ACCIDENT AND EMERGENCY RADIOGRAPHY

INTRODUCTION
Trauma is defined as a sudden, unexpected, dramatic, forceful, or violent event Blunt, penetrating, explosive, and thermal forces are common causes of traumatic injuries

INTRODUCTION
Trauma affects persons in all age ranges Radiographers in the emergency department (ED) must be prepared for a variety of procedures on patients in all age groups

PRELIMINARY CONSIDERATIONS
Specialized trauma imaging systems reduce the amount of time required to obtain diagnostic images
One type provides greater flexibility in IR/CR maneuverability Another type scans the entire body in a few seconds

Mobile radiography is often used for ED procedures

PRELIMINARY CONSIDERATIONS
Mobile fluoroscopy units, or C-arms, may be used in fracture reduction or foreign body localizations Immobilization devices are a necessity in trauma imaging

Trauma patients often cannot hold the required position

Radiographers Role in Trauma

Depends upon department protocol and staffing Primary responsibilities

Perform quality diagnostic imaging procedures Practice ethical radiation protection Provide patient care professionalism

Best Practices in Trauma Radiography

Speed
Efficiency in producing quality images in the shortest possible time Optimum image quality, minimum repeats
Quality cannot be sacrificed for speed Do not use patient condition as an excuse for poor quality images

Accuracy Quality

Best Practices in Trauma Radiography

Positioning
Important not to aggravate patients condition when obtaining images Move tube and IR, instead of patient, whenever possible
Expect to be exposed to body fluids in ED Do not touch a patient without gloves!

Practice standard precautions

Best Practices in Trauma Radiography

Attention to detail
Pay careful attention to patients condition, which could change at any time Know the protocol and scope of practice in your facility Adhere to Code of Ethics

Attention to ED protocol and scope of practice Professionalism

Radiographic Procedures in Trauma

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GENERAL PROCEDURAL GUIDELINES

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GENERAL PROCEDURAL GUIDELINES

Patient preparation IR size SID ID markers Radiation protection Patient instructions Immobilization Documentation Image criteria

Patient Preparation
Use good communication skills with appropriate touch and eye contact Check patient for potential artifacts
Trauma often causes anxiety

Explain what you are removing and why Secure all personal effects using proper procedure for your facility

IR Size
IR size for trauma procedures are the same as for routine procedures Collimate field size to anatomy of interest

SID
SID is standardized as a part of procedural protocol
When SID is not specified under a projection, 40 to 48 60 to 72 SID recommended for projections with increased OID

ID Markers
Right or left side markers must be included on each image

Shield pediatric patients and patients of reproductive age Warn other staff of exposure when performing mobile imaging Other radiation protection measures
Close collimation Optimum technique factors

Radiation Protection

Patient Instructions
Explain and demonstrate positions, when possible Explain respiration instructions for patients who can cooperate Use short exposure times to eliminate possibility of imaging motion

Immobilization
Many trauma patients arrive in some sort of immobilization device Immobilization devices are not to be removed unless ordered by a physician Imaging procedures are often performed without removal of the immobilization

Documentation
Because deviation or adjustment of routine procedures is often required to accommodate a patients injury, documentation is important Make sure that deviation from routine is still within your scope of practice! Keep all the patient files in a separate room for back up. Everything must be documented

Image Criteria
Image evaluation for trauma procedures is the same as for routine procedures Image quality is critical for an accurate diagnosis It is poor practice to accept lower quality images due to patient condition or difficulty of procedure

Trauma Projections

AP APICAL OBLIQUE AXIAL PROJECTION: SHOULDER (TRAUMA) Pathology Demonstrated: An optimal trauma projection for possible scapulohumeral dislocations (especially posterior dislocation), glenoid fractures and soft tissue calcifications. Technical Factors: IR size - 18 x 24 cm (8 x 10 inches), lengthwise Moving or stationary grid Digital IR - very close collimation required 75 +- 5 kV range

Shielding: Erect apical oblique axial projection - 45 degrees posterior oblique CR 45 degree caudad Shield pelvic area. Patient Position: Perform radiograph with the patient in an erect or supine position. (The erect position is usually less painful, if patient's condition allows.) Rotate body 45 degree toward affected side

AP APICAL OBLIQUE AXIAL PROJECTION: SHOULDER

Part Position: Center scapulohumeral joint to CR and mid-IR. Adjust IR so that the 45 degree angled CR will project the scapulohumeral joint to the center of the IR. Central Ray: CR 45 degree caudad, centered to the scapulohumeral joint. Minimum SID of 40 inches (100 cm) Respiration: Suspend respiration during exposure.

TRANSTHORACIC LATERAL PROJECTION: PROXIMAL HUMERUS (TRAUMA) LAWRENCE METHOD

Pathology Demonstrated: Fracture and/or dislocations of the proximal humerus are demonstrated. Technical Factors: IR size - 24 x 30 cm (10 x 12 inches), lengthwise Moving or stationary grid, vertical, CR to centerline 75 +- 5 kV range Minimum of 3 seconds exposure time with breathing technique (4 -5 seconds is desirable)

Shielding: Shield pelvic area. Patient Position: Perform radiograph with the patient in an erect or supine position. Place patient in lateral position with side of interest against IR. With patient supine, place grid lines vertically and center CR to centerline to prevent grid cutoff.

TRANSTHORACIC LATERAL PROJECTION

TRANSTHORACIC LATERAL PROJECTION

Central Ray: CR perpendicular to IR, directed through thorax to surgical neck Minimum SID of 40 inches (100 cm)

Respiration: Patient should be asked to gently breathe short,

Warning: Do NOT attempt to rotate arm if fracture or dislocation is suspected; perform in neutral rotation, which generally places humerus in an oblique position. Pathology Demonstrated: Fracture and/or dislocations of the shoulder girdle are demonstrated Technical Factor: IR size - 24 x 30 cm (10 x 12 inches)

AP PROJECTION - NEUTRAL ROTATION : SHOULDER (TRAUMA)

Patient Position: Perform radiograph with the patient in an erect or supine position. Rotate body slightly toward affected side is necessary to place shoulder in contact with IR or tabletop. Part Position: patient to center scapulohumeral joint to IR. Place patient's arm at side in "as is" neutral rotation

Neutral position

Central Ray: CR perpendicular to IR, directed to mid-scapulohumeral joint, which is approximately 2 cm inferior and slightly lateral to the coracoid process

Collimation:

Collimate on four sides, with lateral and upper borders adjusted to soft tissue margins.

Lateral Cervical Spine

Horizontal CR centered to midpoint of IR Image should demonstrate entire C-spine from sella turcica to top of T1
If all seven cervical vertebrae are not seen, then a swimmers view is required

Lateral Cervical Spine

Lateral projection of C-spine in dorsal decubitus position; dislocation of C3-C4; C7 not demonstrated, so swimmers view is needed

Swimmers (cervicothoracic)
Required if C7 and top of T1 not demonstrated on lateral C-spine Trauma usually requires dorsal decubitus position Patient supine without rotation Ask patient to raise arm opposite the x-ray tube over head
Assist patient and provide support

Cervicothoracic Spine
Relax shoulder closer to x-ray tube Vertical IR centered just above jugular notch Horizontal CR centered to C7-T1 interspace and midcoronal plane Use breathing technique if possible

Cervicothoracic Spine

Patient and IR positioned for trauma lateral projection of cervicothoracic vertebrae using dorsal decubitus position

Cervicothoracic Spine

Lateral projection, dorsal decubitus position of cervicothoracic vertebrae

AP Axial Cervical Spine

Patient is supine
Usually immobilized with collar and spine board

Place IR under spine board, if present, centered to C4 (Adams apple) Head and shoulders without rotation
Ask patient to look straight ahead

AP Axial Cervical Spine

Patient and IR positioned for trauma AP axial C-spine

AP Axial Cervical Spine

CR directed 15 to 20 degrees cephalad to enter MSP at C4 Image demonstrates C3-T1 or T2, including all soft tissues

If backboard is present, unavoidable artifacts may be seen

AP Axial Cervical Spine

Trauma AP axial C-spine; complete dislocation at C2-C3

Thoracic and Lumbar Spine

laterals performed first Vertical grid and IR

Have patient cross arms on anterior chest

Top of IR 1.5 to 2 above shoulders for thoracic spine Centered to level of iliac crests for lumbar spine

Trauma Lateral Lumbar Spine

CR and IR positioned for trauma lateral projection of lumbar spine using dorsal decubitus position

Thoracic and Lumbar Spine

CR horizontal Breathing technique improves visualization of thoracic vertebrae Exposure made on suspended respiration for lumbar vertebrae
Centered to spine and IR

Trauma Lateral Lumbar Spine

Lateral projection of thoracolumbar spine, dorsal decubitus position; note fracture and dislocation of L2 and spine board artifacts

Chest
Supine position used if general survey image of chest desired Check for need to demonstrate air-fluid levels
If patients condition permits, lateral decubitus position with patient lying on affected side will also show air-fluid levels

Trauma AP Chest
Obtain help to lift patient for IR placement Arms abducted MCP parallel to IR Use maximum SID to reduce heart magnification
Top of IR placed about 1.5 to 2 above shoulders

Trauma AP Chest
Ensure chin extended out of anatomy of interest CR directed perpendicular to center of IR
look for light field slightly above shoulders and on sides of chest,

Exposure made upon second full inhalation, if possible

Trauma AP Chest
Image demonstrates lung fields in their entirety
Minimal rotation and distortion present

Abdomen
If transfer to x-ray table is not possible, obtain lift help for IR placement IR centered to MSP at level of iliac crests Check for possibility of fluid accumulation in abdominal cavity
Affects exposure factors

Abdomen
Align shoulders and hips in same plane MCP parallel to table CR perpendicular to center of IR Image demonstrates entire abdomen with pubic symphysis visible at lower border

Pelvis
Pelvic fractures have a high risk of hemorrhage pay close attention to patient for status change Obtain lift help for IR placement if transfer to x-ray table is not possible IR centered 2 above pubic symphysis or 2 below ASIS MCP parallel to IR

Pelvis
Lower limbs internally rotated only if possible Ensure arms are not in anatomy of interest CR perpendicular to center of IR Exposure made on suspended respiration Image demonstrates entire pelvis and proximal femora

Trauma AP Pelvis

Trauma AP pelvis; note fracture of left ilium and separation of pubic bones

Cranium
Patients with head trauma are often referred to CT first When x-rays are ordered, a general survey requires AP and lateral projections Generally, the patient is supine

Lateral projection uses dorsal decubitus position

Trauma Lateral Cranium

Elevate head on radiolucent support
Ensure C-spine injury has been ruled out

Trauma Lateral Cranium

Trauma lateral projection of cranium; note multiple fractures in frontal bone

Trauma Cranium

Patient and IR positioned for trauma AP cranium

Patient and IR positioned for trauma AP axial cranium

Trauma AP Cranium

Trauma AP cranium; note fracture line

Facial Bones
Patients with facial bone injuries are often referred to CT first Anticipate profuse bleeding and use universal precautions

Upper and Lower Limbs

Obtain lift help for IR placement Injured limbs should be lifted with support at both joints Two projections at 90 degrees from each other required
Lift only enough to place IR

Do not attempt to rotate severely injured limbs for true positions

Upper and Lower Limbs

Long bones require demonstration of adjacent joints Maximize patient safety and comfort by moving IR and CR, rather than injured limb
Take separate projections, if necessary

Reversing or Modifying Projections

Most trauma patients arrive in the supine position They should be radiographed in that position Many projections can be reversed or modified

Reversing or Modifying Projections

A Waters method for obtaining orbits and facial bones can be reversed Position the patient the same Direct the central ray cephalic to the acanthion with 35 degree angulation Do not angle the patients head unless it is safe to do so Angle the CR more or less to accommodate for lack of patient cooperation

Reversing or Modifying Projections

Obtain x-table lateral or decubitus films if patient is unable to stand If patient cannot rotate an extremity to obtain an AP or lateral, obtain a cross-table of that image

Routine Positioning For Waters Method

Modified Waters Method Positioning

AP axial projection(modified towns view)

Patient position: remove all metal and plastic items from head Part position:) -Posterior-Anterior view, mouth open -View can be used to observe fractures involving the condylar neck, and also when displacement of the condyle is suspected -cassette held by a holding device vertically

Central ray: head is centered in front of film with the canthomeatal line projected 45 -50 downward; CENTRAL beam goes horizontally through the occipital bone; 75-80 kVp

Submentovertex view(zygomatic arch)

Patient position: the is done in erect or supine The erect is easier for the patient Part position: raise chin, hyperextended neck until IOML is parallel to IR Rest head on the vertex of skull Align midsagittal plane perpendicular to midline of the grid or the table, avoiding all tilt or rotation

Central ray: align CR perpendicular to IR Centre CR midway between to the zygomatic arch at a level I1/2 inferior to the mandible
symphysis Centre image receptor to the CR Minimum SID is 40 inches Respiration: suspended

Pathology demonstrated: fractures of the zygomatic arch and neoplastic/inflammatery process are shown Technical factors:8x10 inches 60-70 kv

Facial-bones Lateral
Indications for imaging Trauma Anatomy Demonstrated Facial bones (superimposed) roof of orbits, zygoma and mandible.

Patient Position The patient lies supine on the trolley the midsaggital plane aligned to the long axis of the trolley, inter-pupilary line parallel to the floor. The cassette is supported alongside the affected side of the face parallel to the mid-saggital plane. The chin is raised to bring the orbital meatal line vertical.

Facial-bones Lateral Patient Position

Radiation protection Avoid irradiation of the thyroid region, direct lead rubber protection my be used.

Central Ray The horizontal ray is centered to a point midway between the outer canthus of the Eye and the EAM.

Kv 65

mAS 8/12

FFD (cm) 100

Grid No/Yes

Focus Fine

AEC No

Cassette 18 x 24 cm

Evaluation of the Image ID and anatomical markers must be present and correct in the appropriate area of the film. Optimal exposure should penetrate all the bone structures and contrast should be low enough to visualise fully the bone and soft tissue structures. Look for fluid/air level in the sphenoid sinus.

The 10 Commandments
1) Treat the patient, not the radiograph

2) Take a history and examine the patient

before requesting a radiograph 3) Request a radiograph only when necessary Never look at a radiograph without seeing the patient, and never see the patient without the looking at the radiograph

4) Look at every radiograph, the whole radiograph, and the radiograph as a whole 5) Re-examine the patient when there is an incongruity between the radiograph and the expected findings 6) Take radiographs before and after procedures

7)If a radiograph does not look quite right ask and listen: there is probably something wrong 8) Ensure you are protected by fail safe mechanisms

9) ABCs for Interpreting Radiographs

A. A. B. C. S. Adequacy Alignment Bones Cartilage and Joints Soft tissues

10) The rule of twos

Two views at right angles Two joints include either end of the long bones Two sides to compare the normal and injured side

Trauma Radiography Guidelines

Place the cassette as close to the body part as possible without hurting the patient Include both joints when radiographing long bones Do not remove splints, bandages or cervical collars unless ordered to do so by competent personnel Shield unless it interferes with the examination