EMERIKSAAN RADIOLOGI

ADA KASUS TRAUMA

ODUL 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 (ABCs)

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.

TRAUMA KEPALA

MEKANISME
Direct
skull

: trauma langsung pada brain &

Indirect : trauma karena akselerasi dan

deselerasi.

PENINGKATAN TEKANAN INTRAKRANIAL

MID LINE
SHIFTING

VENTRICULA
R
OBLITERATIO
NS

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

CONTUSION
BLOW

Brain injury
52% hemorrhagic
Parenchymal micro bleedings
If confluent Hematoma
Multipel in 30%
Localization : coup & contrecoup

FALL

HAEMORRHAGIC
CONTUSIONS

TRAUMA THORAX

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
SUBCUTI
S

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

TRAUMA ABDOMEN &

PELVIS

INSIDEN

Abdominal trauma classification

Hemodynamically
stable

Complete clinical and

radiological workup

Hemodynamically
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 ( Mourisons 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) 13 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 (3040 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 seatbelt 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

pa

Meseteric
hematoma

nc

re a

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

Minor

Type
I

Description

Treatment

Contusion
Superficial laceration

Observe
Serial

hematocrits
Major

Catastrophic

Catastrophic

Type
II

Deep laceration
Involvement of collecting
system

Conservative

Type
III

Major laceration
Laceration involving pedicle
Shattered kidney (multiple
lacerations)

Surgery

Type
IV

Avulsion from ureteropelvic

junction

Nephrectomy

(majority)
Surgery
(majority)
Conservative

(majority)

Renal laceration

Contrast-enhanced CT:

hypoattenuated lesions parallel to

intervascular tissue planes

Contrast enhanced CT:

Renal Laceration

Contrast enhanced CT:

Renal Laceration

pan
c

Small perirenal hematoma

rea
s

Renal laceration

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
Laceration

Right renal artery extravasation

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

Parenchymal contusion or
minor hematoma

Conservative or minimal
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

TERIMA KASIH