PENCITRAAN PADA KEADAAN PENCITRAAN PADA KEADAAN GAWAT DARURAT GAWAT DARURAT (EMERGENCY RADIOLOGI (EMERGENCY RADIOLOGI dr.Yanto Budiman , Sp.Rad, M.Kes Bagian Radiologi FKUAJ/RSAJ
Oct 22, 2014
PENCITRAAN PADA PENCITRAAN PADA KEADAAN GAWAT DARURAT KEADAAN GAWAT DARURAT (EMERGENCY RADIOLOGI(EMERGENCY RADIOLOGI
dr.Yanto Budiman , Sp.Rad, M.Kes
Bagian Radiologi FKUAJ/RSAJ
Head and faceCervical spineChestAbdomenExtremities
Head and Face Head and Face Skull FractureFacial FractureCerebral contusioEpidural HematomaSubdural HematomaSub Arachnoid HematomaCVD /Stroke
Skull FractureSkull FractureTipe Fracture :
◦Liniar◦Depressed◦Basal Clinical signs:rhinorrhoea,
otorrhoea, Battles’ sign (retro-auricular haematoma),Racoon Eyes
Facial Fracture-Maksilla Facial Fracture-Maksilla
Facial Fracture-Infra Facial Fracture-Infra Orbital Orbital
*
Tear drop sign
Facial Fracture-MandibullaFacial Fracture-Mandibulla
Cerebral ContusionCerebral ContusionRadiological features Non-contrast computed tomography (CT)
useful in the early posttraumatic period. Contusions are seen as multiple focal areas of
low or mixed attenuation intermixed with areas of increased density representing haemorrhage ( Salt & Pepper app)
True extent becomes apparent over time with progression of cell necrosis and oedema.
Magnetic resonance imaging (MRI) is the best modality for demonstration of oedema and contusion distribution.
Epidural HematomaEpidural HematomaRadiological featuresCT signs include a biconvex hyperdense
elliptical collection with a sharply defined edge. Mixed density suggests active bleeding.
The haematoma does not cross suture lines.May separate the venous sinuses/falx from
the skull; this is the only type of haemorrhage to do this.
Mass effect depends on the size of the haemorrhage and associated oedema.
Associated fracture line may be seen.
Subdural HematomaSubdural HematomaRadiological featuresCT shows a crescentic fluid collection
between the brain and inner skull. Concave inner margin with minimal brain substance displacement.
In the acute phase high density; in the subacute phase (2–4 weeks
post-injury) isodense to brain.in the chronic phase (4 weeks post-
injury) low density.
Subdural HematomaSubdural Hematoma
acute Sub acute Chronic
Subarachnoid hematomaSubarachnoid hematomaRadiological featuresNon-contrast CT is sensitive within 4–5
hours of onset.Look for acute haemorrhage (increased
density) in the cortical sulci, basal cisterns, Sylvian fissures, superior cerebellar cisterns and in the ventricles.
Older MRI macine is relatively less sensitive than CT Scan, but in modern MR Machine , using special sequences like GRE , FLAIR and DWI is comparable to CT Scan
Subarachnoid Subarachnoid HematomaHematoma
MRI FLAIR CT Scan
CVD /StrokeCVD /StrokeIschemic Stroke Haemorrhage Stroke
Non-contrast CT in the first instance.
CT is useful in detecting haemorrhage.
Hyperacute/ acute infarct may not visible at CT Scan till > 24 Hours.
Ischemic Ischemic StrokeStroke
Haemorrhage strokeHaemorrhage stroke
Cervical spine injuryCervical spine injuryClassified according to mechanism
of trauma:Flexion injuriesRotational injuriesExtension injuriesVertical compression injuries
Clay shovelers’ Clay shovelers’ fracturefracture
Tear drop fractureHangman Fracture
Comminuted compression fracture
Chest Chest RIB/STERNAL FRACTURE FLAIL CHEST PNEUMOTHORAX HAEMOTHORAX AORTIC RUPTURE DIAPHRAGMATIC RUPTURE/HERNIA FOREIGN BODY PNEUMONIAPULMONARY EDEMA
Rib/sternal fractureRib/sternal fractureConsider associated injuries:– Clavicle/1st or 2nd rib fractures suggest or indicate a significant force, often associated with great vessel, tracheo-bronchial or spinal injury.– Sternal injuries may be associated with myocardial contusion.– With lower rib fractures, abdominal visceral injury, such as liver, spleen or kidney, may occur.
Rib/sternal fracture (2)Rib/sternal fracture (2)Radiological featuresA PA/AP CXR/lateral / top lordotik /
oblique view are performed to assess for both complications and to identify any underlying fracture.
Preferebly 2 viewsSigns of secondary complications
may be evident – pneumothorax,haemothorax, pulmonary contusion, etc.
Flail ChestFlail ChestRadiological features:
● Multiple rib fractures.● Costochondral separation may not be evident.● Signs of secondary complications may be evident – pneumothorax,haemothorax, pulmonary contusion, etc
PneumothoraxPneumothoraxRadiological featuresA luscent area with no vascular
marking and Visceral pleural edge visible.
Mediastinal shift to contralateral affected side
A small pneumothorax may not be visualised on a standard inspiratory film.A expiratory film may be of benefit
HydroPneumothorax
HaemothoraxHaemothoraxAccumulation of blood within the pleural space following blunt or penetrating trauma.Radiological featuresBlunting of the costophrenic angles – seen with approximately 200 ml of blood.General increased opacification of the hemithorax is seen on a supine film.
HaemothoraxHaemothorax
Erect Film Supine Film
Aortic RuptureAortic Rupture
Aortic rupture
Diaphragmatic Diaphragmatic rupture/herniarupture/herniaRadiological features
● In the acute phase, unless there is visceral herniation, sensitivity is poor for all imaging modalities.● CXR:– Air filled or solid appearing viscus above the diaphragm.This may only be recognised following passage of an NG tube.– Other features include mediastinal shift away from the affected side, diaphragmatic elevation, apparent unilateral pleural thickening or suspiciousareas of atelectasis.● In the non-acute setting contrast studies may be useful.
Diaphragmatic rupture/hernia
Diaphragmatic Diaphragmatic rupture/herniarupture/hernia
Foreign body – Foreign body – Inhaled/ingested foreign Inhaled/ingested foreign
bodiesbodies
Pulmonary EdemaPulmonary Edema•Cardiac : Heart Failure•Non-Cardiac : renal failure, IV overload, ARDS, anaphylaxis, near drowning.
•Radiologic Features:•Alveolar edema :tiny nodular/acinar areas of increased opacity, frank consolidation, batwing appearance•Interstitial edema : appearance of Kerley lines
IntestitialPulmonary edema-heart failure
Alveolar pulmonary edema/ Bat Wing ( Butterfly ) apperances.
Non cardiac Pulmonary edema-ARDS
AbdomenAbdomen● ABDOMINAL AORTIC ANEURYSMS● OBSTRUCTION – LARGE BOWEL● OBSTRUCTION – SMALL BOWEL● PERFORATION ● TRAUMA – BLUNT ABDOMINALT RAUMA
Spleen, Hepatic, and pancreas
CT SCAN USG - FASTPlain Abdomen Film
Abdominal aortic Abdominal aortic aneurysmsaneurysms
Radiological features◦ Abdominal X-ray (AXR): Look for curvilinear
‘egg shell’ type calcification◦ Ultrasound (US) can accurately determine
size.Limited use in assessing rupture.◦ CT is accurate in assessing aneurysm
rupture as well as visualising adjacent structures.
(up)Ruptured aortic aneurysm. The arrowheads denote the breach in the wall of the aneurysm (A), with extensive associated retroperitonealhaemorrhage (H).
(Left)Calcification in the left lateral wall of an aortic aneurysm (arrowheads).
Obstruction-SBOObstruction-SBORadiologic Features: AXR (3pos.)
◦Dilated small bowel, multiple airfluid level
◦Bowel wall Thickening, “Herring Bone appearances”
◦Little gas in colon, especially rectumKey: disproportionate dilatation of
SB, bowel sound ↑Causes : Adhesions,Hernia, Volvulus,
Gallstone ileus,Intussusception
Mechanical Small Bowel Obstruction
Supine
Cross Table
Erect
Obstruction-LBOObstruction-LBORadiologic features
◦Dilated colon to point of obstruction◦Multiple air fluid level=Step Ladder◦“Herring Bone appearances”◦Little or no air in rectum/sigmoid◦Little or no gas in small bowel,
Ileocecal valve remains competent. Distended small bowel shows incompetent ileocecal valve
Large bowel Obstruction
PerforationPerforationPerforation of an air containing
hollow viscus will result in free intraperitoneal air
Radiological features◦CXR : free sub-diaphragmatic air
AXR : Left Lateral DecubitusAir will then outline the lateral edge of the liver
Perforation
pneumoperitonium
AXR , LLD position
BLUNT HEPATIC TRAUMABLUNT HEPATIC TRAUMAThe third most common organ injured in the
abdomen.
The need for surgery is determined by the size of the laceration, the amount of
hemoperitoneum, & the patient’s clinical status.
Ultrasound findings: - Laceration (right lobe > left lobe)
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- Intrahepatic hematoma: * Hyperechoic in the first 24 hours * Hypoechoic & sonolucent thereafter
- Subcapsular hematoma: * Unilateral, along the area of laceration * Anechoic, hypoechoic, septated
lenticular, or curvelinear (DD/ascitic fluid)
- Capsular disruption
- Intraperitoneal fluid
Ultrasound findingsUltrasound findings
A crescent-shaped hyperechoic collection along the right lateral aspect of the liver consistent with subcapsular hematoma.
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BLUNT HEPATIC TRAUMABLUNT HEPATIC TRAUMACT grading (blunt hepatic trauma)
Grade I Capsular avulsion, superficial laceration (s) (<1 cm deep),subcapsular haematoma (<1 cm thick), isolated periportal blood tracking
Grade II Parenchymal laceration (s) 1-3 cm deep, central/subcapsularhaematoma (s) 1-3 cm
Grade III Laceration (s) > 3 cm deep, central/subcapsular haematoma(s)> 3 cm
Grade IV Massive central/subcapsular haematoma (> 10 cm), lobartissue destruction (maceration) or devascularisation
Grade V Bilobar tissue destruction (maceration) or devascularisation
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BLUNT HEPATIC TRAUMABLUNT HEPATIC TRAUMA
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BLUNT HEPATIC TRAUMABLUNT HEPATIC TRAUMA
SUBACUTE SUBCAPSULAR SUBACUTE SUBCAPSULAR HAEMATOMA OF THE LIVERHAEMATOMA OF THE LIVER
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BLUNT HEPATIC TRAUMABLUNT HEPATIC TRAUMA
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Liver laceration with extravasation. Liver laceration with extravasation. An enhanced axial CT scan of the An enhanced axial CT scan of the upper abdomen shows a large laceration through the right lobe of the liver upper abdomen shows a large laceration through the right lobe of the liver (blue arrow), blood in the peritoneal cavity (black arrows) and active (blue arrow), blood in the peritoneal cavity (black arrows) and active extravasation of the intravenous contrast (red arrow). The stomach is extravasation of the intravenous contrast (red arrow). The stomach is labeled "S."labeled "S."
SPLENIC INJURYSPLENIC INJURYMost commonly injuredUltrasound findings: - Splenomegaly, with progressive enlargement - Irregular splenic border - Intrasplenic hematoma - Contusion (splenic inhomogeneity) - Subcapsular and pericapsular fluid collections - Free intraperitoneal blood (disappear 2-4 weeks) - Left pleural effusion - When the spleen returns to normal → small irregular foci /normal parenchyma
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SPLENIC INJURYSPLENIC INJURY
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SPLENIC INJURYSPLENIC INJURY
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HAEMOPERITONEUM (FRAGMENTED HAEMOPERITONEUM (FRAGMENTED SPLEEN)SPLEEN)
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BLUNT PANCREATIC INJURYBLUNT PANCREATIC INJURYCT grading (blunt pancreatic injury)
Grade I Minor contusion or laceration without duct injury
Grade II Major contusion or laceration without duct injury or tissue loss
Grade III Distal transection or parenchymal injury with duct injury
Grade IV Proximal transection (to the right of mesenteric vein) or parenchymal injury involving ampulla
Grade V Massive disruption of pancreatic head
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BLUNT PANCREATIC INJURYBLUNT PANCREATIC INJURY
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ExtremitiesExtremitiesTrauma : Plain X-Ray, CT Scan,
MRIRule of two (Plain X-Ray)
◦Two views◦Two joints◦Two sides
Clavicle fracture
Scapular Fracture
AC Separation
AP position
Lateral position
Galeazzi Fracture
Monteggia Fracture
Posterior hip dislocation
Left Acetabulum Fracture- CTScan 2D -3D
Left femoral neck Fracture
Shenton’s line
ANY QUESTIONS??ANY QUESTIONS??
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