Trauma Radiography

Trauma Definition

• A sudden, unexpected, dramatic, forceful or violent event

• Affects people of all age ranges

• Requires major adaption of CR angles and image receptor placement

• All images must be as true to those of routine general radiography as possible

Intentional and unintentional trauma rank in causes of death

The top five causes of death across all ages, genders and races in the US

Intentional Trauma Examples

• Assault

• Homicide

• Suicide

Unintentional Trauma Examples

• Motor vehicle accidents

• Falls

According to the CDC how many people age 15-44 died from intentional and unintentional trauma (2019 statistic)

95,000

More than how many people die from injuries each year

275,000 - 1 person every 3 minutes (CDC)

The CDC

The centers for disease control and prevention is the US federal agency under the Department of Health and Human Services responsible for protecting public health and safety through the control and prevention of disease, injury, and disability

Trauma Centers

The term trauma center signifies a specific level of emergency medical care as defined by the American College of Surgeons commission on Trauma

Level I Trauma Center

The most comprehensive and is usually a university of research center, or a large medical center. All types of physicians, including radiologists, and all types of services are available 24 hrs/day

Level II Trauma Center

Similar to Level I, but not a teaching or research based facility. Some types of specialty physicians are not available on site

Level III Trauma Center

Usually located in smaller communities where Level I and II centers are not available. They have the capability of resuscitation, stabilizing, and preparing a patient for transfer to a higher level facility

Level IV Trauma Center

May not even be a hospital, rather a clinic or outpatient facility that treats minor injuries. A level IV center may offer stabilization and preparation for transfer to other facilities if necessary

Blunt Trauma

• MVAs

• Collisions

• Falls

• Aggravated Assaults

Penetrating Trauma

• GSWs

• Stab Wounds

• Impalement

• Foreign Body Ingestion

• Aspiration

Explosive Trauma

• Pressure shock waves

• High velocity projectiles

• Burns

Heat Trauma

• Burn injuries from fire,

• Steam

• Hot water

• Chemicals

• Electricity

• Frostbite

Immobilization Devices (Trauma Uses)

• Used to stabilize the body and prevent further injury

  • Limits movement

• Radiographer must be knowledgeable of

  • Radiolucency of devices

  • Devices that are requires to remain on during initial examination

    • Only to be removed after radiologist and attending physician has reviewed initial images

Common Immobilization Devices

• Cervical Collar

• Spine or Backboard

• *If patient becomes sick on backboard patient must be logrolled

Immobilization Devices (For normal positioning)

• Communication is the #1 method for immobilizing and limiting voluntary motion

• Specialized aids are often used to obtain accurate positioning of the patient and/or placement of the IR

• Used to help control patient movement, eliminate positioning inaccuracy by the radiographer, and decrease radiation exposure to the patient caused by repeat exams

• ER personnel, radiographers, or family members must not be used in place of these aids

Types of immobilization devices

• Positioning sponges

• Tape

• Velcro Straps

• Sandbags

• Sheets

Exposure Factors

• Use shortest time to decrease chance of patient motion

• Technique adjustments may need to be made when exposures are made through immobilization devices

• Pathologic conditions require adjustment in techniques. Internal bleeding (Increase) collapsed lung (Decrease), etc.

Imaging of the Patient

• Goal is to minimize movement of the patient

• When possible obtain all AP Projection while moving superiorly to inferiorly. Then all lateral projections moving inferiorly to superiorly

• Before imaging a patient, a radiographer should remove any items that may appear as artifacts on the image. This does not apply to immobilization devices such as backboard or neck braces. Necklaces, coins, keys, should be removed prior to imaging. Every facility will have a policy regarding placement of a patient’s personal items

• Radiographers must always use markers. Being in a rush is not an excuse to leave the marker off and annotate later

Adaption Tip: Two Projections

• Taken at 90 degrees (right angles from each other)

• True AP/PA and True lateral preferred

  • Turning the body part or angling the CR and IR as needed

• CR-Part-IR alignment maintained

Adaption Tip: Entire Structure on Image Receptor

• For all body parts, include entire area

  • For large patient may require two IRs

• Both joints of long bones should be included

  • For possible secondary fractures

• Always include a joint rule

  • Include a minimum of one joint nearest the site of injury

  • The joints nearest the fracture should always be included

• Include entire structure on horizontal beam laterals

  • Ensure that the image is not projected off the IR due to beam divergence with vertical IR

Trauma Alert Team Example

• EMS

• Dept Manager

• ED Physician

• ED Charge Nurse

• 2 ED Nurses

• ED LPN

• Respiratory Therapy

• Radiology

• Medical Lab

• Security

• Pt Access Representative

• House Supervisor

Radiographer’s Role in Trauma

• Depends on facilities protocol

• Primary responsibilities include

  • Perform quality diagnostic imaging procedures as requested

  • Practice ethical radiation protection for self, patient, and other personnel

    • Close collimation

    • Lead aprons for all personnel who remain in room

    • Exposure factors that minimize dose

    • Announcement of impending exposure to allow unnecessary personnel to exit room

  • Provide competent patient care

    • Take accurate vital signs and knowing normal ranges

    • The radiographer must be competent in CPR, oxygen administration, and dealing with various types of medical emergencies

    • The location of the crash carts and other emergency equipment is also necessary

    • If a patient begins to vomit while strapped to a backboard, the patient/board must be log rolled to prevent aspiration

Best Practices: Speed

Rapid quality imaging is essential to assist diagnosis and treatment

Best Practices: Accuracy

Accurate imaging and patient assessment are critical for identifying injuries with little distortion and guiding appropriate trauma care

Best Practices: Quality

High quality radiographs ensure optimal visualization of injury and reduce repeat exposures

Best Practices: Positioning

Proper positioning must be adapted to patient condition while maintaining diagnostic value

Best Practices: Practice Standard Precautions

Use proper PPE, hand hygiene, and protected accessory devices to reduce the risk of infection and cross contamination during trauma imaging

Best Practices: Immobilization

Injured body parts must remain stabilized to prevent further trauma during imaging procedures

Best Practices: Anticipation

Trauma radiographers should anticipate physician needs and possible additional imaging requests

Best Practices: Attention to detail

Continuously monitor patient status, never leave the patient unattended, and promptly notify the physician of critical changes or findings

Best Practices: Attention to dept protocol and scope of practice

Following established trauma protocols ensures safe, efficient, and compliant patient care

Best Practices: Professionalism

Adhere to ARRT Code of Ethics. Compassionate communication and calm behavior help maintain patient trust during stressful trauma situations

Pt Assessment: Primary Survey

• A - Airway

• B - Breathing

• C - Circulation

• D - Disability (Neurologic exam)

• E - Exposure (Remove clothing)

• Should be completed by the trauma team within minutes of the the patient’s arrival

• The first requirement is not radiographic proof of a given pathology, it is the rapid assessment and support of vital life functions

Pt Assessment: Radiographic Assessment

• A - Axial Skeleton (C-Spine)

• B - Breathing (Chest)

• C - Circulation (Pelvis)

• D - Definitive dx study (CT, IVP, Angio)

• E - Extremities

• The radiographic assessment is performed as early as possible during the secondary survey phase. All victims of blunt multi system trauma must be assumed to have a c-spine or other spinal injury until ruled out. It is essential to know early on in case of resuscitation whether a spinal injury has occurred. This may substantially alter management decisions

Noted Symptom: Cool, Clammy Skin

• Possible Cause

  • Shock

  • Vasovagal reaction

• When to immediately report to physician

  • Other Symptoms of Shock Present

Noted Symptom: Excessive sweating (diaphoresis)

• Possible Cause

  • Shock

• When to immediately report to physician

  • Other Symptoms of Shock Present

Noted Symptom: Slurred Speech

• Possible Cause

  • Head injury

  • Stroke (cerebrovascular accident)

  • Drug or ethanol influence

• When to immediately report to physician

  • Accompanied by vomiting, especially if vomiting stops when patient is moved to different position

Noted Symptom: Agitation or Confusion

• Possible Cause

  • Head injury

  • Drug or ethanol influence

• When to immediately report to physician

  • Accompanied by vomiting, especially if vomiting stops when patient is moved to different position

Noted Symptom: Vomiting (Without abdominal complaints) (Hyperemesis)

• Possible Cause

  • Head injury

  • Hyperglycemia

  • Drug or ethanol overdose

• When to immediately report to physician

  • Position of patient abruptly stimulates vomiting or abruptly stops vomiting

Noted Symptom: Increased Drowsiness (Lethargy)

• Possible Cause

  • Shock

  • Head injury

  • Hyperglycemia

• When to immediately report to physician

  • Other symptoms of shock present or accompanied by vomiting

Noted Symptom: Loss of Consciousness (Unresponsive to voice or touch)

• Possible Cause

  • Shock

  • Head Injury

  • Hyperglycemia

• When to immediately report to physician

  • Immediately

Noted Symptom: Pale or Bluish Skin Pallor (Cyanosis)

• Possible Cause

  • Airway compromise

  • Hypovolemic Shock

• When to immediately report to physician

  • Immediately

Noted Symptom: Bluish Nail Beds

• Possible Cause

  • Circulatory compromise

• When to immediately report to physician

  • Immediately

Noted Symptom: Patient Complains of Thirst

• Possible Cause

  • Shock

  • Hyperglycemia

  • Hypoglycemia

• When to immediately report to physician

  • Other symptoms of shock present

Noted Symptom: Pt complains of tingling or numbness (paresthesia) or inability to move a limb OR Pt states that they cannon feel your touch (paralysis)

• Possible Cause

  • Spinal cord injury

  • Peripheral nerve impairment

• When to immediately report to physician

  • Accompanied by any symptom of shock or altered consciousness

Noted Symptom: Seizures

• Possible Cause

  • Head Injury

• When to immediately report to physician

  • Immediately

Noted Symptom: Extreme eversion of foot

• Possible Cause

  • Fracture of proximal femur or hip joint

• When to immediately report to physician

  • Report only if x-ray request specifies “frog leg” lateral projection of hip. This movement would exacerbate patient’s injury and cause intense pain. Surgical lateral position should be substituted. Watch for changes in abdominal size and firmness

Noted Symptom: Increasing abdominal distention and firmness to palpation

• Possible Cause

  • Internal bleeding from pelvic fracture or organ laceration

• When to immediately report to physician

  • Immediately