Radiological Trauma Survey

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surgeryTrauma is the leading cause of death for children and young adults below the age of 44. Thousands of people die everyday from RTAs (road traffic accidents) which gives the topic a great importance, and necessitates improving the knowledge and skills of the medical teams in dealing with such catastrophic events.

Major trauma, be it RTA or falling from a height, or any other cause of major trauma, is one of the medical conditions that particularly needs highly coordinated team work, as the standard of care required in such patient subgroup involves many specialties,from Emergency medicine specialists, passing by intensivists, general surgeons, orthopedic surgeons, radiologists, as well as vascular and neurosurgeons.

It is worth noting that in some respectful medical institutes, there are specialized trauma teams consisting of different specialists who are well trained to deal with major trauma patients, a protocol that would hopefully be operating everywhere soon.

Our main concern in this article is to shed light on the role of radiologists in performing the primary and secondary radiological survey for trauma victims as well as properly diagnosing any present pathology and guiding the therapeutic interventions in the right direction, and more importantly in a timely manner as when we talk about trauma victims, time is life.

But though discussing the radiological aspect of the issue is our main concern, we will try to shed light on the issue generally because of its great importance, which makes it necessary for any health care provider to have a minimal degree of awareness about it, and that is what we will be doing now.

The high energy trauma which we call major trauma can be caused by many things, like falling from a height (higher than second floor), a motor car accident and warfare injuries. It is charecterised by being of high energy, and affecting different body areas. The main cause of death in this patient group is major bleeding with subsequent circulatory shock and cardiac arrest, which usually happens before reaching the hospital. Other causes of death include head trauma with intracerebral lacerations and haemorrhage, as well as other possible injuries including chest wall injury with tension peneumothorax, or massive fatal hemothorax. There is also the risk of abdominal trauma injuring highly vascular organs like the liver or spleen with subsequent intensive and usually fatal internal haemorrhage.

We should also never forget the risk of spinal injury, we actually should always assume that any major trauma patient has an injured cervical spine until proven otherwise, and that is why neck immobilisation with a neck collar is one of the first and most important steps in the primary care provided to trauma patients. Lastly, there are the pelvic fractures that could injure major vessels in the area, and also leading to a massive fatal internal haeomorrhage.

When we deal with a trauma patient we should follow a systematic approach, and we start with what we call the (ABCD), which means checking the airway, breathing circulation and any obvious disability. This is achieved by inspecting the airways and removing any obstruction by suction or keeping it patent by an oropharynegeal airway or possibly intubation, checking the pulse and arterial blood pressure and supporting the circulation with fluids after securing a venous access, immobilising the neck with a neck collar, and any apparent fracture. Also we start checking the mental status with a scoring system like the Glasgow coma scale system, and applying pressure to any external wounds to stop bleeding.

After stabilising the patientís vital signs, we proceed with clinical examination to all body systems, and then start the primary radiological survey which is usually done across the table via a portable X-ray machine, or possibly the patient is transferred to the emergency department radiology unit to run all radiological screening at once.
The main radiological studies that should be done to trauma patients differ a little from one place to another according to the local protocol, but there are some universal guidelines for trauma radiological survey that are done everywhere in the world, and these include:

1. Lateral view cervical spine X-ray to detect any fracture, dislocation, or fissure fracture. The film should be examined by a senior radiologist or an orthopedic surgeon. In some institutes, a dorsal spine X-ray is also a routine.

2. Postro-anterior chest X-ray to detect any rib fractures, pneumothorax, hemothorax, or lung contusions (though lung contusions are more apparent in a chest CT rather than a chest plain X-ray).

3. Antro-posterior pelvic X-ray film should be obtained to detect any fracture or fissure fracture. (It is important to remember that a pelvic fracture with hemodynamic compromise usually implies a vascular injury, and requires a quick surgical intervention)

4. Brain CT scan is not a universal routine screening test for trauma patients unless there is a sign of head injury (altered mental status or external scalp hematoma) but due to the high mortality associated with a missed cerebral haeomorrhage and due to the fact that a small extradural hematoma might not give any signs except after several hours, many institutes have added brain computed tomography scan to their routine trauma survey, to detect any type of haemorrhage including, extradural and subdural haemorrhages subarachnoid, and intracerebral haemorrhages, also to detect any skull fractures.

5. Abdominal ultrasound is mandatory in the presence of any hemodynamic compromise, and is also a routine test in some institutes, so as to detect any mild hemorrhagic collection in the pouches, an injured spleen or liver. Ruptured liver is one of the common consequences of abdominal massive trauma that is fatal if proper surgical intervention was not applied in a timely manner.

6. X-ray films for upper and lower limbs should be done upon request if there is a suspected fracture of any limb bone. Fracture femur, tibia, and humerus are frequently encountered in road traffic accident patients.

Currently, there are several trials studying the possibility of using the full-body computed tomography screening for trauma patients instead of the classic screening tests. The physicians who are enthusiastic about the idea argue that it would be an easier, faster and more convenient way of screening, but there are still some concerns about the unnecessary high radiation dose the patients would be exposed to, as well as the high economic cost. There is still a lot of debate regarding this, and the studyís results would help with that debate, but the use of this screening method doesnít seem to be happening regularly in the near future.

An important point to consider when imaging a major trauma victim especially those with head trauma is the lack of patient compliance due to many reasons like pain, anxiety and the sense of impending death encountered by this patient group, also the altered mental status in head trauma patients, and for these reasons, proper pain control and sedation is usually required prior to running any radiological imaging.

At last, we stress that diagnostic radiology plays a crucial role in the proper diagnosis and management of high energy trauma patients, and again the experience and skill of radiographers and radiologists in film taking and interpretation would have a great impact on patient management plan and care.

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