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Whole Body Trauma CT

- the Bleeding Edge

Dansk Radiologisk Selskabs årsmöde, Aarhus 2013

Bertil Leidner, MD

Karolinska University Hospital Huddinge, Stockholm, Sweden

Outline

Karolinska Trauma Center

Trauma Radiology

Why WBCT?

Protocol; dose; pregnancy, iv contrast

Critical cases – Head to toe

» BCVI

The future – problems & possibilities

Karolinska Level 1 Trauma Center

•2 million inhabitants

•1300 trauma whole

body CT per year

•approx 300 ISS >15

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Radiology in trauma today

First survey – ABCDE –trauma room radiology » Chest + pelvis X-ray +

» US abd + pleurae + pericard

Second survey – head to toe – Whole Body CT

Treatment – angio - embolization

Follow-up – CT & contrast ultrasound

Trauma Radiology before CT Surgeon´s Viewpoint

X-ray = X-time

Radiology in multitrauma

Circulatory STABLE patient

» Whole body CT

Now also “borderline” stable

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Trauma

What injuries?

Image from trauma.org

Trauma CT

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Why Whole Body CT?

Single area CT guided by clinical

findings or Whole Body CT

Why “Whole Body” CT ?

Clinical exam inadequate

Distracting injuries

Systematic ATLS adjunct

» multislice CT used as a second survey

» standardized procedure every time

– possible to train for techs

– fast

– minimizes possible omissions

Whole Body CT - advantage

The Golden Hour

Whole body evaluation in one setting

Inclusive:

» C/T/L- spine & pelvis

» angiographic evaluation

Evaluation of circulation

» hypovolemia

» active bleeding

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Why Whole Body CT?

Routine Whole body CT reveals more

injuries than selective CT

» Van Vugt R et al, Eur J Trauma 2011

Whole Body CT has proved to decrease

mortality compared to selective CT

» Körner et al, Lancet 2009

Clinical outcome

Single area CT guided by clinical findings or Whole Body CT

100 trauma units in Germany 2002-2004

» 5000 patients

» CT area by clinical evaluation vs whole body CT

» Outcome by TRISS / RISC

» Whole body CT increased survival 12-25% !

(Körner et al, Lancet 2009)

VCT in Trauma

Whole body coverage

Feet first

190 cm helical

weight 227 kg

Tube 100 kW

Fast scanning:

11-14-18 cm / sec

64 channel @ 0.625 mm

Detailed Volume Imaging

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Trauma CT protocol – GE VCT

no i.v. contrast

Head – sequence acq 0.6 im 5/2.5 3 planes

C-spine – spiral acq 0.6 im 2.5 ax pre BCVI

im 1/1 3 planes

with i.v. contrast

125 ml @ 320mg I/ml 2.5 ml/s scan start 50 sec

Body – if BCVI suspicion start above circle of Willis

if not – start jugulum to symphis or to toe

spiral pitch 0.9 acq 0.6 im 5/5 axial 1st view

workst 3 planes

Dose

CT Dose

» head 2.0 mSv

» c-spine 3.5 mSv

» body 9.0 mSv

Total dose ~14.5 mSv

4-6 years Swedish background radiation

CT & pregnancy

Save the mother

» Save the child

Trauma

» CT!! not ultrasound

» 4x whole body scan

CT PE = OK

CT head = OK

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Approximate fetal doses

Examination Mean dose

(mGy)

Maximum dose

(mGy)

Abdomen 1,5 5

Pelvis (one image) 0,5 1

Abdomen CT 15 35

Pelvis CT (low dose) 5 10

Pelvis CT (normal dose) 12 32

Chest CT 0,02 <0,1

Head CT ~0 ~0

Theoretical approximate fetal doses calculated from non pregnant patients at Karolinska University Hospital

Courtesy Physicist Jon Holm, GE

Probability of bearing healthy child

Dose to conceptus

(mGy)

Probability of no

malformation

Probability of no cancer

(0-19yrs)

0 97 99,7

1 97 99,7

5 97 99,7

10 97 99,6

50 97 99,4

100 97 99,1

>100 Possible

Courtesy Physicist Jon Holm, GE

IV contrast

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Case

50 y o man

Motorbike accident

GCS 13, slightly tender abdomen, no shock

What if

» Earlier heavy skin reaction after iv iodine CM

» Known renal disease; P-creatinine 200

Trauma CT with iv CM?

Or not?

Standard scans + iv No iv contrast

FAST neg

+

CT + No fluid in the abdomen.

Injury ruled out??

Standard scans + iv No iv contrast

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Dx?

MVA

Findings?

Mixed density lesion

Trapped fluid in ipsi-

lateral ventricle

DX?

Hyperacute subdural

hematoma

» Unclotted blood

Motorcross-accident

25 y o female

thrown off bike

hit the bushes

Findings?

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Wood – wide window

CT Acute Spinal Canal Imaging

Spinal Cord threats » herniating disc

» epidural hematoma

» ligamentous injuries

64x0.625 mm » 50% recon overlap

» bone algorithm

» mpr sag 6 mm thick

» 50% image overlap

» WW 400 WL 100

C 7

T 2

Bilateral occipital condyle fx

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C-spine epidural (+ occipital condyle fx)

C2 fx – MR correlation

Bilateral facett luxation C 6-7

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Bilat facett dislocation -

disc evalution

Bechterew

Epidural hematoma

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VRT spine

VRT mimics

standard

radiographs

» Fast viewing

» Easy for

comparative

follow-up

» Easy for

orthopedic

surgeons

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MDCT: angiography

Neck vessels

Aorta

Extremities

Parenchymal organs

» Liver, spleen, kidneys

» Mesentary, abdomen

Case 1 @ Karolinska Male 40 years

Car accident

» Side hit

» Temporal superficial wound

Clinical status

» No LOC

» Alert, neck pain

CT head + c-spine 2 h later

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CT # 1 - 2 h post injury

CT exam # 1 and # 2 @ 4h

CT # 3 day 2 – 16 h

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Following BCVI images – courtesy Clint Sliker

Walter L. Biffl, M.D. Associate Professor of Surgery Denver Health Medical Center

University of Colorado

Clint W. Sliker, M.D. Assistant Professor of Radiology

R Adams Cowley Shock Trauma Center

University of Maryland School of Medicine

Sigtuna Consensus Conference 2007

BCVI - IMPACT OF SCREENING

Pre-Screening Screening

1/90-7/96 8/96-10/01

Incidence

Symptomatic

Biffl, Ann Surg 2002; 235:699

1.6%

24%

0.1%

100%

STROKE PREVENTION – MEMPHIS

Patients Treated While Asymptomatic

Carotid Artery injuries

Heparin: 1 of 9 (11%) Stroke

Antiplatelet: 1 of 6 (17%) Stroke

Overall: 33% Stroke Miller, Ann Surg 2002; 236:386

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Summary

Patients with defined risk factors should be investigated to detect BCVI

Using Multislice CT 16 + channels,

» Whole Body CT (WBCT) protocol

» or dedicated Neck Vessel CTA

When examination is positive treat

» barring contraindication,

» treat regardless of grade.

Grade I <25% – Intimal Injury

Sagittal MIP

3D-VR Angiography

Grade II > 25% – Intramural Hematoma

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Grade III - Pseudoaneurysm

Grade IV - Occlusion

TAI

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Aortic rupture, TAI

Thorax

Thorax

» You are called to

the CT suite by

the tech.

» Now what?

How to deal with a tension pnthx?!

Make a quick report?

Call for an anesthesiologist?

Call for a surgeon?

or...

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How to deal with a tension pnthx?!

or...

Puncture

» 2 -3 intercostal space

» Medio-clavicular line

» Large needle

(venflon)

» Keep until drainage

cath is placed

MVA 1977 – ER 2013

Presents jan 2013

Abd pain, shortness of breath

Decreased saturation

Bradycardia

Improved at arrival

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Consequences - diaphragma rupture sequele

Dilated ivc

Decreased venous return

» cf tension pnthx

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Abdominal trauma

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Female 45 y, kicked by horse

Female 45 y, kicked by horse

Female 48 y, MC-accident

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Female 48 y, MC-accident

Hypovolemia in CT

Significant injuries - bleeding sources » Thorax

» Abdomen

» Retroperitoneum – pelvis

» Femur

» ”in the street”

@ risk » Young persons

» Pregnant

» Compensates well for hypovolemia

Steeringwheel towards abdomen

Male 28 y

Findings:

Abundant free

abdominal fluid,

mesenteric

hematoma

TF 105

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Clinical course

Period of tachycardia

and BP-fall 15 min

before CT

Findings

significant bleeding

constriction of aorta

low volume IVC

Hypovolemia

TF 105

Female 25 y Car crash

Free abdominal

fluid

Free air

Hypovolemic signs

» Significant bleed

» Constriction of aorta

» Low volume of IVC

» Intensive kidney enhancement

Summary: Signs of hypovolemia

Significant injuries bleeding sources

Increased enhancement » Aorta

» mesentery

» bowel

» kidneys

» Pancreas

» Pulmonary atelectasis

Decreased diameter

» Aorta –thoracic/abd

» Aortic branches

» Inf/sup v cava

» Cardiac chambers

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References

Taylor et al (1987) Hypovolemic shock in children:

abdominal CT manifestations. Radiology 164, 479-

481.

Jeffrey et al (1988) The collapsed inferior vena

cava: CT evidence of hypovolemia. AJR 150, 431-

432.

Rotondo et al (1998) Thoracic CT findings at

hypovolemic shock. Acta Rad 39, 400-404.

Trauma CT- limitation

» Motion and metal artifacts

» A snapshot in time!!!! – the information is true for the time of scanning

– Do rescan on clinical deterioration

» Timing of scanning – iv.-contrast, oral contrast

» Difficult diagnosis - GI-injuries, pancreas

» 1500++ images – – SOS – Satisfaction Of Search

» Reader knowledge

» Patient transfer problems

Future development

CT in the trauma room

» Put patient directly on the CT-table

» Triage CT

Lower CT radiation dose

Faster CT with even better resolution

CT intervention / Hybrid Suites

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Triage CT study Conclusion I

Triage CT in stable blunt trauma victims

» feasible in limited way

» more diagnostic information cf traditional

X-ray and FAST

The more accurate diagnostic findings

are likely to better guide the trauma

team in the patient management

Conclusion II

@ Karolinska trauma center

» the logistic problems so far seem to be

greater than the advantages of the superior

imaging method.

Triage CT was thus not feasable to use

for circulatory unstable patients.

Organizational improvements necessary

for Triage CT implementation

Be careful out there!!

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www.nordictraumarad.com

www.nordictraumarad.com

Questions?

Extra material

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The clinical effects of MDCT

Fewer “exploratory” surgeries

Far fewer explorations for penetrating torso trauma

More non-operative treatment for solid organ injuries

Greater role for interventional angiography

Decreased need for diagnostic angiography » (aorta, extremities)

Earlier diagnosis of complications

Faster access to imaging results with improved post-processing (Mirvis)

Over-utilization

» (ineffective clinical triage) --- cost, time, and radiation

Injury grading standardization

» (surgical and imaging integrated, high-reader agreement, grade predicts optimal care)

Patient transport events

» (lines, tubes, motion, personel intensive, support, safety)

(Mirvis)

Problems today in trauma imaging

The Impact of New Technology

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• Faster

• Lower dose

• More detectors – flat panel

• More coverage

• Multiple passes

• Time resolved angiography

• Perfusion: physiology

• Faster transmission of image data

• images accessable everywhere “i-Pad”

(Mirvis)

New CT Technology

Faster image reformation and post-processing

(pre-planned, automated, user independent)

Easier transfer of patient

» docking CT

CT-ICU (dedicated critical care CT)

More (wireless) monitoring

In-field sonography – wireless transmission

(Mirvis)

The Impact of New Technology

• Mobile

• “Big Boy” capacity

• Tailored emergency CT Scanner – Suite

(Mirvis)

New Technology

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Dual/Multi-energy CT in Trauma

Virtual non-contrast head

Bone subtraction – angiography

Hemosiderin detection

Gross increase in data volumes

» New ways of handling data

Image presentation – Virtual Autopsy Table - CMIV

Next step:

simulated operation

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The Hybrid Suite @ Solna

”CT ”Images Hybrid Imaging

TELE-traumatology project Karolinska Trauma Center @ Regional hospitals

On-line communication between Karolinska

Trauma Center & trauma room in other hospitals

» Live video in trauma room

» Head set communication

» Radiological images

Clinical advice

Radiological expertice