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1
Whole Body Trauma CT
- the Bleeding Edge
Dansk Radiologisk Selskabs årsmöde, Aarhus 2013
Bertil Leidner, MD
Karolinska University Hospital Huddinge, Stockholm, Sweden
Outline
Karolinska Trauma Center
Trauma Radiology
Why WBCT?
Protocol; dose; pregnancy, iv contrast
Critical cases – Head to toe
» BCVI
The future – problems & possibilities
Karolinska Level 1 Trauma Center
•2 million inhabitants
•1300 trauma whole
body CT per year
•approx 300 ISS >15
2
Radiology in trauma today
First survey – ABCDE –trauma room radiology » Chest + pelvis X-ray +
» US abd + pleurae + pericard
Second survey – head to toe – Whole Body CT
Treatment – angio - embolization
Follow-up – CT & contrast ultrasound
Trauma Radiology before CT Surgeon´s Viewpoint
X-ray = X-time
Radiology in multitrauma
Circulatory STABLE patient
» Whole body CT
Now also “borderline” stable
3
Trauma
What injuries?
Image from trauma.org
Trauma CT
4
Why Whole Body CT?
Single area CT guided by clinical
findings or Whole Body CT
Why “Whole Body” CT ?
Clinical exam inadequate
Distracting injuries
Systematic ATLS adjunct
» multislice CT used as a second survey
» standardized procedure every time
– possible to train for techs
– fast
– minimizes possible omissions
Whole Body CT - advantage
The Golden Hour
Whole body evaluation in one setting
Inclusive:
» C/T/L- spine & pelvis
» angiographic evaluation
Evaluation of circulation
» hypovolemia
» active bleeding
5
Why Whole Body CT?
Routine Whole body CT reveals more
injuries than selective CT
» Van Vugt R et al, Eur J Trauma 2011
Whole Body CT has proved to decrease
mortality compared to selective CT
» Körner et al, Lancet 2009
Clinical outcome
Single area CT guided by clinical findings or Whole Body CT
100 trauma units in Germany 2002-2004
» 5000 patients
» CT area by clinical evaluation vs whole body CT
» Outcome by TRISS / RISC
» Whole body CT increased survival 12-25% !
(Körner et al, Lancet 2009)
VCT in Trauma
Whole body coverage
Feet first
190 cm helical
weight 227 kg
Tube 100 kW
Fast scanning:
11-14-18 cm / sec
64 channel @ 0.625 mm
Detailed Volume Imaging
6
Trauma CT protocol – GE VCT
no i.v. contrast
Head – sequence acq 0.6 im 5/2.5 3 planes
C-spine – spiral acq 0.6 im 2.5 ax pre BCVI
im 1/1 3 planes
with i.v. contrast
125 ml @ 320mg I/ml 2.5 ml/s scan start 50 sec
Body – if BCVI suspicion start above circle of Willis
if not – start jugulum to symphis or to toe
spiral pitch 0.9 acq 0.6 im 5/5 axial 1st view
workst 3 planes
Dose
CT Dose
» head 2.0 mSv
» c-spine 3.5 mSv
» body 9.0 mSv
Total dose ~14.5 mSv
4-6 years Swedish background radiation
CT & pregnancy
Save the mother
» Save the child
Trauma
» CT!! not ultrasound
» 4x whole body scan
CT PE = OK
CT head = OK
7
Approximate fetal doses
Examination Mean dose
(mGy)
Maximum dose
(mGy)
Abdomen 1,5 5
Pelvis (one image) 0,5 1
Abdomen CT 15 35
Pelvis CT (low dose) 5 10
Pelvis CT (normal dose) 12 32
Chest CT 0,02 <0,1
Head CT ~0 ~0
Theoretical approximate fetal doses calculated from non pregnant patients at Karolinska University Hospital
Courtesy Physicist Jon Holm, GE
Probability of bearing healthy child
Dose to conceptus
(mGy)
Probability of no
malformation
Probability of no cancer
(0-19yrs)
0 97 99,7
1 97 99,7
5 97 99,7
10 97 99,6
50 97 99,4
100 97 99,1
>100 Possible
Courtesy Physicist Jon Holm, GE
IV contrast
8
Case
50 y o man
Motorbike accident
GCS 13, slightly tender abdomen, no shock
What if
» Earlier heavy skin reaction after iv iodine CM
» Known renal disease; P-creatinine 200
Trauma CT with iv CM?
Or not?
Standard scans + iv No iv contrast
FAST neg
+
CT + No fluid in the abdomen.
Injury ruled out??
Standard scans + iv No iv contrast
9
10
Dx?
MVA
Findings?
Mixed density lesion
Trapped fluid in ipsi-
lateral ventricle
DX?
Hyperacute subdural
hematoma
» Unclotted blood
Motorcross-accident
25 y o female
thrown off bike
hit the bushes
Findings?
11
Wood – wide window
CT Acute Spinal Canal Imaging
Spinal Cord threats » herniating disc
» epidural hematoma
» ligamentous injuries
64x0.625 mm » 50% recon overlap
» bone algorithm
» mpr sag 6 mm thick
» 50% image overlap
» WW 400 WL 100
C 7
T 2
Bilateral occipital condyle fx
12
C-spine epidural (+ occipital condyle fx)
C2 fx – MR correlation
Bilateral facett luxation C 6-7
13
Bilat facett dislocation -
disc evalution
Bechterew
Epidural hematoma
14
VRT spine
VRT mimics
standard
radiographs
» Fast viewing
» Easy for
comparative
follow-up
» Easy for
orthopedic
surgeons
15
MDCT: angiography
Neck vessels
Aorta
Extremities
Parenchymal organs
» Liver, spleen, kidneys
» Mesentary, abdomen
Case 1 @ Karolinska Male 40 years
Car accident
» Side hit
» Temporal superficial wound
Clinical status
» No LOC
» Alert, neck pain
CT head + c-spine 2 h later
16
CT # 1 - 2 h post injury
CT exam # 1 and # 2 @ 4h
CT # 3 day 2 – 16 h
17
Following BCVI images – courtesy Clint Sliker
Walter L. Biffl, M.D. Associate Professor of Surgery Denver Health Medical Center
University of Colorado
Clint W. Sliker, M.D. Assistant Professor of Radiology
R Adams Cowley Shock Trauma Center
University of Maryland School of Medicine
Sigtuna Consensus Conference 2007
BCVI - IMPACT OF SCREENING
Pre-Screening Screening
1/90-7/96 8/96-10/01
Incidence
Symptomatic
Biffl, Ann Surg 2002; 235:699
1.6%
24%
0.1%
100%
STROKE PREVENTION – MEMPHIS
Patients Treated While Asymptomatic
Carotid Artery injuries
Heparin: 1 of 9 (11%) Stroke
Antiplatelet: 1 of 6 (17%) Stroke
Overall: 33% Stroke Miller, Ann Surg 2002; 236:386
18
Summary
Patients with defined risk factors should be investigated to detect BCVI
Using Multislice CT 16 + channels,
» Whole Body CT (WBCT) protocol
» or dedicated Neck Vessel CTA
When examination is positive treat
» barring contraindication,
» treat regardless of grade.
Grade I <25% – Intimal Injury
Sagittal MIP
3D-VR Angiography
Grade II > 25% – Intramural Hematoma
19
Grade III - Pseudoaneurysm
Grade IV - Occlusion
TAI
20
Aortic rupture, TAI
Thorax
Thorax
» You are called to
the CT suite by
the tech.
» Now what?
How to deal with a tension pnthx?!
Make a quick report?
Call for an anesthesiologist?
Call for a surgeon?
or...
21
How to deal with a tension pnthx?!
or...
Puncture
» 2 -3 intercostal space
» Medio-clavicular line
» Large needle
(venflon)
» Keep until drainage
cath is placed
MVA 1977 – ER 2013
Presents jan 2013
Abd pain, shortness of breath
Decreased saturation
Bradycardia
Improved at arrival
22
Consequences - diaphragma rupture sequele
Dilated ivc
Decreased venous return
» cf tension pnthx
23
Abdominal trauma
24
Female 45 y, kicked by horse
Female 45 y, kicked by horse
Female 48 y, MC-accident
25
Female 48 y, MC-accident
Hypovolemia in CT
Significant injuries - bleeding sources » Thorax
» Abdomen
» Retroperitoneum – pelvis
» Femur
» ”in the street”
@ risk » Young persons
» Pregnant
» Compensates well for hypovolemia
Steeringwheel towards abdomen
Male 28 y
Findings:
Abundant free
abdominal fluid,
mesenteric
hematoma
TF 105
26
Clinical course
Period of tachycardia
and BP-fall 15 min
before CT
Findings
significant bleeding
constriction of aorta
low volume IVC
Hypovolemia
TF 105
Female 25 y Car crash
Free abdominal
fluid
Free air
Hypovolemic signs
» Significant bleed
» Constriction of aorta
» Low volume of IVC
» Intensive kidney enhancement
Summary: Signs of hypovolemia
Significant injuries bleeding sources
Increased enhancement » Aorta
» mesentery
» bowel
» kidneys
» Pancreas
» Pulmonary atelectasis
Decreased diameter
» Aorta –thoracic/abd
» Aortic branches
» Inf/sup v cava
» Cardiac chambers
27
References
Taylor et al (1987) Hypovolemic shock in children:
abdominal CT manifestations. Radiology 164, 479-
481.
Jeffrey et al (1988) The collapsed inferior vena
cava: CT evidence of hypovolemia. AJR 150, 431-
432.
Rotondo et al (1998) Thoracic CT findings at
hypovolemic shock. Acta Rad 39, 400-404.
Trauma CT- limitation
» Motion and metal artifacts
» A snapshot in time!!!! – the information is true for the time of scanning
– Do rescan on clinical deterioration
» Timing of scanning – iv.-contrast, oral contrast
» Difficult diagnosis - GI-injuries, pancreas
» 1500++ images – – SOS – Satisfaction Of Search
» Reader knowledge
» Patient transfer problems
Future development
CT in the trauma room
» Put patient directly on the CT-table
» Triage CT
Lower CT radiation dose
Faster CT with even better resolution
CT intervention / Hybrid Suites
28
Triage CT study Conclusion I
Triage CT in stable blunt trauma victims
» feasible in limited way
» more diagnostic information cf traditional
X-ray and FAST
The more accurate diagnostic findings
are likely to better guide the trauma
team in the patient management
Conclusion II
@ Karolinska trauma center
» the logistic problems so far seem to be
greater than the advantages of the superior
imaging method.
Triage CT was thus not feasable to use
for circulatory unstable patients.
Organizational improvements necessary
for Triage CT implementation
Be careful out there!!
29
www.nordictraumarad.com
www.nordictraumarad.com
Questions?
Extra material
30
The clinical effects of MDCT
Fewer “exploratory” surgeries
Far fewer explorations for penetrating torso trauma
More non-operative treatment for solid organ injuries
Greater role for interventional angiography
Decreased need for diagnostic angiography » (aorta, extremities)
Earlier diagnosis of complications
Faster access to imaging results with improved post-processing (Mirvis)
Over-utilization
» (ineffective clinical triage) --- cost, time, and radiation
Injury grading standardization
» (surgical and imaging integrated, high-reader agreement, grade predicts optimal care)
Patient transport events
» (lines, tubes, motion, personel intensive, support, safety)
(Mirvis)
Problems today in trauma imaging
The Impact of New Technology
31
• Faster
• Lower dose
• More detectors – flat panel
• More coverage
• Multiple passes
• Time resolved angiography
• Perfusion: physiology
• Faster transmission of image data
• images accessable everywhere “i-Pad”
(Mirvis)
New CT Technology
Faster image reformation and post-processing
(pre-planned, automated, user independent)
Easier transfer of patient
» docking CT
CT-ICU (dedicated critical care CT)
More (wireless) monitoring
In-field sonography – wireless transmission
(Mirvis)
The Impact of New Technology
• Mobile
• “Big Boy” capacity
• Tailored emergency CT Scanner – Suite
(Mirvis)
New Technology
32
Dual/Multi-energy CT in Trauma
Virtual non-contrast head
Bone subtraction – angiography
Hemosiderin detection
Gross increase in data volumes
» New ways of handling data
Image presentation – Virtual Autopsy Table - CMIV
Next step:
simulated operation
33
The Hybrid Suite @ Solna
”CT ”Images Hybrid Imaging
TELE-traumatology project Karolinska Trauma Center @ Regional hospitals
On-line communication between Karolinska
Trauma Center & trauma room in other hospitals
» Live video in trauma room
» Head set communication
» Radiological images
Clinical advice
Radiological expertice