Trauma Guideline Manual - SUNY Upstate Medical University

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38____________ Trauma Guideline ManualUpstate Medial University Trauma CenterOPERATIONAL GUIDELINES: RADIOLOGIC STUDIES ON TRAUMA PATIENTSOBJECTIVE:To provide a guideline for the proper ordering of X-rays on multiple trauma patients.GUIDELINES:1. Trauma Room Radiographic studies:a. Radiographic studies in the Trauma room should initally focus on identification ofimmediate life threats.b. Trauma Room supine chest X-ray:i. In general, almost all multiply injured patients require a supine chest X-ray.ii. On all patients with suggestion of chest injury.iii. On all patients transferred from another hospital, even if intubated.iv. Obtain as soon as possible on intubated patients.c. Trauma Room AP pelvis.i. A pelvis film does not need to be ordered on every patient. An initial pelvis film isnot necessary on a patient who will receive an abdominal/pelvis CT scan.ii. Obtain on all obtunded patients with a possible mechanism suggesting a pelvicii.injury.If the patient is alert and cooperative, obtain portable pelvis X-ray when there aresigns and symptoms of pelvic injury.d. Other Trauma Room films should be obtained only if the information from them isurgently needed (e.g., foreign body identification in GSW, etc.) or if the patient isunstable – remember: portable films are expensive and may be of poorer quality!2. Other X-rays: Will be obtained in the main X-ray facility (in ED or in main radiologydepartment). In general, spine and extremity X-rays are obtained on the basis of physicalsigns or symptoms.3. Thoracic and lumbar films: Obtained for those patients with a significant mechanism ofinjury for blunt trauma and are unable to provide an adequate physical exam due to otherinjury or diminished mental status. If a CT scans of the chest and abdomen are beingobtained, then reformat the CT scan to provide AP and lateral T,L,S spine views. This mustbe ordered at the time of ordering the CT scans. If CT scans are not performed than obtainAP and lateral T,L,S spine films4. Extremity arteriogram or duplex scan (for larger vessels):a. Any fracture with evidence of poor arterial perfusion (e.g., ankle brachial index
Trauma Guideline Manual______________Upstate Medical University Trauma Center396. Carotid evaluation (angiogram, duplex scan, or CT angiogram) Obtain on patients withlateralizing neurologic deficit unexplained by findings on head CT (ie., to evaluate forcarotid occlusion/dissection). Consider evaluation of carotid for any patient with significanthematoma, echymosis, or abrasion of lateral neck. These findings can be associated withcarotid dissection and should be evaluated with a duplex scan or CTA. Carotid angiogramis used to evaluate neck vasculature when non-operative management of Zone IIpenetrating neck injury is considered.7. Wound clips: Use for identification of point of injury on X-rays:a. On all penetrating stab or gunshot wounds.b. Do not clip abrasions or scratches.8. Retrograde cystogram:a. Should be considered for all cases of gross hematuria, penetrating abdominal traumaand pelvic fractures where bladder disruption is suspected.( NOTE: A CT Cystogrammay replace this study if available)b. Allow 300 ml of contrast agent to flow into Foley catheter and then clamp.c. X-ray the pelvis.d. Obtain repeat x-ray after emptying bladder.e. Cannot accept a cystogram from the abdominal/pelvis CT scan unless contrast hasbeen injected into the bladder, ie., a CT cystogram.9. Retrograde urethrogram:a. Should be considered for all cases of gross hematuria, penetrating abdominal traumaand pelvic fractures where disruption of the urethra is suspected.i. Blood at the urethral meatus.ii. Displaced or non-palpable prostate.iii. Obvious perineal injury (perineal hematoma or open perineal injury or scrotalhematoma).b. May position patient in right anterior oblique (45º) in “bicycling” position with right hipflexed and penis placed on medial aspect of right thigh if possible. Insert small (12 Fr.)Foley catheter into the meatus for a distance of 2-3 cm. gently inject 10 – 25 ml ofrenograffin contrast.c. X-ray tube centered over pubic tubercle.d. If Foley catheter has been previously placed, may be performed alongside the catheterby inserting 18 gauge angiocath next to Foley.10. CT scans:a. Head -- Mechanism for brain injury andi. GCS ≤ 14ii. “Witnessed” loss of consciousness in a patient with GCS = 15.b. Cervical spine – mechanism for C-spine injury andi. Unconscious patient who is not anticipated regain consciousness within 24 hours.ii. C-spine tendernessc. Abdomen / Pelvis – Mechanism for abdominal / pelvic injury andi. Abdominal or pelvic pain.ii. Substantial mechanism for abdominal injury in the comatose or unresponsivepatient.iii. Pelvic fracture on plain film.iv. Fluid in the abdomen on FAST exam in the hemodynamically stable patient.
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