DIAGNOSTIC

APPROACH TO TRAUMA
M I C H E L L E F. G E S T O PA
P O S T- G R A D U AT E I N T E R N
W E S T V I S AYA S S TAT E U N I V E R S I T Y- M E D I C A L C E N T E R
CRANIAL CT SCAN
• All patients with loss of consciousness
• All patients with significant closed head injury (GCS score <14)
• Elderly patients
• Patients on antiplatelet agents or anticoagulation despite a GCS of 15
• Presence of lateralizing findings (unilateral dilated pupil unreactive to light, asymmetric
movement of extremities) suggests intracranial mass lesion or major structural damage
CRANIAL CT SCAN
CRANIAL CT SCAN
• Epidural hematoma • Subdural hematoma
– Blood accumulates between the skull and – Between the dura and cortex
dura – Caused by venous disruption or laceration
– Caused by disruption of the middle of the parenchyma of the brain
meningeal artery or other small arteries
typically after a skull fracture
CRANIAL CT SCAN
• Epidural hematoma
– Lenticular or biconcave shape on CT
– Hemorrhages cannot cross the suture line
(dura is anchored to the sutures) but can
expand rapidly causing uncal herniation
and death
– Patients lose consciousness immediately
after injury and undergo “lucid interval”
after which they become comatose
– Emergent craniotomy
CRANIAL CT SCAN
• Subdural hematoma
– Crescent-shaped bleed on CT
– Blood fills the potential space between the
dura and arachnoid mater
– Hemorrhage cross suture lines
– Craniotomy if CT shows midline shift
CRANIAL CT SCAN
• Diffuse axonal injury
– Severe rapid-deceleration head injuries
– Blurring and punctate hemorrhaging
along the gray-white matter junction
CRANIAL CT SCAN

Normal CT Diffuse axonal injury

 CERVICAL X-RAY
• All blunt trauma patients should be
assumed to have cervical spine injuries
until proven otherwise
• Take an AP and lateral view with the
neck stabilized by a collar
 CERVICAL X-RAY
• All blunt trauma patients should be
assumed to have cervical spine injuries
until proven otherwise
• Take an AP and lateral view with the
neck stabilized by a collar
CHEST X-RAY
• Most common imaging study performed
in trauma patients
• Easily obtained during the resuscitation
phase
• Performed in any patient with
penetrating chest trauma to evaluate for
pneumothorax or hemothorax
• Aids in the placement of chest and
endotracheal tubes
CHEST X-RAY
• Most common imaging study performed • Presence of fluid in the pleural space
in trauma patients (hemothorax)
• Easily obtained during the resuscitation • Lung expansion (pneumothorax)
phase • Fractures (ribs, sternum, clavicles,
• Performed in any patient with scapulae)
penetrating chest trauma to evaluate for • Mediastinal shift (tension
pneumothorax or hemothorax pneumothorax)
• Aids in the placement of chest and • Widening of mediastinum
endotracheal tubes
• Loss of anatomic detail
• Abdominal viscera within chest cavity
CHEST X-RAY
CHEST X-RAY
• Step 1: Identify general data
• Step 2: Determine view
• Step 3: Assess the quality of the film
• Step 4: Assess anatomy and determine
abnormalities
 CHEST X-RAY
• Step 2: Determine view

Scapula winged out Scapula not winged

out

Ribs and clavicles

more angulated Clavicles more
horizontal

Mongolian hat sign

present (C7 & T1 Mongolian hat sign
spinous + not appreciated
transverse process)

PA view AP view
CHEST X-RAY
• Step 3: Assess the quality of the film
– Visualization
• Apices of the lungs to the
costophrenic angle
• Edges of the ribs laterally
CHEST X-RAY
• Step 3: Assess the quality of the film
– Inspiratory effort
• >8 intercostal spaces
• 6-8 anterior ribs
• 9-11 posterior ribs
CHEST X-RAY
• Step 3: Assess the quality of the film
– Exposure
• Upper four thoracic vertebrae
should be visualized
CHEST X-RAY
• Step 3: Assess the quality of the film
– Obliquity
• Medial ends of both clavicles
equidistant from midline
• The spinous process of the
thoracic vertebrae should be in
the midline
CHEST X-RAY
• Step 3: Assess the quality of the film
– Obliquity
• Medial ends of both clavicles
equidistant from midline
• The spinous process of the
thoracic vertebrae should be in
the midline
CHEST X-RAY
• Step 4: Assessing anatomy and
abnormalities
CHEST X-RAY
• Step 4: Assessing anatomy and
abnormalities
– Airways
• Trachea is at the midline (or
slightly to the right) as an area
of radiolucency
• Branches at the carina into the
two main bronchi
CHEST X-RAY
• Step 4: Assessing anatomy and
abnormalities
– Bones
• Check for rib fractures, breast
shadow
• Vertebral bodies and the
sternum for fractures or other
osteolytic changes
CHEST X-RAY
• Step 4: Assessing anatomy and
abnormalities
– Cardiac
• Assess CT ratio: >0.50 in PA
view suggests cardiomegaly
• Heart borders
• Aorta (widening, tortuosity)
CHEST X-RAY
• Step 4: Assessing anatomy and
abnormalities
– Diaphragm
• Well-defined domed structures
• Right hemidiaphragm should
be higher than the left
• Below the left hemidiaphragm,
a round area of lucency is
found (stomach bubble)
CHEST X-RAY
• Step 4: Assessing anatomy and
abnormalities
– Effusions
• Blunting of costophrenic angle
CHEST X-RAY
• Step 4: Assessing anatomy and
abnormalities
– Fields (Lung fields)
• Infiltrates
• Air bronchograms, tram
tracking, Kerley B-lines
CHEST X-RAY
• Step 4: Assessing anatomy and
abnormalities
– Gastric bubble
• Below the left hemidiaphragm
CHEST X-RAY
• Step 4: Assessing anatomy and
abnormalities
– Hilum
• Check for position and size
• Left hilum is often higher than
the right
 TRAUMA OF THE CHEST
• Tension Pneumothorax • Open Pneumothorax (“Sucking chest
– Progressive build-up of air in pleural wound”)
space usually due to a lung laceration – Associated with a full-thickness loss of
– Normally negative intrapleural pressure chest wall (>2/3 diameter of the trachea)
becomes positive and pushes – Free communication between pleural
mediastinum to contralateral side and space and the atmosphere preventing lung
obstructs venous return to the heart inflation and alveolar ventilation
TRAUMA OF THE CHEST
 TRAUMA OF THE CHEST
• Tension Pneumothorax

Large right pneumothorax with evidence of tension - Post insertion of a right pleural pigtail catheter -
mediastinal shift to the left and slight ongoing right pneumothorax with resolution of
hyperexpansion of the right hemithorax. tension.
 TRAUMA OF THE CHEST
• Open Pneumothorax
 TRAUMA OF THE CHEST
• Massive hemothorax
– More than 1500 ml of blood or >25%
of patient’s blood volume in pleural
space
 TRAUMA OF THE CHEST
• Flail chest
– Three or more contiguous ribs are
fractured in at least two locations
– Usually occurs in high impact trauma
 TRAUMA OF THE CHEST
• Pulmonary contusion
– Blunt trauma of the chest
– Hemorrhage into the lung parenchyma
– Patchy or diffuse areas of airspace
disease
– Absence of air bronchograms (bronchi
are filled with blood)
 ABDOMINAL X-RAY
• Amount of injury sustained or the
structures involved (gunshot wound)
 ABDOMINAL X-RAY
• Amount of injury sustained or the
structures involved (gunshot wound)
 PELVIC X-RAY
• Confirm the presence of significant
pelvic fractures which are often the sites
of hemorrhage
FOCUSED ASSESSMENT WITH
SONOGRAPHY IN TRAUMA (FAST)
• Most acceptable, repeatable and cheaper
compared to CT scan
• Ultrasound examination of the abdominal
cavity and pericardial sac for liquid
• Not only limited in the abdomen but in the
cardiac box as well, wherein if blood is
present, it may indicate hemopericardium
or cardiac tamponade
FOCUSED ASSESSMENT WITH
SONOGRAPHY IN TRAUMA (FAST)
• Determine if fluid in the abdominal cavity is
secondary to blood from solid organ or
succus (rupture of a hollow viscus)
– succus patient should be submitted for surgery
– blood and the patient is still hemodynamically stable
 observation

• Sensitive for intra-abdominal fluid >250ml

• In lower volumes, fluid accumulates in the
pelvis or near the site of injury
• Larger intraperitoneal fluid volumes
(>500ml)
– Fluid is detectable in the perihepatic and
perisplenic space
FOCUSED ASSESSMENT WITH
SONOGRAPHY IN TRAUMA (FAST)
• Determine if fluid in the abdominal cavity is
secondary to blood from solid organ or
succus (rupture of a hollow viscus)
– succus patient should be submitted for surgery
– blood and the patient is still hemodynamically stable
 observation

• Sensitive for intra-abdominal fluid >250ml

• In lower volumes, fluid accumulates in the
pelvis or near the site of injury
• Larger intraperitoneal fluid volumes
(>500ml)
– Fluid is detectable in the perihepatic and
perisplenic space
FOCUSED ASSESSMENT WITH
SONOGRAPHY IN TRAUMA (FAST)
• Advantages
– Decreases the time to diagnosis for acute
abdominal injury in blunt abdominal
trauma
– Helps accurately diagnose
hemoperitoneum
– Helps assess the degree of
hemoperitoneum
– Is noninvasive
– Can be performed quickly
FOCUSED ASSESSMENT WITH
SONOGRAPHY IN TRAUMA (FAST)
• Advantages
– Can be repeated for serial examinations
– Safe in pregnant patients and children, as it
requires less radiation than CT
– Leads to fewer diagnostic peritoneal
lavage
FOCUSED ASSESSMENT WITH
SONOGRAPHY IN TRAUMA (FAST)
• Indications
– Blunt abdominal trauma
– Stable penetrating trauma
– Assessment of the degree of
intraperitoneal free fluid
 FAST E-FAST
• Hepatorenal recess (Morison pouch) • Bilateral hemithoraces
• Perisplenic view • Upper anterior chest wall
• Subxiphoid pericardial window
• Suprapubic window (Douglas pouch)
 FAST
• Hepatorenal recess (Morison pouch)
– Blood tends to pool on dependent areas
– Most dependent space in the supramesocolic
region
– Transducer probe should be placed in the right
upper quadrant or laterally along the
thoracoabdominal junction
– Uses the liver as an acoustic window and
avoids interference from air-filled bowel
– Probe should be moved  toward the inferior
margin of the liver to obtain improved images
of the right kidney
 FAST
• Hepatorenal recess (Morison pouch)
– Normal RUQ findings
 FAST
• Hepatorenal recess (Morison pouch)
– Free fluid in Morison’s pouch
 FAST
• Hepatorenal recess (Morison pouch)
– Free fluid in Morison’s pouch
 FAST
• Perisplenic view
– Transducer-probe should be placed over the
left flank, lateral to the spleen along the
posterior axillary line
– Spleen to be used as an acoustic window and
avoids interference from air-filled bowel
– Probe should then be moved superiorly
(toward the thoracoabdominal junction) and
inferiorly to assess for the presence of free
fluid above the spleen and along the spleen
tip
 FAST
• Perisplenic view
– Left upper quadrant view
 FAST
• Perisplenic view
– Assess the hepatodiaphragmatic and
splenodiaphragmatic spaces
– Blood often accumulates in these areas
 FAST
• Perisplenic view
– Normal splenorenal space
 FAST
• Perisplenic view
– Fluid in splenorenal space
 FAST
• Subxiphoid pericardial window
– Transducer-probe should be placed in the
subxiphoid area and directed into the chest
toward the left shoulder so as to view the
diaphragm and heart
– This view can be difficult to obtain if the
patient is experiencing significant
abdominal pain
• Switching to a parasternal long-axis view
• Assess for pericardial effusions
• Also allows the examiner to assess the size
and collapsibility of the inferior vena cava
 FAST
• Subxiphoid pericardial window
– It often requires pressing the probe into the
abdomen and angling the probe so that it is
nearly parallel to the skin
– It is helpful to place the palm over the top
of the probe with the thumb on the
indicator
 FAST
• Subxiphoid pericardial window
– Traumatic tamponade
 FAST
• Suprapubic window (Douglas pouch)
– Rectouterine space
– Suprapubic view allows assessment of
fluid in the most dependent area in the
inframesocolic region
– Probe should be placed just above the
pubic symphysis and directed inferiorly
into the pelvis
– This view is easier to obtain when the
bladder is full and before the placement of
a Foley catheter
 FAST
• Suprapubic window (Douglas pouch)
– Suprapubic view
 FAST
• Suprapubic window (Douglas pouch)
– Fluid in pelvis
EXTENDED FOCUSED ASSESSMENT WITH
SONOGRAPHY IN TRAUMA (E-FAST)
• In addition to imaging of the abdomen, this
includes views of bilateral hemithoraces to
assess for hemothorax and views of
bilateral upper anterior chest walls to
assess pneumothorax
EXTENDED FOCUSED ASSESSMENT WITH
SONOGRAPHY IN TRAUMA (E-FAST)
• In addition to imaging of the abdomen, this
includes views of bilateral hemithoraces to
assess for hemothorax and views of
bilateral upper anterior chest walls to
assess pneumothorax
EXTENDED FOCUSED ASSESSMENT WITH
SONOGRAPHY IN TRAUMA (E-FAST)
• In addition to imaging of the abdomen, this
includes views of bilateral hemithoraces to
assess for hemothorax and views of
bilateral upper anterior chest walls to
assess pneumothorax
EXTENDED FOCUSED ASSESSMENT WITH
SONOGRAPHY IN TRAUMA (E-FAST)
EXTENDED FOCUSED ASSESSMENT WITH
SONOGRAPHY IN TRAUMA (E-FAST)
• To rule out pneumothorax, place a high-
frequency linear probe (8-12 MHz) with
the indicator toward the patient’s head in a
long-axis orientation.
• Place the probe high on the patient’s chest,
just below the clavicles in the
midclavicular line.
• Look for the pleural line sitting at the back
of the ribs.
EXTENDED FOCUSED ASSESSMENT WITH
SONOGRAPHY IN TRAUMA (E-FAST)

No Pneumothorax With Pneumothorax

- Presence of sliding between the visceral and - Absence of sliding
parietal pleura
EXTENDED FOCUSED ASSESSMENT WITH
SONOGRAPHY IN TRAUMA (E-FAST)
• To rule out hemothorax, the transducer
probe should be placed laterally on the
lower thorax just above the diaphragm.
• This can be visualized by sliding the probe
superiorly from the standard right and left
upper quadrant views.
• Blood appears as an anechoic stripe in the
thorax.
EXTENDED FOCUSED ASSESSMENT WITH
SONOGRAPHY IN TRAUMA (E-FAST)
• To rule out hemothorax, the transducer
probe should be placed laterally on the
lower thorax just above the diaphragm.
• This can be visualized by sliding the probe
superiorly from the standard right and left
upper quadrant views.
• Blood appears as an anechoic stripe in the
thorax.
FOCUSED ASSESSMENT WITH SONOGRAPHY IN
TRAUMA
(FAST AND E-FAST)

• Interpretation
– Positive
• Fluid in pericardium or any 1 of 4
abdominal windows
– Negative
• No fluid in any windows
– Indeterminate
• If any one of the 4 windows is
inadequately visualized
FOCUSED ASSESSMENT WITH SONOGRAPHY IN
TRAUMA
(FAST AND E-FAST)