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Penetrating injury
Most patients with penetrating trauma are injured in the flank, so there is great risk for
bowel perforation.
If there is no reason for immediate surgery on the initial scan, these patients get an
additional scan after the administration of rectal contrast (50 ml contrast in 1000 ml saline).
500 ml can be administered if there is isolated left flank injury, but in all other cases 1000
ml is administered
The spleen is the most commonly injured solid organ (25%).
CT grade of splenic injury is of limited value since it does not predict the succes rate of
a non-operative management.
The finding of contrast extravasation on the other hand, which is not part of the
grading system, has great impact on the patients management, because when there is
active bleeding, there will be failure of a non-operative management in 80% of the
cases.
In these patients the need for intervention is almost ten times as high compared to
patients without extravasation.
On the left a case of splenic injury.
Scroll through the images and determine the degree of splenic injury.
Then continue.
Then continue.
The findings are the following:
Hemoperitoneum around the spleen and the
liver.
So the next question is: does the presence of a contrast blush alter the CT grade of injury?
The answer is: it does not, because active bleeding is not part of the grading system.
However there is increased likelihood of failure of non-operative management.
Whenever there is a contrast blush, it is important to note if the contrast blush is associated
with a hemoperitoneum and if it extends beyond the parenchyma, as in this case.
First look at the images on the left of a patient with liver injury.
What are the CT findings in this case?
What is the CT grade of injury?
The findings are the following:
Subcapsular hematoma greater than 10 cm (i.e. grade 4 injury)
Contrast blush
No associated hemoperitoneum
So despite the fact that there is a grade 4 injury and contrast extravasation, this patient will be
treated non-operatively and probably will do fine, because there is no bleeding into the peritoneal
cavity.
So the important thing to remember it that, the grading system is of limited help in the
management of the patient.
Contrast extravasation on the other hand is of great importance especially if it is associated with
hemoperitoneum.
On the left two more examples of
laceration.
There is i.v. contrast and images were taken in the portal phase.
There is also oral contrast filling of the stomach.
The contrast surrounding the liver could be a result of stomach or bowel perforation, but since
there was no pneumoperitoneum, this was thought to be unlikely.
So the extravasation was thought to be a result of active bleeding and since there is a great
amount of contrast surrounding the liver, this was thought to be a huge leak.
At the OR an avulsed right hepatic vein was found.
This diagnosis has a 90-100% mortality and this patient died in the OR.
Some final remarks conceirning liver injury:
Historically liver injury was managed surgically, but at laparotomy it was
found that 70% of the bleedings had already stopped by the time the
surgeons got there.
Importantly, patients who went for surgery had more transfusions and
more complicaties than patients who were treated non-operatively.
Today about 80% is managed non-operatively.
Delayed complications occur in 10-25% of all patients and include:
hemorrhage (2-6%)
hepatic abscess (1-4%)
biloma (<1%)
Penetrating injury
Look at the images on the left and try to answer the following questions:
What is the role of CT in patients with penetrating trauma?
What are the findings?
Answers:
The key role of CT is to determine if there is peritoneal violation and to predict the need for laparotomy
Findings:
In the vascular phase at 1 minute there is extravasation and fluid in the paracolic gutters indicating
peritoneal violation.
There is also a hematoma in the perirenal space.
In the delayed phase there is more extravasation, although it is not clear whether that is due to the active
bleeding or contrast comming out of the collecting system
In the extretory phase it is clear that there is violation of the collecting system
The next question is, whether the protocol is correct or do we need to give rectal contrast to see if there is
bowelperforation, because there is a penetrating trauma?
In this case the answer is no, do not give this patient rectal contrast.
The reason is that we already have reached the treshold for this patient to go to the OR.
There are 3 reasons for this patient to go to surgery:
Active bleeding
Peritoneal violation (fluid in the paracolic gutters)
Violation of the collecting system.
If rectal contrast was given at the start of the examination, this might pose the problem that it would have been
unclear, whether the contrast deposition was due to active bleeding or bowel perforation.
So the bleeding could have been missed.
Rectal contrast should only have been given if there were no other findings in need of surgery.
Although this patient had severe renal injury, there was no hematuria.
This is often the case in penetrating trauma and does not rule out renal injury.
In blunt trauma however the abcense of hematuria does rule out renal injury.
On the left another patient with a penetrating injury due to a knife stab in
the flank.
The answer is, that like all grading systems, this system also has its limitations.
What we see on the left is not a laceration, because it is not linear.
It is not a contusion, because it is sharply demarcated.
This is an post traumatic segmental infarction.
On the left a typical subcapsular hematoma, which is also a grade I renal injury.
The x-ray shows a moderately displaced fracture of the pubic bone with bony spicules in the
bladder region.
So the question is:
For what other pelvic injuries is this patient at risk and how will it affect our protocol?
First this patient is at risk for arterial injury with pelvic hematoma, rectal, vaginal injury and
bladder injury.
Secondly, a CT-cystogram is indicated after the routine CT.
On the left the images of the routine trauma-CT.
What are the findings?
There is a displaced pelvic fracture with a spicule pointing towards the bladder.
There is fluid in the prevesicle space (space of Rezius).
We instill the contrast retrograde through the foley catheter until one of three things
happen:
Flow stops with bag at 40 cm above the patient.
350-400 cc of contrast is instilled.
Patient no longer tolerates.
On the left another case to illustrate why you do not administer contrast in the bladder at the same time
as the administration of iv. contrast.
The next question that comes up, is whether we should perform an additional CT-cystogram?
The answer to the first question is that if you would have administered contrast to the bladder at the
start of the examination, you would have been puzzled whether the contrast that is seen is due to a
bladder rupture or to active bleeding.
Since no contrast was instilled in the bladder, it is obvious, that this is arterial bleeding.
Secondly because of the enormous extravasation, this patient is in need of immediate embolisation
without further delay.
Concerning pancreatic injury the following remarks can be
made:
Uncommon injury with a 0.4% overall incidence.
1.1% incidence in penetrating trauma and only 0.2% in blunt
trauma.
Rarely an isolated injury.
Usually part of a 'package injury'.
On the left an unrestrained driver who had a car accident.
Vital signs were stable and there was only a mildly tender abdomen.
First look at the images on the left and then continue.
The first thing you'll notice is that the tube is in the right main bronchus.
Chest tube looks okay.
Nasogastric tube comes down and coils in the stomach.
The superior mediastinum looks widened and indistinct, so this certainly has
to be evaluated.
In the left lower zone we have an indistinct diafragmatic border and an
opacity.
This could be a lot of things like hematothorax, lung contusion, diafragmatic
rupture or splenic injury.
So based on the chest film we are conceirned about possible aortic injury,
pulmonary contusion and injury to the diaphragm, spleenic and left kidney.
Continue with the CT images.
Scroll through the images on the left.
What contrast is on board adn wh at are the findings?
There is i.v. contrast in the late arterial phase and when we follow the
nasogastric tube we will notice that there is no contrast in the stomach.
The most important finding in this case is the area of soft tissue density next to
the atelectatic lower lobe of the lung and lateral to it an amount of fat.
This is very suggestive of diafragmatic rupture.
What can we do to get more certainty about this structure?
Since the nasogastric tube is in place, we can administer
contrast to the stomach.
The images on the left prove that the structure is the stomach,
which is in a high position.
Secondly there is a waist in the stomach compatible with the
'collar sign'.
These findings are specific for diafragmatic rupture.
CT 'collar' sign
On the left the coronal reconstruction of hte same patient demonstrating the 'collar
sign', where the stomach passes through the diafragmatic rupture.
So in the case above specific signs of diafragmatic injury are present.
Non-specific signs are discontinuity or thickening of the diafragm or the
'dependent viscera' sign.
'Dependent viscera' sign in left-sided diafragmatic rupture
It is very uncommon to identify findings that are specific for bowel injury like
extravasation of oral contrast or bowel content.
More commonly you will find a combination of intraperitoneal fluid and mesenteric
stranding, focal bowel thickening or interloop fluid, that is very suggestive for bowel
injury.