trauma and solid organ lnjury
TRANSCRIPT
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TRAUMA /
SOLID ORGAN INJURY
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SPLENIC TRAUMA / INJURY
• Blunt splenic trauma occurs when a significantimpact to the spleen from some outside source(i.e. automobile accident) damages or rupturesthe spleen .
• Causes :
- automobile accident ( leading cause of internalbleeding)
- any type of major impact directed to the spleen(bicycling accidents )
*degree of injury ranges from subcapsularhematoma to splenic rupture.
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Sign and symptoms
• The primary symptom: hemorrhage( presentsdifferently depending on the degree of injury,with the symptoms of major hemorrhage, shock,abdominal pain, and distention being clinically
obvious)• Minor hemorrhage often presents as upper left
quadrant pain.
• Patients with unexplained left upper quadrantpain, particularly if there is evidence ofhypovolemia or shock, are generally inquiredregarding any recent trauma.
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CT SCAN
• Although many plain radiographic imaging findingssuggest spleen trauma injury, CT is the radiographicmodality used at most institutions.
• CT scanning should be performed in conjunction with
the intravenous administration of contrast material tomaximize density differences between the splenicparenchyma and hematomas.
• In this fashion, CT provides the best evaluation of thespleen and the surrounding tissues. An additionaladvantage of CT is the ability to use it to image all ofthe abdominal organs simultaneously in excluding asecondary injury.
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Contrast-enhanced arterial-phase CT scan of the abdomen shows a mottledappearance of the spleen. This finding should not be mistaken for splenic injury.Confirmation of a normal spleen can be shown by repeat imaging in a later phase ofcontrast enhancement. The spleen then appears homogeneously enhanced.
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Contrast-enhanced CT scan of the abdomen in the equilibrium phase shows
perisplenic fluid with mass effect on the spleen. The spleen appears
compressed by the fluid, reminiscent of subcapsular fluid collections.
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Contrast-enhanced CT scan of the abdomen shows some perisplenic fluid inthe anterior aspect. A small well-defined irregularity is noted in the splenicwall posteriorly. This was a congenital splenic cleft in a patient with perisplenicfluid secondary to nonsplenic injury.
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Grade I injuries include the following:Subcapsular hematoma of less than
10% of surface area
Capsular tear of less than 1 cm in
depth
Contrast-enhanced CT scan of the
abdomen shows a perisplenic fluid
collection with internal increased
attenuation. The splenic border is
displaced by mass effect. This was a
subacute subcapsular hematoma. Thisis a grade I injury.
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Grade II injuries include the followingSubcapsular hematoma of 10-50% of
surface area
Intraparenchymal hematoma of less
than 5 cm in diameter
Laceration of 1-3 cm in depth and not
involving trabecular vessels
. Contrast-enhanced CT scan of the
abdomen shows a complex lower polesplenic laceration. This is a grade II
injury.
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Grade III injuries include the following:Subcapsular hematoma of greater
than 50% of surface area or expanding
and ruptured subcapsular or
parenchymal hematoma
Intraparenchymal hematoma of
greater than 5 cm or expanding
Laceration of greater than 3 cm indepth or involving trabecular vessels
. Contrast-enhanced CT scan of the
abdomen shows a massive fluid
collection in the upper abdomen. Thiswas a chronic subcapsular splenic
hematoma and a grade III injury.
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Grade IV injuries include lacerationinvolving segmental or hilar vessels,
with devascularization of more than
25% of the spleen (see the images
below).
PIC 1
Contrast-enhanced CT scan of theabdomen shows a small hilar
laceration. This is a grade III-IV injury.
PIC 2
Contrast-enhanced CT scan of the
abdomen shows a complex laceration
extending to the hilum. This is a gradeIV injury.
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Grade V injuries include a shatteredspleen or hilar vascular
Contrast-enhanced CT scan shows a
localized area of dense contrast
collection in the splenic hilum, with a
massive amount of surrounding
fluid/blood. Findings here are
indicative of active extravasation of
contrast in a patient with traumatic
autosplenectomy. This is a grade Vinjury.
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ULTRASOUND
• The primary goal of splenic ultrasonography in
the setting of blunt abdominal trauma is to
detect the presence of blood in the left upper
quadrant (LUQ).
• Acute blood is hypoechoic and can be almost
anechoic.
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PIC 1oblique scans though the spleen and
left kidney.
PIC 2
Oblique and transverse scans through
the spleen.
The spleen was enlarged (173mm) and
had ill-defined, multiple eco-poor
areas within it pic1. There was fluid in
the peritoneal cavity pic2. These
features were in keeping with splenic
rupture.
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Oblique scan of the spleen showingsplenomegally (165mm-pole to pole)
and an irregularly marginated
hypoechoic area within the spleen.
Fluid is seen in the peritoneal cavity,
implying haemoperitoneum (i.e
splenic rupture)
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• The liver is the largest solid abdominal organ witha relatively fixed position, which makes it proneto injury.
•
The liver is the second most commonly injuredorgan in abdominal trauma, but damage to theliver is the most common cause of death afterabdominal injury .
• The most common cause of liver injury is bluntabdominal trauma, which is secondary to motorvehicle accidents in most instances.
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EXAMINATION
• Plain radiographic findings are nonspecific, but they may be usefulin showing the extent of associated skeletal trauma. Contrast-enhanced CT scanning remains the examination of choice inpatients with blunt abdominal trauma.
• Radionuclide study with technetium-99m (99m Tc) iminodiacetic acid
(IDA) is the examination of choice in patients in whom bile leaks aresuspected. Magnetic resonance imaging (MRI) has yet to find a rolebut can be used to monitor liver injury. Magnetic resonancecholangiopancreatography (MRCP) may be used for the diagnosisand follow-up observation of bile duct injuries.
• Angiography is useful in localizing the site of hemorrhage and in
providing an opportunity for the interventional radiologist toproceed to transcatheter embolization of bleeding sites.
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PLAIN RADIOGRAPHS
• Plain radiographic findings are nonspecific,but they are useful in evaluating rib and spinal
injuries in patients with blunt abdominal
trauma.• Fractures of the right lower ribs should
suggest the possibility of underlying liver
injury.• Pneumoperitoneum, major diaphragmatic
injury, gross organ displacement, and metallic
foreign bodies may be identified.
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CT SCAN
• CT scanning, particularly contrast-enhanced CTscanning, is accurate in localizing the site and extent ofliver injuries and associated trauma, providing vitalinformation for treatment in patients CT scanning
without intravenous contrast enhancement is oflimited value in hepatic trauma, but it can be useful inidentifying or following up a hemoperitoneum.
• CT scans can be used to monitor healing. Trauma to theliver may result in subcapsular or intrahepatic
hematoma, contusion, vascular injury, or biliarydisruption. CT scan criteria for staging liver traumabased on the AAST liver injury scale include thefollowing:
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Grade 1 - Subcapsular hematoma lessthan 1 cm in maximal thickness,
capsular avulsion, superficial
parenchymal laceration less than 1 cm
deep, and isolated periportal blood
tracking (see the images below)
Grade 1 hepatic injury in a 21-year-old
man with a stabbing injury to the right
upper quadrant of the abdomen. Axial,
contrast-enhanced computed
tomography (CT) scan demonstrates a
small, crescent-shaped subcapsular
and parenchymal hematoma less than
1 cm thick.
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Grade 2 - Parenchymal laceration 1-3cm deep and
parenchymal/subcapsular hematomas
1-3 cm thick (see the images below)
A 20-year-old man with systemic lupus
erythematosus presented with grade 2
liver injury after minor blunt
abdominal trauma. Nonenhanced axial
CT scan at the level of the hepatic
veins shows a subcapsular hematoma
3 cm thick.
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Grade 3 - Parenchymal laceration morethan 3 cm deep and parenchymal or
subcapsular hematoma more than 3
cm in diameter (see the images below)
Grade 3 liver injury in a 22-year-oldwoman after blunt abdominal trauma.
Contrast-enhanced axial CT scan
through the upper abdomen shows a
4-cm-thick subcapsular hematoma
associated with parenchymal
hematoma and laceration in segments
6 and 7 of the right lobe of the liver.
Free fluid is seen around the spleen
and left lobe of the liver consistent
with hemoperitoneum.
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Grade 4 - Parenchymal/subcapsularhematoma more than 10 cm in
diameter, lobar destruction, or
devascularization (see the images
below)
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Grade 5 - Global destruction ordevascularization of the liver (see the
images below)
Grade 5 injury in a 36-year-old man
who was involved in a motor vehicle
accident demonstrates global injury to
the liver. Bleeding from the liver wascontrolled by using Gelfoam.
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Grade 6 - Hepatic avulsion
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MRI
• MRI has a limited role in the evaluation of
blunt abdominal trauma, and it has no
advantage over CT scanning.
• Theoretically, MRI can be used in follow-up
monitoring of patients with blunt abdominal
trauma, and the modality may be useful in
young and pregnant women with abdominaltrauma in whom the radiation dose is a
concern.
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ULTRASOUND
• Ultrasonograms can demonstrate a number of
traumatic lesions, such as hematomas,
contusions, bilomas, and hemoperitoneum.
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Mechanism of renal trauma
• Blunt trauma ( 80 % ) : MVA , falls , assaults
• Penetrating trauma ( 20 % ) : gunshot ,
stabbing , impalement
• Predisposing factors : preexisting renal
conditions ( tumours , hydronephrosis ) ,
children , associated abdominal injuries
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Radiolody imaging :
1) CT with IV contrast
• Gold standard
• High sensitivity
• Immediate and delayed post contrast images
to view collecting system
• Allows diagnosis and staging
•
Images abdomen and retroperitoneum• Not for haemodynamically unstable patients
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Kidney trauma. Grade 1 renal injury,contusion. Image from a contrast-
enhanced CT scan of the abdomen in a
patient with hematuria after a motor
vehicle collision shows ill-defined area
of hypoenhancement in the medial
right kidney.
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Kidney trauma. Grade 1 renal injury,contusion. Image from a contrast-
enhanced CT scan of the abdomen in a
patient with hematuria after a motor
vehicle collision shows ill-defined area
of hypoenhancement in the medial left
kidney.
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Kidney trauma. Grade 1 renal injury,subcapsular hematoma. CT scan of the
abdomen with intravenous contrast in
a patient after a motor vehicle collision
shows crescentic high-density fluid
collection around the left kidney. Note
the well-defined outer margin.
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Kidney trauma. Grade 5 renal injury.Shattered kidney. Contrast-enhanced
CT scan of the abdomen in a patient
with hematuria and hypotension after
a motor vehicle collision shows
transection of the right kidney with a
large hematoma around and between
the 2 halves of the kidney. The 2
halves are both perfused becausethere were 2 renal arteries. Delayed
images show urinary contrast
extravasation.
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Renal rupture with a large hematoma
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Renal contusion in a 9 year old child
with a small perirenal effusion at the
upperpole
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Urinary bladder
Cli i l i di f bl dd
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Clinical indicator of bladder
rupture
- Suprapubic pain or tenderness
- Inability to void
- Clots in urine
- Swelling or hematoma
- Blood at urethral meatus
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Test available
• Retrograde urethrogram ( plain film )
- Assess the patency of anterior urethra in
males
• Cystogram ( plain film )
•
CT cystogram
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• Retrograde urethrogram (RUG)
- Fluoroscopy study ( ant urethra )
- Rules out urethral tear
- Procedure : pediatric foley catheter inserted
into tip of urethra and inflated
- Gentle injection of 5-30 cc of 30% contrastsolution from the tip of the urethra retrograde
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Urethra, trauma. Normal retrograde
urethrogram. Pericatheter retrograde
urethrogram is negative for urethral traumaand shows continuous filling of contrast
material through the extent of the urethra and
into the bladder without extravasation.
Urethra, trauma. Straddle injury. Retrograde
urethrogram shows a type V urethral injury
with extravasation of contrast material from
the distal bulbous urethra.
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• Cystogram- Fluoroscopy or static image
- Foley catheter in bladder
- Use diluted contrast ( 30 – 50 % ) contrast in saline
- Use 300 – 400 cc total , slowly fill bladder by gravity ( source of fluid is
held above level of pelvis )
- Films taken ( pre filling , full ( 300 cc ) , post drainage )
- Views : AP view if necessary , lateral and or oblique if possible
- * post drainage view : to catch any extravasation hidden by distendedbladder
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Intraperitoneal rupture
-Contrast has smooth regular contours
-- contrast accumulates near dome of
bladder
-Extends laterally filling the peritoneal
cavity
- contarst can surround loops of bowel, intraperitoneal viscera and fill the
paracolic gutters
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Computed tomography (CT) cystogram
demonstrating a simple extraperitoneal
bladder rupture with fluid in the perivesical
space (predominantly in the space of Retziusanteriorly).
Computed tomography (CT) cystogram
demonstrating a complex extraperitoneal
bladder rupture with contrast material
extending through the fascial planes of thepelvis.