PEMERIKSAAN RADIOLOGI

PADA KASUS TRAUMA

MODUL KEGAWATDARURATAN

BAGIAN RADIOLOGI
FAKULTAS KEDOKTERAN UNISSULA
SEMARANG
TRAUMA
•Trauma Kepala
•Trauma Thorax
•Trauma Abdomen & Pelvis
Role of radiologists
Team work
 Surgeons
 Intensive care specialists
 Radiologists
Approach to trauma patient
 Primary survey (ABC’s)
 Resuscitation and primary imaging
 Secondary survey (physical animaging)
 Definitive Care
Imaging on admission
 Lateral C-spine radiograph before
endotracheal intubation
 Chest AP +/- lateral
 Abdominal US
 CT once hemodynamically stable
 MRI has a limited role in imaging of
acutely injured trauma patient
Imaging on admission
 Lateral C-spine: R/O C-spine fracture
 CXR: R/O pneumothorax/wide
mediastinum
 US: R/O hemoperitoneum
 CT (+ IV/oral contrast): R/O organ-specific
injuries
 MRI: limited role
Trauma Emergency Room layout

Ideally the trauma emergency room is centrally

located to provide quick access to the CT
scanner, angiography suite, OR and ICU
Adjacent Trauma Emergency
Room and CT scanner

Ideally, the trauma ER is located

adjacent to the CT scanner thus
enabling the patient to be
transferred without delay.
MEKANISME
Direct : trauma langsung pada brain & skull

Indirect : trauma karena akselerasi dan

deselerasi.
PENINGKATAN TEKANAN
INTRAKRANIAL

MID LINE
SHIFTING

VENTRICULAR
OBLITERATIONS
 INTRACRANIAL
HEMATOMA
• ACUTE EDH
• ACUTE SDH
• Intra Cerebral Hematoma (ICH)

The incidence of Intracranial hematom due to traumatic

brain injury only 2%.
 EPIDURAL HEMATOMA
• Mortality : 41 %
• Text book clinical features :
Trauma  short loss of consciousness ” Lucid
interval “
• Only 10-25% of cases
• Lies between bone and dura
• Bleeding almost always arterial, rarely venous.
 In 80% : fracture
 Crosses midline
 Lenticular / bikonveks
 Localization –almost always
“coup”
 SUBDURAL HEMATOMA

 Between dura & arachnoidea

 Mortality about 60%
 Acceleration-deceleration
 Violation of bridging veins
 More rarely associated with fracture
 Localization –contrecoup
 CONTUSION
BLOW

Brain injury
52% hemorrhagic
Parenchymal micro bleedings
FALL
If confluent Hematoma
Multipel in 30%
Localization : coup & contre-coup
HAEMORRHAGIC
CONTUSIONS
 What To Look For

 Rib fractures
 Pulmonary contusions
 Pulmonary lacerations
 Abnormal collections of air
 Abnormal collections of fluid
 Rib Fractures

 Only important for what they are associated

with or produce
 Rib 1 only — facial fractures
 Ribs 1, 2 and 3 — Serious Trauma — ruptured
bronchus
 Ribs 4 – 9 — pneumothorax, contusion
 Ribs 10 – 12 — lacerations of liver/spleen
 Pulmonary Contusion

 Most common finding in blunt chest injury

 Hemorrhage into lungs
 Appears within 6 hours of injury
 Clears in 48 hours
 Usually at point of impact
A chest X-ray showing left sided pulmonary contusion associated
with rib fractures and subcutaneous emphysema
 Pulmonary Laceration
Traumatic Lung Cyst, Hematoma

 Usually not apparent at first because of

surrounding contusion
 Laceration of the lung parenchyma
 Usually occurs subpleural under point of
maximum impact
 Half are solid, half are cystic
 Takes up to 6 months to clear
25-year-old woman with pulmonary laceration after trauma.
Abnormal Collections Of Air

 Pneumothorax
 Pneumomediastinum
 Pneumopericardium
 Subcutaneous emphysema
 Pneumothorax

 Must see visceral pleural white line

 Absence of lung markings peripheral to
pleural line
 Beware of skin folds
 Beware of bullae
 PLEURAL LINE
PNEUMOTHORAX
PNEUMOTHORAX
 Pneumomediastinum

 May develop after blunt trauma due to

pulmonary interstitial emphysema
 Mediastinal pleura is displaced from heart
border
 Visualization of central part of diaphragm
— continuous diaphragm sign
 Pneumopericardium

 Requires direct penetration of the

pericardium
 Air appears around heart but does not
extend above great vessels
 Very difficult to differentiate from
pneumomediastinum
 Subcutaneous Emphysema

 Streaky air over lateral chest wall or neck

 Localized form implies penetrating injury
 Diffuse form associated with pulmonary
interstitial emphysema
EMPYSEM
A
SUBCUTIS
 Rupture of the Diaphragm

 Left hemidiaphragm affected almost always

 May not occur for weeks after trauma
 Hernia may contain omentum, stomach,
large and small bowel, spleen, kidney
Rupture of the Diaphragm

 X-ray shows bowel, soft tissue at left lung

base
 Differentiation from eventration (no
constricted loops) or hernia (no stomach)
may be difficult
INSIDEN
Abdominal trauma classification
 Hemodynamically  Hemodynamically
stable
 Complete clinical and
radiological workup
unstable
 Minimal radiologic
investigations (eg
F.A.S.T. - Focused
Assessment with
Sonography for
Trauma)
 Immediate surgery or
interventional
radiology treatment
 FAST
Focused Abdominal Sonography for Trauma

Bedside, non-invasive, not expensive

Hemoperitoneum 4 Ps
Pericardiac
perihepatic ( Mourison’s Pouch)
perisplenic
pelvic
Morison's space is filled with blood in this view of the right upper
abdomen. The patient had a large bleeding liver laceration on exploration
Another view of the right upper abdomen demonstrating a liver laceration
and small amount of blood adjacent to the right kidney in Morison's space.
This sagittal scan demonstrates large amount of fluid (blood) in the
subdiaphragmatic space and within the splenorenal recess
Note the laceration of the spleen and the adjacent blood anterior
to it
 Identifies rectovesicular pouch (male) or rectouterina/cul de sac
(female) both in transverse or longitudinal view
More sensitive than abdominal view (less than 200 cc of fluid
sometimes seen)
SPLENIC INJURY
Traumatic splenic injury
 Commonly injured in blunt trauma
 Clinical findings:
 Often no/non-specific symptoms
 Peritoneal irritation
 Signs/symptoms of acute hemorrhage
Traumatic splenic injury
 Imaging
 Plain film: not useful
 US: hemoperitoneum
 Contrast-enhanced CT: imaging modality of
choice
 Angiography: therapeutic embolization
Classification of splenic injury
 Grade I
 Small capsular laceration and/or parenchymal laceration smaller
than 1 cm
 Small subcapsular hematoma smaller than 1 cm

 Grade II
 Parenchymal laceration 1-3 cm

 Central or subcapsular hematoma 1-3 cm

 Grade III
 Parenchymal laceration deeper than 3 cm

 Central or subcapsular hematoma larger than 3 cm

 Grade IV
 Devascularization of the spleen (no contrast enhancement)

 Fragmentation of the spleen

Imaging of splenic injury
 Hematoma
 Laceration
 Infarction
Splenic hematoma
 US
 Echogenic, complex collection
 CT
 Initially hyperdense to normal spleen on
unenhanced scans
 No enhancement with contrast
 Density decreases with time
Contrast enhanced CT:
splenic hematoma
Splenic Laceration:
 US
 Often undetectable
 Perisplenic fluid/blood clot “sentinal clot sign”
 Contrast-enhanced CT:
 Often undetectable
 Perisplenic fluid/blood clot “sentinal clot sign”
 Low-density linear defects, usually extending from the
lateral border towards the hilum
Contrast enhanced CT:
Splenic Laceration
Contrast enhanced CT:
Splenic Laceration

Pseudo-aneurysm

Splenic laceration
LIVER INJURY
Traumatic liver injury
 Commonly injured in blunt trauma
 R lobe, post segment most often injured
 Clinical findings:
 RUQ pain
 R shoulder pain
 Hypotension
 Shock
 Symptoms of bile peritonitis
Classification of hepatic injury
 Grade I
 Capsular avulsion, superficial laceration(s) <1cm deep,
subcapsular hematoma <1cm in maximum thickness, periportal
blood tracking only
 Grade II
 Laceration(s) 1-3 cm deep, central-subcapsular hematoma(s) 1-
3 cm in diameter
 Grade III
 Laceration >3 cm deep, central-subcapsular hemotoma(s)
greater than 3 cm in diameter
 Grade IV
 Massive central-subcapsular hematoma >10 cm, lobar tissue
destruction (maceration) or devascularization
 Grade V
 Bilobar tissue destruction (maceration) or devascularization
CT imaging of liver injury
 Contusions
 Subcapsular hematoma
 Intraparenchymal hematoma
 Linear or stellate lacerations
 Complete hepatic fracture
 Contrast enhance CT:
Intraparenchymal hematoma
 Contrast enhance CT:
Intraparenchymal hematoma

Intraparenchymal
hematoma
Severe
intraparenchymal
bleeding
No enhancement
with contrast
 Contrast enhanced CT:
Subcapsular hematoma
 Peripherally located
 Least common form of liver injury
 Contrast enhanced CT:
Subcapsular hematoma
 Peripherally located
 Least common form of liver injury

Subcapsular hematoma
Low attenuation,
lentiform collection
displacing &
compressing the liver
Hepatic laceration
 Most common liver injury
 Intact vs. disrupted capsule
 Disrupted capsule often accompanied by
hemoperitoneum
 Differentiate from hepatic fissures by their
irregular edges, location and blood density (30-
40 HU)
 Typically runs parallel to hepatic vein or
posterior segment of R portal vein
Hepatic laceration continued
 Stellate pattern:seen in massive trauma,
complex multiple lacerations
 Fluid in R paracolic gutter if ant surface
lacerated
 Extraperitoneal hemorrhage if laceration
involves bare liver surface between the coronary
ligaments (“Halo sign”)
 Hepatic fracture: laceration extending from one
liver surface to other
Contrast enhanced CT:
Hepatic Laceration
TRAUMATIC BOWEL AND
MESENTERY INJURIES
Traumatic mesentery and bowel
injuries
 Clinical findings:
 Triad of abdo tenderness, rigidity, absent
bowel sounds (present in 1/3 of pts)
 NB. Diagnostic peritoneal lavage
insensitive to retroperitoneal injuries
(duodenum, colon)
Traumatic mesentery and bowel
injury
 Imaging:
 Plain film
 Usually insufficient for diagnosis
 Free air (occasionally)
Classification of mesentery and bowel
injury

 Hematoma
 Intramural
 Intraperitoneal
 Retroperitoneal
 Perforation
 Mesenteric laceration
Mesentery and bowel
 US
 Limited role since bowel gas diminishes
quality
 Free fluid may indicate bowel injury
 CT
 Imaging modality of choice
Intramural hematoma
 Mech: automotive steering wheel or seat-
belt injury
 Duodenum and jejunum most commonly
affected due to their retoperitoneal
fixations
 CT
 Bowel wall thickening
Contrast enhanced CT:
Intramural hematoma
 Contrast enhanced CT:
Intramural hematoma

Duodenum Intramural
hematoma

R kidney
L kidney

IVC Aorta
Mesenteric hematoma
 More common than intramural hematoma
 CT
 Initial high density material in mesentery on
unenhanced CT
Contrast enhanced CT:
Mesenteric hematoma
 Contrast enhanced CT:
Mesenteric hematoma

Meseteric
hematoma spleen
Bowel perforation

 CT
 Free fluid
 Free air
 Mesenteric infiltration
 Focal bowel wall thickening
 Extravasation of oral contrast
Contrast enhanced CT: Free air
Contrast enhanced CT: Free air

Free air
TRAUMATIC RENAL
INJURY
Traumatic kidney injury
 Mechanism:
 Blunt trauma (80%)
 Laceration by lower ribs
 Torn by rapid acceleration & deceleration
 Clinical findings:
 Hemodynamic instability
 Hematuria (macro/microscopic)
Imaging of renal trauma
 US:
 Limited use
 Contrast enhanced CT:
 Study of choice
 Delayed images important to differentiate
between hematoma & leakage from collecting
system
Imaging of renal trauma
 Intravenous urography:
 Infrequently performed
 Angiography:
 Supplement to CT when suspect major
vascular injury
 Therapeutic embolization
 Classification and management of renal injuries
Classification Description Treatment

Minor Type Contusion Observe

I Superficial laceration Serial
hematocrits
Major Type Deep laceration Conservative
II Involvement of collecting (majority)
system Surgery

Catastrophic Type Major laceration Surgery

III Laceration involving pedicle (majority)
Shattered kidney (multiple Conservative

lacerations)

Catastrophic Type Avulsion from ureteropelvic Nephrectomy

IV junction (majority)
Renal laceration
 Contrast-enhanced CT:
 hypoattenuated lesions parallel to
intervascular tissue planes
Contrast enhanced CT:
Renal Laceration
 Contrast enhanced CT:
Renal Laceration

Renal laceration
Small perirenal hematoma
Lacerations transecting the
collecting system
 Contrast-enhanced CT
 Contrast extravasation in medial part of
perirenal space
Contrast enhanced CT:
Collecting system leak
 Contrast enhanced CT:
Collecting system leak

Collecting system
leak

R kidney
Renal Pedicle injury
 Renal artery injury:
 Absence of contrast enhancement
 Cortical rim sign

 Hematoma surrounding the renal pedicle

 Abrupt cut-off of contrast filled renal artery

 Central retroperitoneal hematoma associated with

limited perinephric hematoma causing lateral
displacement of kidney

Contrast enhanced CT: Absence
of contrast enhancement
 Contrast enhanced CT: Absence
of contrast enhancement

R kidney:
Absence of contrast
enhancement
 Contrast enhanced CT:
Renal artery extravasation
 Contrast enhanced CT:
Renal artery extravasation

Perirenal
hematoma
Right renal artery extravasation
Laceration
 TRAUMATIC
PANCREATIC INJURY
Traumatic pancreatic injury
 Rare
 Mechanism:
 Blunt: force compresses pancreas against spine
 Penetrating
 Clinical findings:
 Pancreatitis (liberation of pancreatic enzymes)
 Clinical manifestations appear slowly (hrs-wks)
Traumatic pancreatic injury
 Imaging:
 US: limited use
 Contrast-enhanced CT: modality of choice
 ERCP: to demonstrate pancreatic duct
anatomy prior to pancreatic surgery
 MRCP
Classification and management of
pancreatic injury

Grade Description Management

I Parenchymal contusion or Conservative or minimal
minor hematoma surgical treatment
(drainage)
II Sml parenchymal laceration Conservative or minimal
surgical treatment
(drainage)
III Parenchymal laceration with Surgical
rupture of the main pancreatic
duct
IV Severe crush injury Surgical
Imaging of pancreatic injury
 Laceration
 Contusion
 Pancreatic duct rupture
Pancreatic laceration (fracture)

 US:
 Not useful
 Contrast-enhanced CT:
 Hypodense line usually oriented
perpendicular to long axis of pancreas
 Infiltration of peripancreatic fat
 Thickening of L ant perirenal fascia
 Contrast enhanced CT:
Lacerated pancreatic tail
 Contrast enhanced CT:
Lacerated pancreatic tail

Intra and peripancreatic fluid

Pancreatic contusion
 Contrast-enhanced CT
 Hypodense area
 Secondary pancreatitis:
 peripancreatic fluid
 focal enlargement

 increased density of ant pararenal fat

 Thickening of pararenal fascia

 History: Young patient with blunt trauma to abdomen,
had tender epigastrium & a drop in her hemoglobin
Contrast enhanced CT: 4 successive cuts through level of pancreas
 History: Young patient with blunt trauma to abdomen,
had tender epigastrium & a drop in her hemoglobin
Contrast enhanced CT: 4 successive cuts through level of pancreas

Pancreatic
contusion