improving quality of acute trauma care in radiology dr r. nyabanda radiologist kenyatta national...
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Improving quality of acute trauma care In Radiology
Dr R. NyabandaRadiologistKenyatta National Hospital19th April 2013
RADIOLOGY DEPARTMENT
VISIONTo be a world class centre of excellence in the provision of innovative diagnostic imaging and
interventional radiology services.MISSION
To provide specialized quality diagnostic imaging and interventional radiology services,
facilitate medical training, research and participate in national health planning and
policy.
JOINT COMMISSION INTERNATIONAL (JCI)ACCREDITATION STANDARDS FORHOSPITALSStandards Lists Version
trauma in radiology in severely injured patients
Management of Severely Injured Patients (SIPs)• The acute trauma setting is not the place for
disagreement about the patient. Immediate management decisions must be made by the designated trauma leader.
• The trauma team leader is an overall charge in acute care.
• Just as the trauma team leader must be an experienced consultant, there must be a consultant in Radiology in charge of trauma.
• Protol driven imaging and intervention must be available and delivered by experienced staff!
Location and Facilities• Just like in A&E, triaging of patients is very
important.• Imaging SIPs more accurately delineates the extent
of injury than clinical examination.• Imaging technique of choice is the one which is
definitive in trauma setting. In SIPs this is most often head to thigh CE-MDCT.
• The MDCT should be adjacent to emergency room.• Radiography must also be present in the emergency
room• The imaging environment requires all the life support
facilities available in the emergency room. This will include monitoring and gases.
Radiography• CXR-Chest radiograph must be obtained to
document the position of tubes and lines and to evaluate for pneumothorax or hemothorax and mediastinal abnormalities
• AXR or pelvic X Ray are usually irrelevant if patient is going in for CT.
• The British Orthopaedic Association and British Society of Spine Surgeons do not recommend plain films of the C-spine in a SIP and their standard of practice is CT.
• Cervical spinal injury precautions and pelvic binders should remain in place until the MDCT has been fully assessed
C6 #
Focused Abdominal Sonography in Trauma (FAST)FAST is used to demonstrate - intra-abdominal hemorrhage - Solid organ injuries- spleen, liver, kidney - Pericardial effusion
MDCTClear of the need for protocols must exist for
notifying the CT department urgent imaging and how the department will respond to ensure that the scanner is clear to receive the incoming injured patient.
IV assess right antecubital assess is preferred for contrast adminstration
Radiation dose should be considered
Polytrauma protocol MDCT is indicated when:There is hemodynamic instabilityThe mechanism of injury or representation
suggests that there may be occult severe injuries that cannot be excluded by clinical examination or plain films
If plain films suggest significant injury, such as pneumothorax, pelvic fractures
Obvious severe injury on clinical assessment
Interventional Radiology(IR)
• The role of IR in the SIP is to stop hemorrhage as quickly as possible
• The decision on whether a patient with traumatic hemorrhage undergoes endovascular treatment, open surgery, a combination of the two or non-operative management is typically a decision made by both the trauma team leader and interventional radiologist after consultation.
• Interventional treatment modalities include Balloon occlusion, transarterial embolization to stop hemorrhage.
MRIMRI is not indicated in the setting of acute
trauma care. However availability of clear protocols for the transfer of SIPs to MRI facilities after stabilizing the patient is recommended.
No Imaging !There may be circumstances where imaging
is inappropriate; for example, where a SIP is admitted with profound shock, is not responding to intravenous fluids and the site of bleeding is clear from the mechanism of injury and rapid assessment. Such patients may be best taken straight to theatre.
Quality IndicatorAll imaging should be discussed at debriefing
meetings and errors of protocol or facts discussed at discrepancy meetings
Radiologists should ensure they participate in ongoing audit and morbidity and mortality meetings of trauma services
Non-accidental injury
Note massive edema minimally hyper- dense subdural, extreme mass effect and herniation despite open fontanelle
ReferencesStandards of practice and guidance for trauma
radiology in severely injured patients. Operating Framework for the NHS in ENGLAND 2011/2012
Ann Osborn. Craniocerebral Trauma update 2010Emergency Radiology, Advanced trauma life
support ABCDE from a radiology point of view.
Emerg Radiol. 2007 July; 14(3): 135–141McGahan J P, Wang L, Richards J R. Focused
abdominal US for trauma. Radiographics. 2001;21:S191–S199. [PubMed]