Chapter 15

Trauma imaging may be used to provide rapid and broad surveys when clinical evaluation is likely to be incomplete or unreliable or used to characterize recognized injuries as part of treatment planning. And it may be used to guide observational, operative, and minimally invasive decisions. Therefore, trauma imaging may inform clinical diagnosis and can guide, but not make, management decisions.

Imaging strategies are affected by the proximity of available imaging technology to the resuscitation area, the capabilities of the imaging equipment, the experience and availability of radiology technologists performing emergent imaging procedures, and timely access to expert interpretation and reporting.

The timing of diagnostic imaging should reflect the needs of individual patients and the local system. With some exceptions for image-guided endovascular hemostasis, hemodynamically unstable patients should be resuscitated prior to imaging according to accepted guidelines and recommendations. In order to enhance efficiency, triage priorities for imaging should be based on the acute needs for accurate information that can be used to direct treatment of the patient. Close cooperation and open communication between the emergency physicians, traumatologists, consultants, nurses, imaging technologists, and radiologists are always necessary to optimize any imaging assessment.

One chapter cannot reasonably teach interpretation of diagnostic images. Therefore, a general approach to the role of imaging in the evaluation of selected clinical scenarios is presented, while pointing out the advantages and disadvantages of a given imaging strategy.

### Trauma Series

As part of the secondary survey of victims of blunt trauma, an imaging survey of the chest (supine anteroposterior [AP] chest with 10° of caudal angulation of the central x-ray beam), pelvis (supine AP pelvis), and cervical spine (horizontal-beam, cross-table lateral cervical spine obtained with bilateral arm pull) may be performed, if clinical evaluation alone is deemed insufficient (Fig. 15-1). The goals of these initial imaging studies are to identify life-threatening, but clinically occult, injuries such as an unstable pelvic fracture, hemomediastinum, or instability of the cervical spine.1,2

###### Figure 15-1

Trauma series. This 27-year-old unrestrained left rear seat passenger sustained multiple injuries, superfluous in a high-speed side-impact crash. (A) Anteroposterior (AP) recumbent chest radiograph shows hyperexpanded and hyperlucent left hemithorax with “deep sulcus” sign (short white arrow) and rightward mediastinal shift (double-ended arrow) due to left tension pneumothorax. Short black arrows show multiple displaced rib fractures. Asterisk shows irregularity of left hemidiaphragm, which strongly suggests herniation of abdominal contents through left diaphragmatic laceration. (B) AP pelvis radiograph shows lateral-compression-type pelvic ring disruption consisting of bilateral iliopubic and ischiopubic ramus and left sacral fractures (long arrows) with sacroiliac joint disruptions (short arrow). (C) Cross-table lateral cervical spine radiograph is grossly normal to C5. Therefore, this constitutes a nondiagnostic study. Craniocervical alignment should be assessed and may be easily overlooked. Dens–basion distance (white double-ended arrow) is normally no greater than ...

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