Week 10: Trauma & mobile radiography

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Trauma Radiography Introduction

• Trauma is a sudden, unexpected, dramatic, forceful, or violent event.
• Common causes of traumatic injuries include blunt, penetrating, explosive, and thermal forces.
• Trauma patients can be of any age.
• Radiographers must be prepared for various procedures on patients of all ages in the ED.

Preliminary Considerations

• Specialized trauma imaging systems reduce diagnostic image acquisition time.
• Some trauma imaging systems provide greater flexibility in IR/CR maneuverability.
• Some trauma imaging systems scan the entire body in seconds.
• Mobile radiography is often used for ED procedures.
• Mobile fluoroscopy units (C-arms) are useful in fracture reduction or foreign body localization.
• Immobilization devices are essential since trauma patients often can't hold required positions.

Radiographer's Role

• Duties depend on department protocol and staffing.
• Primary responsibilities include quality diagnostic imaging, ethical radiation protection, and patient care.
• Patient status changes are common in trauma.
• Table 12-1 provides a guide for assessing patient status change.

Best Practices in Trauma Radiography

• Speed is important which means efficiency in producing quality images quickly.
• Accuracy is important, focus on optimum image quality and minimizing repeats.
• Quality should not be sacrificed, and the patient's condition is not an excuse for poor images.
• Proper positioning is a priority but avoid worsening the patient's condition while imaging.
• The tube and IR should be moved instead of the patient whenever possible.
• Standard precautions should be practiced due to likely exposure to bodily fluids in the ED.
• Immobilization devices should not be removed without a physician's order.
• Motion risks should be reduced through proper support and immobilization.
• Anticipation of needed follow-up procedures is helpful.
• Constant attention to the patient's condition is needed, because it can change.
• Adherence to ED protocol and knowing the scope of practice in the facility is important.
• Follow the code of ethics.

General Procedural Guidelines

• Patient preparation
• IR/collimated field size
• Source-to-image receptor distance (SID)
• Identification (ID) markers
• Radiation protection
• Patient instructions
• Immobilization
• Documentation
• Image critique

Patient Preparation

• Good communication with appropriate touch and eye contact is important because trauma causes anxiety.
• Check patients for potential artifacts.
• Explain artifact removal and reasons.
• Use facility procedures to secure personal effects.

IR/Collimated Field Size

• IR/collimated field size for trauma procedures is the same as routine procedures.
• Use the smallest IR and closest collimation to demonstrate anatomy

SID

• SID is standardized in procedural protocol.
• When SID is not specified, Merrill's Atlas recommends 40 inches (102 cm).
• A SID or 60 to 72 inches (152 to 183 cm) is recommended for projections with increased object-to-image receptor distance (OID).

ID Markers

• Right or left side markers must be included within the collimated exposure field.
• Avoid using digital annotation for side markers.
• Markers are used to identify entrance and exit wounds in penetrating trauma.

Radiation Protection

• Pediatric and reproductive-age patients should be shielded.
• Radiation protection measures include close collimation and optimum technique factors.

Patient Instructions

• Positions should be explained and demonstrated when possible.
• Respiration instructions should be explained to cooperative patients.
• Short exposure times should be used to minimize imaging motion.

Immobilization

• Many ED patients arrive with immobilization devices.
• Immobilization devices are not removed unless ordered by a physician.
• Imaging is often performed without removing immobilization.
• Images are used to rule out injury and determine whether it is safe to remove immobilization.

Documentation

• Deviation or adjustment of routine procedures is often required in trauma cases, so documentation is vital.
• Any deviation from routine must remain within your scope of practice.

Image Evaluation

• Image evaluation is the same as for routine procedures.
• Image quality is critical for accurate diagnosis.
• Lower quality images should not be accepted due to patient condition or difficult procedures.

Lateral Cervical Spine

• This is typically performed first and checked by a physician before proceeding.
• The patient position is dorsal decubitus.
• The shoulders should be relaxed.
• The head must be without rotation, patients should look straight ahead without moving head or neck.
• The vertical IR should be placed at the top of the shoulder in a holder.
• Horizontal CR centered to midpoint of IR.
• The entire cervical spine (C-spine) from sella turcica to top of T1 should be viewable.
• A lateral projection of the cervicothoracic spine is required if all seven cervical vertebrae are not seen.

Lateral Cervicothoracic Spine

• Required if C7 and the top of T1 are not demonstrated on lateral C-spine.
• Trauma usually requires dorsal decubitus position.
• Patient supine without rotation.
• The patient should raise the arm opposite the x-ray tube over their head, assisting and supporting as needed.
• Relax the shoulder closer to the x-ray tube.
• The vertical IR should be centered just above the jugular notch.
• Horizontal CR is centered to the C7-T1 interspace and midcoronal plane (MCP).
• Use a breathing technique if posisble to blurr the ribs and lung markers to better demonstrate the spine.
• The image demonstrates lower cervical and upper thoracic vertebrae in profile between the shoulders.

AP Axial Cervical Spine

• The position is typically supine.
• The patient is usually immobilized with a collar and spine board.
• Place the IR under the spine board, if present, centered to C4.
• The head and shoulders should be without rotation, ask the patient to look straight ahead and not rotate their head.
• CR is directed 15 to 20 degrees cephalad to enter midsagittal plane (MSP) and C4.
• Images demonstrates C3-T1 or T2, including all soft tissues.
• Unavoidable artifacts may be seen if a backboard is present, use care to identify the location of said devices.

AP Axial Oblique Cervical Spine

• Patient is supine, usually immobilized with collar and spine board.
• Place IR under the spine board, if present, centered to C4 and adjacent mastoid process, approximately 3 inches lateral to MSP.
• Head and shoulders without rotation, ask the patient to look straight ahead and to not rotate their head.
• CR has double angle of 45 degrees lateromedially and 15 to 20 degrees cephalad.
• CR enters lateral to MSP at the level of C4.
• Centre of IR should be where CR exits.
• Images demonstrates the side opposite CR; C1-T1 or T2 bodies and disk spaces, intervertebral foramina open.
• Unavoidable artifacts may be seen if a backboard is present, use care to identify the location of said devices.

Thoracic and Lumbar Spine

• Dorsal decubitus positions are performed first.
• Use a vertical grid IR.
• Center to level of iliac crests for lumbar spine.
• Place the top of IR 1½ to 2 inches (3.8 to 5 cm) above the shoulders for thoracic spine.
• Have the patient cross their arms on the anterior chest.
• With a CR horizontal and centred to the spine and IR.
• Breathing a technique improves visualization of thoracic vertebrae.
• Exposure is made on suspended respiration for lumbar vertebrae.
• The Thoracic image demonstrates T3 or T4 to L1 Vertebral bodies and spinous processes in profile.
• Lumbar image demonstrates T12 to sacrum Vertebral bodies and spinous processes in profile.

Trauma Lateral Lumbar Spine

• CR and IR positioned for trauma lateral projection of lumbar spine using dorsal decubitus position.

Chest

• Check for need to demonstrate air-fluid levels.
• If air-fluid levels are suspected, use dorsal decubitus position.
• A lateral decubitus position with the patient lying on the affected side will also show air-fluid levels, only if the patients condition permits.
• Supine position is used if a general survey image of chest desired.

Trauma AP Chest

• Obtain help to lift patient for IR placement placing the top of IR approximately 1½ to 2 inches (3.8 to 5 cm) above shoulder.
• Arms should be abducted with the MCP parallel to IR.
• Use maximum SID to reduce the possibility of heart magnification.
• Ensure chin extended out of anatomy of interest
• CR is directed perpendicular to the center of the IR, it enters the MSP at approximately 3 inches (7.6 cm) below the jugular notch.
• Exposure should be made on second full inhalation, if possible.
• Image demonstrates lung fields in their entirety with minimal rotation and distortion present.

Abdomen AP

• If transfer to x-ray table is not possible, obtain lift help for IR placement and center the IR to MSP at level of iliac crests
• Check for possibility of fluid accumulation in abdominal cavity, which affects exposure factors. Requires close monitoring of patient for status change during procedures.
• mark entrance and exit wounds, if present.
• Ensure shoulders and hips are aligned in the same plane.
• MCP parallel to table and the CR perpendicular to center of IR. Image will demonstrates entire abdomen with pubic symphysis visible at lower border.

Lateral Abdomen Dorsal Decubitus Position

• For very ill or severely injured patients.
• Is the image to assess fluid accumulation or free air in the abdominal cavity? Reduce Exposure factors decreased for free air to be visible against the anterior abdomen.
• With fluid accumulation, ensure the IR is centered to the level of MCP.
• Center 2 inches (5 cm) above iliac crest to include diaphragm
• Horizontal CR enters perpendicular to 2 inches (5 cm) above iliac crest to include diaphragm with the Exposure made on exhalation

Pelvis

• Pelvic fractures have a high risk of hemorrhage-pay close attention to patient for status change
• Lift assist may be required if transfer to x-ray table is not possible.
• IR centered 2 inches (5 cm) above pubic symphysis or 2 inches (5 cm) below anterior superior iliac spine (ASIS) with the MCP parallel to IR.
• Ensure the lower limbs will usually not internally rotated in trauma cases, Ensure arms are not in anatomy of interest too!
• CR perpendicular to center of IR with Exposure taken on suspended respiration.
• Image demonstrates entire pelvis and proximal femora with Femoral necks foreshortene.

Axiolateral Hip (Danelius-Miller)

• Pt position is supine
• Part Position: Elevate pelvis for thin patients. Flex knee and hip of unaffected limb to place thigh vertical. Rest unaffected leg and foot on a support, with No rotation of pelvis, and Rotate affected limb 15 to 20 degrees medially
• IR positioning should have the Vvertical with upper border in crease above iliac crest and Angle lower border away from body until parallel with femoral neck and Support IR in position
• A CR horizontal and perpendicular to long axis of femoral neck is needed with a a collimated field 10 × 12 inches (24 × 30 cm)

Modified Axiolateral Hip Clements-Nakayama Method

• used on patients with suspected bilateral hip fractures, bilateral hip arthroplasty, or limited movement of the unaffected limb
• Position should be on the Grid IR aligned parallel to the femoral neck at a height to place the center the hip on the IR
• Tilt the top of the grid IR back(away from the hip) 15 degrees with no attempt to internally rotate the limb.
• Central is Directed 15 degrees posteriorly and aligned perpendicular to the femoral neck and grid IR
• Collimate is needed for the radiation field to 10 × 12 inches (24 × 30 cm) and no larger than the IR, Adjust to 1 inch (2.5 cm) beyond the skin shadows on both sides on thinner adults or pediatric patientsand to Place side marker in the collimated exposure field

Cranium

• Patients with head trauma are often referred to computed tomography and when x-rays are ordered, a general survey requires AP and lateral projections
• Position patient supinewith Lateral projection and dorsal decubitus position.

Trauma Lateral Cranium

• elevate head on radiolucent support ensuring that C-spine injury has been ruled out first
• place vertical IR centered to cranium. Ensure that Interpupillary line is perpendicular to IR and MSP is vertical
• horizontal CR enters center of IR and patient at 2 inches (5 cm) above external auditory meatus (EAM)
• Image demonstrates a profile of superimposed halves of the cranium with side closest to IR demonstrated

Trauma AP Cranium

• check with physician to determine anatomy ofinterest and if AP projection and AP axial (reverse Caldwell) demonstrates anterior cranium. A (Reverse Caldwell) projects petrous ridges in lower third of orbits while AP axial projection (Towne) demonstrates posterior cranium and that c-spine injury should be ruled out before cranium projections.
• lift is needed if transfering the patient to x-ray

Trauma AP Cranium AP Axial (Reverse Caldwell)

• for rotation and tilt of head make sure MSP is vertical and perpendicular to IR with a MCP parallel. Also, that the OML is Perpendicular to IR If possible.
• IR is Centered to Level of Nasion with the CR being AP perpendicular to center of IR,and Reverse Caldwell15°cepholad, and Enters Patient at MSP at Level of Nasion
• AP image will demonstrates anterior cranium with petrous ridges filling orbits, Reverse Caldwell also demonstrates anterior cranium but with petrous ridges in lower third of orbits

Trauma AP Axial Cranium (Towne)

• rotation and tilt of head make sure MSP is vertical and perpendicular to IR and MCP parallel,place OML perpendicular to IR and ,iI Infraorbitomeatal line (IOML) is used 37 degrees is needed.
• IR is centered to level of foramen magnum ,CR is angled 30 degrees caudad (OML perpendicular)Exits at level of foramen magnum,If 37 degrees caudad if IOML perpendicular.
• Image:Posterior cranium, foramen magnum in center

Facial Bones

• those with Injuries usually take CT first due to profuse bleeding a universal precautions are needed. In that cased Lift is needed for help to IR placement if transfer to x-ray table isn´t possible

Acanioparietal facial bone:

• also known as Reverse water with IOML placed perpendicularly to IR with MCP Perpendicular.
• CR is angled cephad till perpendicula to mentomeatal line.
• CR also mustenter must AC and MSP

Upper and Lower limbs:

• Apertura de upper and lower limbs requires a lift for help to IR and limbs support especially at both joints minimizing any movement.
• Two 90 degrees images are recomeded but if the linmb isseverly broken avoid to rotate it.

upper limb:

• upper limb has Long bones that needs the demonstration of adjacent joints making other Take separate projections may be an option but avoid as much as you can because there is a need to maximize patient safety is a primary concern. Avoid injurying the injured lamb and move the IR and the CR if it´s necesary.

Mobile Radiography Principles.

• transportable x-ray equipment brings imaging services to the patient
• Common to implement procedures at patient rooms, emergency departments, intensive care units, surgery and recovery rooms, and nursery and neonatal units
• Its first use was in first military with the units were carried to field sites

Mobile X-Ray Machines

• less power than stationary units
• Exposure controls and power source (generators) may be different
• the normal control is mÁs and KvP controls
• has anatomical progras the Kvp is from 40 to 130, the Mas goes

from 0.04 a 320 they are only able to use 15 to 25 kW to operate

Mobile Unit Specifications

• digital capability enables image acuisition and display on device. It uses flat panel detector (wireless-cord connection) the dose is reduce the image can be PACS send it.

Technical Considerations

• Grid, Anode heel effect and ID should be considered.
• There should be an exposure technique chart.

the Grids

• increase the sensivity by removing the scatered radiation, should be well positioned to reduce cut-off and the unstability of the zone.
• a midline of should be 1 o 1. 5 radius.

Anode Heel Effect

Anode Heel Effect: less under the anode, you see it with short ID, lager fileld sizes and the tube position will depend on the anatomy.

Standard IDs

• The standard ID should be maintained at 40 in (102 cms), but in large field it´s greater 40 in, but this one requires great mas.

Technique Charts.

should be available for every machine and the standard technical factors for all projections, A calipper should also be available for accurate patient measurement

Rad Safety

• this one has the highest dosis, the minimum
• distance 6 f (2 mm ) and 90 grades for primary shield for pediatric, reproductive age patients, on-patient requests, when the gonads lies on the beam. minimum (30 com)

Considerations about isolated pacientees

• contagious isolation, wash or sterilize
• equipment and instruments

Steps performing Mobile Examinations (Initial Procedures)

• plan the trip
• Devices (id grids caliper etc)
• present to staff, assistance, patient confirmation ID, Introduce yourself, explain
• Observe medical equipment ask visitors to leave

EXAMINATION PREPARATIONS

• move anything
• super positioning the place.
• check collimate, CR, to not have double check
• LOG:Keep a log of procedures, time of examination, andtechnical factors for image ID.

Patient Considerations

• patient condition: alertness, Respiration, Ability,and limits mobility: dont ever move if not permitted
• fractures patients gentle and the more assistance there is the better.

Interfeering dev:

Angling the CR if it is possible to replace or remove any object consult it to the autorized personnel.

Positioning and Assepsis

• patients should aware of the cold, avoid skin contact on aged. Also, protect IR from contamination or disinfect it.

Procedures of the Mobile studies

.Ap chest abdomen, pelvis, fermur , cervical spine neonate and

AP -CHEST

• position: the patient will always depend if he as the possibility of sitting up well, otherwise well see him spine center Sagittal plane Msp with 1 top of ir 2 inches over the shoulders to the arm with the arm , then

• Rays cr with 90 d and 7cms inferior to the jugglar notch,colimation to not exedd tbe 35cm and the breath full. This way you could evaluate with the best shape , everything.

APA CHEST LATERAL

• Right/ the patient is. side fluid ,the other air a minimum period of time of minutes elevating 2 o 3 with the knee flexion
• the central Ray H has to be perpendicular to the collimation no exeed the size.

AP abdomen:

• The pt needs to be adjusted his bed to a horizontally to be align you know. after MSP placing a centered grid ( with it all) and you need to roll the patient there, take time the skin shouldnt be in contact with the IR grid; all the the thing.
• If there a side grid two in over to be better. alignate the shoulder etc and put the arms there.

the same will be Ray Ap collamated exhalation all

AP PElvis:

• bed in horizontal, align pt in a super position so, use assist. MSP there
• is no rotations for legs all
• IR and and you know 40 mas all

AP-FERMUR:

• careful with position , grid lengthwise with the , midline , grid the cr aligned. to prevent cutoff
• you see, respire the position and use
• collamate the radius not the asis .

AP and 88

• the same as before except we see a different line

Best Practice

—the knowledge equipment is essential for perform

• the best performance on the area to be tested