Imaging in trauma

Dr (Brig) Akshay Bhargava, Director, Radiology & Imaging at Nayati Hospital, Mathura highlights the role of imaging for rapid detection and assessment of damage in trauma patients

Trauma is a sudden, and most often, wholly unexpected phenomenon. The consequent injury to any or multiple parts of the body requires immediate, expert medical attention to minimise morbidity. Rapid detection and accurate assessment of the severity of damage to any part(s) of the body is best done by imaging.

Trauma to the body can range from trivial to grievous, and can occur to any part of the body, the most susceptible being the head, neck, chest, abdomen and pelvis, the lower spine and the limbs.

Trauma imaging almost always commences with plain X-rays, which take minimal time or preparation, and are used to diagnose fractures of the bones of the skull, limbs, spine , chest or pelvis, and also provide additional vital information about injuries to the chest, such as lung contusions, lung collapse or pneumothorax following rib fractures, traumatic hemothorax or hemopericardium (accumulation of blood in the linings of the lungs or the heart), and reveal the presence of penetrating foreign bodies damaging the lungs or heart.

Plain X-rays are also used to diagnose injuries to the abdominal organs such as the intestines, when a perforation can cause the leakage of intestinal gas into the peritoneal cavity, and consequent detection on radiology.

Frequently, though more details are required to assess the damage to deeper structures within the body, and the eminent modality to detect these is a CT. CT takes only a few seconds to perform, and its diagnostic yield is phenomenal. From head to toe, a plain CT will confirm any fracture of the skull bones, underlying extradural or subdural hematomas (collections of blood in the linings of the brain) or frank intracerebral or intraventricular haemorrhages, with attendant features causing compression or shift of vital internal structures, all of which necessitate urgent neurosurgical intervention. Injury to other intracranial structures such as the eyes, middle and internal ears, nose and paranasal sinuses, teeth and jaws are also eminently detected by a CT that takes barely 8-10 seconds to perform.

Fracture dislocations of the vertebrae of the neck or lower spine that can have catastrophic consequences such as paralysis are easily diagnosed on CT, especially with new elegant reconstruction techniques in sagittal, coronal or oblique planes that picturise the images in 3D, providing surgeons with a round-the-clock view of the spine before surgical intervention.

Trauma to the chest , abdomen and pelvis is exquisitely demonstrated on CT, outlining even sub-millimeter rents of  pleura, liver, splenic or kidney  capsules, deeper parenchymal injury to the organs contained within, collections of blood or bile, or leakage of blood or urine from vascular or renal trauma – a single intravenous administration of  non-ionic contrast can then demonstrate the site of vascular trauma and leak , or discontinuity of tissues in the kidneys, ureters or urinary bladder causing leakage of urine.

Likewise, damage to the pelvic organs can be accurately assessed without delay, and any trauma to the uterus, ovaries or vasular structures delineated as a road map for the gynaecologist or the surgeon.

Oftentimes, fractures of long bones, notably the femurs cause large attendant collections of blood (hematomas) in the surrounding soft tissue/ muscle compartments, and a CT can quantify the extent and severity of the same, as well as demonstrate any nerve or vascular compression that may compromise the viability of distal structures. The road map is then of vital importance to the orthopedician. Again, simple contrast administration can reveal any vascular trauma, discontinuity or leak for the surgeon to repair with alacrity.

While CT is rapid, and patient throughput takes minimal time, an MRI takes longer to perform. Its employ is eschewed in trauma imaging except when there is damage to vital organs such as the brain and spinal cord.  An MRI is a far superior modality and thus essential to accurately assess the extent of damage to gray matter, and assist the neurosurgeon in deciding  whether to relieve pressure, or compression on the same surgically. Many cases of traumatic quadriparesis, or Cauda Equina syndrome with bladder and bowel involvement have been rescued from lifelong debility by timely imaging and surgical intervention.

At times, when the patient is badly injured and moving him takes time, a bedside ultrasound performed by the radiologist in the emergency is invaluable in imaging damage to abdominal and pelvic organs,  providing image guidance for draining a pleural (chest cavity) collection, or assessing a soft tissue hematoma or collection. The practice of FAST, or Focussed Assessment by Sonography in Trauma, has proved itself time and again in emergency situations, and localised the site and extent of trauma to organs for doctors in emergency and surgeons to act upon without delay.

In trauma imaging, time is of paramount importance. Alongside, accuracy in diagnosis is vital to prevent further morbidity in the injured patient.  The radiologist must at all times be well trained and aware of what to look for in every circumstance, and also has to be clinically oriented.

Indeed, radiologists are the pathfinders in imaging in any situation. The essence of film interpretation lies always in the trained eye of the radiologist. At Nayati, the team is dedicated to excellence in performance, committed to bringing medical care to every patient, and indeed, in sending them home in better shape than they came to the hospital in.