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Improving quality of acute trauma care In Radiology Dr R. Nyabanda Radiologist Kenyatta National Hospital 19th April 2013 RADIOLOGY DEPARTMENT VISION To be a world class centre of excellence in the provision of innovative diagnostic imaging and interventional radiology services. MISSION To provide specialized quality diagnostic imaging and interventional radiology services, facilitate medical training, research and participate in national health planning and policy. JOINT COMMISSION INTERNATIONAL (JCI) ACCREDITATION STANDARDS FOR HOSPITALS Standards Lists Version trauma in radiology in severely injured patients Management of Severely Injured Patients (SIPs) • The acute trauma setting is not the place for disagreement about the patient. Immediate management decisions must be made by the designated trauma leader. • The trauma team leader is an overall charge in acute care. • Just as the trauma team leader must be an experienced consultant, there must be a consultant in Radiology in charge of trauma. • Protol driven imaging and intervention must be available and delivered by experienced staff! Location and Facilities • Just like in A&E, triaging of patients is very important. • Imaging SIPs more accurately delineates the extent of • • • • injury than clinical examination. Imaging technique of choice is the one which is definitive in trauma setting. In SIPs this is most often head to thigh CE-MDCT. The MDCT should be adjacent to emergency room. Radiography must also be present in the emergency room The imaging environment requires all the life support facilities available in the emergency room. This will include monitoring and gases. Radiography • CXR-Chest radiograph must be obtained to document the position of tubes and lines and to evaluate for pneumothorax or hemothorax and mediastinal abnormalities • AXR or pelvic X Ray are usually irrelevant if patient is going in for CT. • The British Orthopaedic Association and British Society of Spine Surgeons do not recommend plain films of the Cspine in a SIP and their standard of practice is CT. • Cervical spinal injury precautions and pelvic binders should remain in place until the MDCT has been fully assessed C6 # Focused Abdominal Sonography in Trauma (FAST) FAST is used to demonstrate - intra-abdominal hemorrhage - Solid organ injuries- spleen, liver, kidney - Pericardial effusion MDCT Clear of the need for protocols must exist for notifying the CT department urgent imaging and how the department will respond to ensure that the scanner is clear to receive the incoming injured patient. IV assess right antecubital assess is preferred for contrast adminstration Radiation dose should be considered Polytrauma protocol MDCT is indicated when: There is hemodynamic instability The mechanism of injury or representation suggests that there may be occult severe injuries that cannot be excluded by clinical examination or plain films If plain films suggest significant injury, such as pneumothorax, pelvic fractures Obvious severe injury on clinical assessment Interventional Radiology(IR) • The role of IR in the SIP is to stop hemorrhage as quickly as possible • The decision on whether a patient with traumatic hemorrhage undergoes endovascular treatment, open surgery, a combination of the two or non-operative management is typically a decision made by both the trauma team leader and interventional radiologist after consultation. • Interventional treatment modalities include Balloon occlusion, transarterial embolization to stop hemorrhage. MRI MRI is not indicated in the setting of acute trauma care. However availability of clear protocols for the transfer of SIPs to MRI facilities after stabilizing the patient is recommended. No Imaging ! There may be circumstances where imaging is inappropriate; for example, where a SIP is admitted with profound shock, is not responding to intravenous fluids and the site of bleeding is clear from the mechanism of injury and rapid assessment. Such patients may be best taken straight to theatre. Quality Indicator All imaging should be discussed at debriefing meetings and errors of protocol or facts discussed at discrepancy meetings Radiologists should ensure they participate in ongoing audit and morbidity and mortality meetings of trauma services Non-accidental injury Note massive edema minimally hyperdense subdural, extreme mass effect and herniation despite open fontanelle References Standards of practice and guidance for trauma radiology in severely injured patients. Operating Framework for the NHS in ENGLAND 2011/2012 Ann Osborn. Craniocerebral Trauma update 2010 Emergency Radiology, Advanced trauma life support ABCDE from a radiology point of view. Emerg Radiol. 2007 July; 14(3): 135–141 McGahan J P, Wang L, Richards J R. Focused abdominal US for trauma. Radiographics. 2001;21:S191– S199. [PubMed]