Imaging of polytrauma patients in Vilnius region: experience and new trends

Evelina Mockienė (1, 2), Juozas Jarašūnas (1,2), Vytautas Augustinavičius (1), Raminta Šydeikienė (2), Artūras Samuilis (1)1- Vilnius university hospital Santaros Klinikos; 2- Republican Vilnius university hospital

Key wordsmultiple trauma; whole body imaging; emergency service; diagnostic techniques and procedures;CTprotocols.

Conclusions• There are different tactics in managing a

polytrauma patients depending on patient condition as well as medical institution experience. Latest publications show no significant difference in standard or whole-body-CT in patients survival or outcome rates.

• Ultrasound plays a key role in hemodynamically unstable patients detecting free fluid. It cannot reliably exclude a parenchymal injury, therefore, a CT scan must be performed for selected patients.

• Whole-body CT allows quick and accurate examination for critically-ill patients, injury grading and preoperative planning. We are lacking approved criteria to select right patients for whole-bodyCT.

Objective• To introduce polytrauma imaging protocols used in

Vilnius region• To elucidate the role of early and fast diagnostic

imaging in patients after severe trauma• To highlight the importance of modern ultrasound

and rational use of FAST protocol• To present currently worldwide accepted protocols

for polytrauma CT imaging an d selection of trauma patients

MethodsWe have two major trauma centers in Vilnius region: “Vilnius university hospital Santaros Klinikos” (VUHSK) and “Republican Vilnius university hospital” (RVUL). Our standard approved examination of

severe trauma patients is composed of ATLS guidelines. It consists of a primary survey, where E-FAST and cervical spine, chest and pelvis x-rays are performed and a secondary survey, which consists of ultrasound and CT (selective or whole-body). In RVUL there is possibility to perform LODOX scan - which is a whole body x-ray scanner adopted for polytrauma patients. Whereas in VUHSK there is possibility to perform a contrast enhanced ultrasound examination.

ResultsEvery suspected politrauma patient in both Vilnius politrauma centers starts examination based on ATLS guidelines and imaging tests are ordered adjunct to the primary survey. Imaging is considered helpful but should it should not interrupt or delay the resuscitation process of severely injured patients. Chest, pelvis and C spine radiographs may be taken adjunct to the primary survey. No clinical decision rule is available concerning the indication for chest radiographs and it is not clear if a chest radiograph should be performed in every patient, though it is recommended. A pelvic radiograph should be performed when the mechanism of injury or the physical examination indicates the possibility of a pelvic fracture and cervical spine radiographs are not indicated in patients who are awake, alert, sober, neurologically normal, have no neck pain or midline tenderness, can flex and extend without pain.

In ultrasound examination techniques differ in various clinical situations. In hemodynamically unstable patients we perform E-FAST examination asap to evaluate free abdominal fluid or air as well as fluid in pleural cavities. In hemodynamically stable patients primary role of ultrasound is to select patients who require CT examination. Baseline ultrasound performed on victims is a valuable tool and it can be used at patient's bedside and does not interfere with the resuscitation procedures, it has a high sensitivity for the detection of free abdominal fluid, nevertheless, it has a very poor accuracy for the assessment of parenchymal injuries, which highly depend on lesion location. To overcome these limitations, CEUS can be approached as a valuable imaging method for selected hemodynamically stable patients, mostly pediatric patients and females of reproductive age, because it provides additional data not achievable by conventional ultrasound imaging and can reduce radiation exposure, though its application is still considered off-label. In addition to ultrasound observing patients for 12 hours assists in excluding life-threatening injury, otherwise a CT examination should be performed.

There are a few differences in our trauma centers regarding the usage of CT for polytrauma patients. New biphasic whole body CT is adopted from Camp Bastion (Graham RN. Battlefield radiology. Br J Radiol. 2012;85(1020):1556-65) and CT is performed more frequently in VUHSK, while in RVUL there are more selective CT scans performed due to surgeons request. There are wide discussions concerning the of usage of whole-body CT, including when it is necessary and how it should be performed, so far no clear consensus exists. New information came to light after REACT 2 trial, in which no differences in mortality rates were observed comparing standard protocol and right-to-CT protocol. Though it seems that doing selective CT scan yields results similar to WBCT, future research should focus on the selection of patients who will benefit from immediate total-body CT. Concerning CT protocols there is a concensus that non-contrast scans of chest and abdomen does not add any useful information in patient management (The value of precontrast thoraco-abdominopelvic CT in polytrauma patients. Eur J Radiol. 2015;84(6):1212-8). Other CT protocol parameters greatly vary between trauma centres around the world and no clear consensus exists.

The Lodox scanner in Emergency Department of Republican Vilnius University Hospital, Lithuania. It was installed in December 12, 2012 making Lithuania a second country in Europe having this machine

Positions of ultrasound probe to screen patient for free fluid using FAST protocol. E-FAST is an exdented protocol to check pleural cavitys for free air or fluid

Measurment of IVC diameter is useful to evaluate for hypovolemic state; less that 9 mm shows hypovolemia or shock

Contrast enhanced ultrasounds schows liver rupture, wich was unseen in native ultrasound scan

Example of whole body CT using Bastion protocol (Graham RN. Battlefield radiology. Br J Radiol. 2012;85(1020):1556-65): native head scan and whole body with biphasic contrast enhancement.One set of images allows for radiologist faster and easier to interpterate images for organ traumatic injury.