractures

• Flail chest

• Sternal fractures

• Scapula fractures

• Thoracic spine fractures

• Diaphragmatic trauma

• Diaphragmatic injuries

Oikonomou A, Prassopoulos P. CT imaging of blunt chest trauma. Insights into Imaging. 2011;2(3):281-295.

doi:10.1007/s13244-011-0072-9. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3259405/

PULMONARY CONTUSIONS

• The most common injury seen in up to 75% of patients.

• Contusions result from leakage of fluid and red cells into alveolar air spaces.

• Ground glass changes and lung consolidation with air bronchogramsrepresent the spectrum of injury.

• Lung contusions do not respect fissures and are often peripherally located

https://radiopaedia.org/articles/pulmonary-contusion


• Radiographic clearing of pulmonary contusion is relatively rapid and the signs of contusion have often resolved within 48 hours.

• By day 10 they should have resolved completely. If the consolidation progresses after a day or two after the traumatic injury, then superimposed aspiration, atelectasis and infection should be considered.



It is post-traumatic damage to the lung tissues resulting in hemorrhage and localized edema.


PULMONARY LACERATIONS

• Caused by traumatic disruption of the lung architecture that results in the formation of a cavity that can be filled with blood, air or with an air fluid level.

• They tend to be ovoid in shape and unlike contusions may take weeks to months to resolve.

• Complications of lacerations include superimposed infection with abscess formation and bronchopleural fistulae.

https://radiopaedia.org/articles/pulmonary-laceration-1


• Regions of pulmonary contusion with added blebs (lat.pneumatocoeles) with air fluid levels.

• Due to normal pulmonary elastic recoil, lung tissues surrounding a laceration often pull back from the laceration itself. This results in the laceration manifesting at CT as a round or oval cavity, instead of having the linear appearance typically seen in other solid organs.

• Severe lacerations have gross disruption of lung parenchymal architecture.

https://radiopaedia.org/articles/pulmonary-laceration-1


• The tear in the lung is filledwith blood or air.

PNEUMOTHORAX

• Occurs when air fills a space between parietal and visceral pleura of lungs.

• Occurs in up to 40% of patients following blunt chest trauma.

PNEUMOTHORAX TYPES / ETIOLOGY

• Spontaneous• Primary (occurs without any

underlying lung disease and in the absence of an inciting event).

• Secondary (occurs in people with underlying parenchymal lung disease (chronic obstructive pulmonary disease, pulmonary fibrosis).

• Iatrogenic / Traumatic

• Open/ Close

• Tension Pneumothorax

SIMPLE PNEUMOTHORAX• On a chest radiograph,

pneumothorax may be identified by a discrete shadowed line beyond which no lung markings are present. Visceral pleural line

• They most commonly occur in the lung apices, which are the least dependent part of the lung.

• Erect AP/PA view is the best

• Visceral pleural line

• No vessels or markings

• Variable degree of lung collapse

• No shift

• However, on supine radiographs has limited sensitivity ca. 50%, pneumothoraces may be subpulmonic or anteromedial in location. Comparison between inspiratory and expiratory films may

aid in detection.

• Supine AP view Deep sulcus sign

• Too sharp heart border/hemidiaphragm sign

• Increased lucency over lower chest

• Subpulmonic air sign

• Visible vessels

DEEP SULCUS SIGN

https://radiopaedia.org/articles/deep-sulcus-sign

Lucency at right costophrenic angle

which projects well below the

costophrenic angle on the opposite

side is the "Deep sulcus sign" indicating

the presence of a pneumothorax on a

supine radiograph of the chest .

SUBPULMONIC SIGN

• Occasionally, a posteriorsubpulmonary pneumothoraxwill result in visualization of the more superior anteriordiaphragmatic surface and the inferior posterior diaphragmaticsurface, resulting in the double-diaphragm sign.

PNEUMOTHORAX

• Pneumothorax is a pocket of air between the two layers of pleura (parietal or visceral), resulting in collapse of the lung.

Subcutaneous emphysema

PNEUMOTORAX CT

Subcutaneous emphysema

• Much more sensitive than plain films.

• Even a small traumatic pneumothorax is important, especially if patient ismechanically ventilated or going to OR

• A simple pneumothorax can be converted into a life- threatening tension pneumothorax.

US?

U/S signs of pneumothorax

• Loss of lung sliding.

• Loss of comet tails.

• Loss of seashore( Sandy Beach) sign (M mode).

• Stratosphere sign or bar code sign(M mode).

PITFALLS????

Giant bulla - bullous emphysema?

http://radiologyinthai.blogspot.com/2010/08/giant-bulla-vs-pneumothorax.html

TENSION PNEUMOTHORAX

• Is the accumulation of air under pressure in the pleural space.

• It develops, when injured tissue creates a one-way valve for air to enter, but it can notescape from the pleural space.

• Diagnosis should be made on clinical grounds by contralateral tracheal deviation, ipsilateral hyperresonance to percussion, ipsilateral decreased breath sounds, distended neck veins and hypoperfusion.

A TENSION PNEUMOTHORAX

• The typical radiographic findings are ipsilateral lung collapse with widened intercostal spaces and contralateral mediastinal.

• With left hemithorax, left hemidiaphram may be depressed, but liver prevents this from developing on the right side.

A TENSION PNEUMOTHORAX

• It is life threatening condition.

• The pleural pressure is more than the atmospheric pressure.

Radiological manifestations of large pneumothorax :

•Mediastinal shift

•Flattening of the hemidiaphragm

• Lung collapse.

PNEUMOMEDIASTINUM

• Pneumomediastinum - free air in the mediastinal structures.

• Usually it occurs after trauma or iatrogenic injury of esophagus.

PNEUMOMEDIASTINUM

• On chest radiography, free air may outline anatomic structures.

• Common findings are:

• a thin line of radiolucency that outlines the cardiac silhouette,

• vertically oriented streaks of air in mediastinum,

• a double bronchial wall sign or lucency around right pulmonary artery,

• the "ring around artery" sign.

Air is most easily detected retrosternally on lateral chest radiographs. Air is fixed in pneumomediastinum and does not rise to the highest point.

PNEUMOMEDIASTINUM CT

HEMOTHORAX

• literally means blood within chest,

• is a term usually used to described a pleural effusion due to an accumulation of blood.

HEMOTHORAX

ERECT

HAEMOPNEUMOTHORAX

• Haemopneumothorax is a term given when there is a concurrent presence of haemothorax and pneumothorax.

• It is a variant of hydropneumothorax.

HAEMOPNEUMOTHORAX - CT

SKELETAL TRAUMA

• Rib fractures

• Flail chest

• Sternal fractures

• Scapula fractures

• Thoracic spine fractures

RIB FRACTURES

• A rib fracture is a break in a rib bone.

• Usually caused by a blunt chest trauma (fall, blow to the chest, etc).

• Rib fractures are the most common skeletal injury in a blunt chest trauma.

• Fractures of upper three ribs are a marker of high impact trauma.

• Lower rib fractures are associated with upper abdominal injuries.

• Chest complications of rib fractures include pneumothorax, haemothorax, haemopneumothorax, pulmonary contusions and subcutaneousemphysema.

RIB FRACTURES

FLAIL CHEST

• The breaking of 2 or more ribs in 3or more places, resulting in free-floating rib segments.

• The flail segment has no bony or cartilaginous connection.

• Moves independently of the chest wall.

• Paradoxical chest movement ispresent!

FLAIL CHEST

https://radiopaedia.org/articles/flail-chest

STERNAL FRACTURES

• Sternal fractures occur in ~5% of blunt chest trauma.

• The manubrium being the most commonly injured part.

• MDCT with multiplanar reconstructions (MPR) is superior to plain chest radiographs in their diagnosis.

STERNAL FRACTURES

https://radiopaedia.org/articles/sternal-fracture

SCAPULA FRACTURES

• Scapula fractures are uncommon injuries, representing ~3% of all shoulder fractures.

• Requires high energy trauma (e.g. motor vehicle accidents account for 50% of scapular fractures).

• Scpaular fractures are often associated with other injuries as clavicle fracture, rib fracture, sternal fracture.

SCAPULA FRACTURES

https://radiopaedia.org/articles/scapular-fracture

THORACIC SPINE FRACTURES

• Spinal fractures are usually the result of significant

trauma to a normally formed skeleton, or the result

of trauma to a weakened spinal column.

This model is used to predict the soft tissue injury from bone injury.Spinal stability is dependent on at least two intact columns.When two of the three columns are disrupted, it will allow abnormal segmental motion, i.e. instability.

So a simple anterior wedge fracture or just sprain of the posterior ligaments is a stable injury.However a wedge fracture with rupture of the interspinous ligaments is unstable, because the anterior and the posterior column are disrupted.A burst fracture is always unstable because at least the anterior and middle column are disrupted.

http://www.radiologyassistant.nl/en/p54885e620ee46/spine-injury-tlics-classification.html

The Thoraco-Lumbar Injury Classification and Severity

score (TLICS)


• Look for fractures and paraspinal

hematomas.

• The findings may be very subtle.

• Most common: wedge fractures

(compression fractures ) and burst

fractures

http://www.radiologyassistant.nl/en/p4906c8352d8d2/spine-thoracolumbar-

injury.html


MRI examination of the lumbar spine reveals and confirms the presence of three compression fracture deformities of

T12, L1, and L2. There is no retropulsion of the vertebral contents into the spinal canal. There are no associated

herniated discs although the associated endplate fractures do show early acute Schmorl’s node defects

(intravertebral herniations).

TRAUMATIC INJURIES: IMAGING OF ABDOMINAL AND PELVIC INJURIES

The common goal of

management of patients with

abdominal trauma is the rapid

identification of life-threatening

lesions, their causes, and the

adequate treatment

IMAGING STRATEGIES IN PATIENTS WITH ABDOMINAL AND PELVIC TRAUMA

• Ultrasound is a rapid and reliable method for screening of patients with sustained abdominal trauma for the presence of hemoperitoneum

• The primary goal of this initial rapid examination is to determine the need for immediate laparotomy

• Focused abdominal US for screening of free fluid includes inspection of the perihepatic area (which includes the Morrison pouch), the perisplenic region and the paracolicgutters and the pelvis

FAST• The Focused Assessment with Sonography for Trauma is a

rapid, bedside, ultrasound examination performed to identify intra-peritoneal haemorrhage or pericardialtamponade.

• FAST examines four areas for free fluid:

• Perihepatic & hepato-renal space

• Perisplenic

• Pelvis

• Pericardium

CLINICAL SCENARIOS WHERE „FAST” IS MOST USEFUL:

• Hemodynamically unstable patients, when the cause of hypotension is unclear.

• Patients who need an emergent bedside procedure.

• Intoxicated patients who can be observed and re-examined.

• Patients with penetrating trauma with multiple wounds or unclear trajectory, especially with wounds in upper abdomen or lower chest.

http://www.supertechx-ray.com/Ultrasound/TrainingPhantoms/FASTERFAN.php

IMAGING STRATEGIES IN PATIENTS WITH ABDOMINAL AND PELVIC TRAUMA

• Computed tomography examinations of the abdomen are recommended for trauma patients with suspected abdominal injuries

• Compared with US, CT is less operator dependent and is not limited by superficial wounds, subcutaneous emphysema, obesity, or bowel gas

DIAPHRAGM RUPTURE

• Blunt trauma of the abdomen results in sudden increase of intra-abdominal pressure and may cause spontaneousrupture of the diaphragm

• The incidence of diaphragmatic ruptures ranges up to 4.5%

in patients with major trauma

DIAPHRAGM RUPTURE

• 90% of the clinically diagnosed cases of diaphragmaticrupture involve the left side of the diaphragm

• The left side is anatomically less protected compared with the right, liver-shielded side

• Injuries to the right diaphragm are usually smaller in size compared with the left side

THE CT FEATURES OF DIAPHRAGMATIC RUPTURE

• diaphragmatic discontinuity

• intrathoracic herniation of abdominal organs and structures

• the "collar" sign which is focalconstriction of abdominalviscera, mostly bowel orstomach, at the site of the herniation

DIAPHRAGM RUPTURE

Indirect signs of a diaphragmatic tear

• elevation of the diaphragm with the pleural effusion

• deformation of the hepatic or spleniccontour by herniating viscera

THE MANIFESTATIONS CAN BE DELAYED.

The patient may be asymptomatic for years!

DIAPHRAGM RUPTURE

A 67-year-old woman who had suffered

abdominal pain, nausea and vomiting

rupture of the left hemi-

diaphragm with associated

collapse of the left lung

http://www.trauma.org/imagebank/chest/images/chest0023a.jpg

http://www.trauma.org/imagebank/chest/images/chest0023a.jpg

DIAPHRAGM RUPTURE

• elevation of the lefthemi-diaphragmconsistent with ruptureddiaphragm

A 67-year-old man struck by a bus

with left sided chest pain

DIAPHRAGM RUPTURE

stomach in the left

thoracic cavity

rib fractures responsible for the

diaphragmatic laceration

http://www.trauma.org/imagebank/chest/images/chest0023b.jpg

http://www.trauma.org/imagebank/chest/images/chest0023b.jpg

HERNIATION OF STOMACH THROUGH A

RUPTURED LEFT HEMIDIAPHRAGM

reduced transparency of the left lower

lung lobe

herniation of the stomach into the left

lower chest through a diaphragmatic

tear

HERNIATION OF STOMACH INTO THE LEFT LOWER CHEST THROUGH A RUPTURED LEFT HEMIDIAPHRAGM

the medial left diaphragmatic crus abruptly

terminates at the site of the rupture

focal constriction of the distal

body of the stomach ("collar

sign")

HEMOPERITONEUM

• Intraperitoneal bleeding secondary to abdominaltrauma with laceration of liver, spleen or otherintraabdominal organs

• Traumatic hemoperitoneum is a frequent finding on CT scans following abdominal trauma and may be detected by CT anywhere in the peritoneal cavity

HEMOPERITONEUM

• Typical attenuation values of hemoperitoneum a few hours after trauma are 30-45 HU

• Clot measures 50-60 HU or even more; attenuationvalues decrease after 48 h due to clot lysis

• Clots usually form around sites of bleeding and can be recognized by CT adjacent to injuries as higher density sentinel clots

HEMOPERITONEUM AND SPLENIC TRAUMA

Hemoperitoneum around spleen and

the perihepatic space

lacerations and

intraparenchyma

l hematomas

The sentinel clot sign.

The densest blood, representing

thrombus is seen closest to the site of

splenic injury in the perisplenic space

HEMOPERITONEUM

• Active bleeding sites can be identified by extravasation of IV contrast media

• Using CT, active hemorrhage may be detected originating from various organs including liver, spleen, pancreas, kidneys, bowel, mesentery, and abdominal soft tissues

ACTIVE BLEEDING RESULTING FROM TRAUMATIC RECTUS MUSCLE AVULSION

focal area of contrast

extravasation in the

thickened distal part of the

right rectus abdominal

muscle with avulsion from its

insertion at the pubic

tubercle

HEMOPERITONEUM

• Abdominal ultrasound for screening of free fluid includes sonographic inspection of the perihepatic area (which includes the Morrison pouch), the perisplenicregion (which includes the splenorenal recess), the paracolic gutters and the pelvis.

fluid in the left flank, ventrally to a bowel loop

THANKS FOR ATTENTION• http://www.radiologyassistant.nl

• https://radiopaedia.org/

• Hochhegger B, Ley-Zaporozhan J, Marchiori E, et al. Magnetic resonance imagingfindings in acute pulmonary embolism. The British Journal of Radiology. 2011;84(999):282-287. doi:10.1259/bjr/26121475.

• Oikonomou A, Prassopoulos P. CT imaging of blunt chest trauma. Insights into Imaging. 2011;2(3):281-295. doi:10.1007/s13244-011-0072-9. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3259405/

• ECR 2008 / C-275Blunt chest trauma: Spectrum of findings with emphasis on MDCT

• Blunt Polytrauma: Evaluation with 64-Section Whole-Body CT Angiography, David Dreizin, MD, and Felipe Munera, MD

• Multidetector CT of Blunt Abdominal Trauma, Jorge A. Soto, MD, and Stephan W. Anderson, MD

• Chan O, Wilson A, Walsh M. Major trauma. BMJ : British Medical Journal. 2005;330(7500):1136-1138.

• Lee B, Newberg A. Neuroimaging in Traumatic Brain Imaging. NeuroRx. 2005;2(2):372-383.

multiorgan trauma - warszawski uniwersytet...

Documents