PENCITRAAN PADA KEADAAN GAWAT DARURAT (EMERGENCY RADIOLOGI

dr.Yanto Budiman , Sp.Rad, M.Kes Bagian Radiologi FKUAJ/RSAJ

Head and face Cervical spine Chest Abdomen Extremities

Head and Face

Skull Fracture Facial Fracture Cerebral contusio Epidural Hematoma Subdural Hematoma Sub Arachnoid Hematoma CVD /Stroke

Skull Fracture

Tipe Fracture :
Liniar Depressed Basal Clinical signs:rhinorrhoea, otorrhoea, Battles sign (retro-auricular haematoma),Racoon Eyes

Facial Fracture-Maksilla

Facial Fracture-Infra Orbital

Tear drop sign

Facial Fracture-Mandibulla

Cerebral Contusion
Radiological features
Non-contrast

computed tomography (CT) useful in the early posttraumatic period. Contusions are seen as multiple focal areas of low or mixed attenuation intermixed with areas of increased density representing haemorrhage ( Salt & Pepper app) True extent becomes apparent over time with progression of cell necrosis and oedema. Magnetic resonance imaging (MRI) is the best modality for demonstration of oedema and contusion distribution.

Epidural Hematoma
Radiological features

CT signs include a biconvex hyperdense elliptical collection with a sharply defined edge. Mixed density suggests active bleeding. The haematoma does not cross suture lines. May separate the venous sinuses/falx from the skull; this is the only type of haemorrhage to do this. Mass effect depends on the size of the haemorrhage and associated oedema. Associated fracture line may be seen.

Subdural Hematoma
Radiological features
CT shows a crescentic fluid collection between the brain and inner skull. Concave inner margin with minimal brain substance displacement. In the acute phase high density; in the subacute phase (24 weeks postinjury) isodense to brain. in the chronic phase (4 weeks post-injury) low density.

Subdural Hematoma

acute

Sub acute

Chronic

Subarachnoid hematoma
Radiological features
Non-contrast CT is sensitive within 45 hours of onset. Look for acute haemorrhage (increased density) in the cortical sulci, basal cisterns, Sylvian fissures, superior cerebellar cisterns and in the ventricles. Older MRI macine is relatively less sensitive than CT Scan, but in modern MR Machine , using special sequences like GRE , FLAIR and DWI is comparable to CT Scan

Subarachnoid Hematoma

MRI FLAIR

CT Scan

CVD /Stroke
Ischemic Stroke Haemorrhage Stroke

Non-contrast CT in the first instance. CT is useful in detecting haemorrhage. Hyperacute/ acute infarct may not visible at CT Scan till > 24 Hours.

Ischemic Stroke

Haemorrhage stroke

Cervical spine injury

Classified according to mechanism of trauma: Flexion injuries Rotational injuries Extension injuries Vertical compression injuries

Clay shovelers fracture

Tear drop fracture

Hangman Fracture

Comminuted compression fracture

Chest

RIB/STERNAL FRACTURE FLAIL CHEST PNEUMOTHORAX HAEMOTHORAX AORTIC RUPTURE DIAPHRAGMATIC RUPTURE/HERNIA FOREIGN BODY PNEUMONIA PULMONARY EDEMA

Rib/sternal fracture
Consider associated injuries: Clavicle/1st or 2nd rib fractures suggest or indicate a significant force, often associated with great vessel, tracheo-bronchial or spinal injury. Sternal injuries may be associated with myocardial contusion. With lower rib fractures, abdominal visceral injury, such as liver, spleen or kidney, may occur.

Rib/sternal fracture (2)

Radiological features A PA/AP CXR/lateral / top lordotik / oblique view are performed to assess for both complications and to identify any underlying fracture. Preferebly 2 views Signs of secondary complications may be evident pneumothorax,haemothorax, pulmonary contusion, etc.

Flail Chest
Radiological features: Multiple rib fractures. Costochondral separation may not be evident. Signs of secondary complications may be evident pneumothorax,haemothorax, pulmonary contusion, etc

Pneumothorax
Radiological features A luscent area with no vascular marking and Visceral pleural edge visible. Mediastinal shift to contralateral affected side A small pneumothorax may not be visualised on a standard inspiratory film.A expiratory film may be of benefit

HydroPneumothorax

Haemothorax
Accumulation of blood within the pleural space following blunt or penetrating trauma. Radiological features
Blunting of the costophrenic angles seen with approximately 200 ml of blood. General increased opacification of the hemithorax is seen on a supine film.

Haemothorax

Erect Film

Supine Film

Aortic Rupture
Radiological features Chest radiograph
Widened mediastinum

CT Thorax
Vessel wall disruption or extra-

Blurred aortic outline with loss of luminal blood seen in contiguity aortic knuckle. with the aorta is indicative of Left apical pleural cap. rupture. Left sided haemothorax. Depressed left/raised right main stem bronchus. Tracheal displacement to the right

Aortic rupture

Diaphragmatic rupture/hernia
Radiological features
In the acute phase, unless there is visceral herniation,

sensitivity is poor for all imaging modalities. CXR: Air filled or solid appearing viscus above the diaphragm.This may only be recognised following passage of an NG tube. Other features include mediastinal shift away from the affected side, diaphragmatic elevation, apparent unilateral pleural thickening or suspicious areas of atelectasis. In the non-acute setting contrast studies may be useful.

Diaphragmatic rupture/hernia

Diaphragmatic rupture/hernia

Foreign body Inhaled/ingested foreign bodies

Pulmonary Edema
Cardiac : Heart Failure Non-Cardiac : renal failure, IV overload, ARDS, anaphylaxis, near drowning. Radiologic Features:
Alveolar edema :tiny nodular/acinar areas of increased opacity, frank consolidation, batwing appearance

Interstitial edema : appearance of Kerley lines

IntestitialPulmonary edema-heart failure

Alveolar pulmonary edema/ Bat Wing ( Butterfly ) apperances.

Non cardiac Pulmonary edema-ARDS

Abdomen
ABDOMINAL AORTIC ANEURYSMS OBSTRUCTION LARGE BOWEL OBSTRUCTION SMALL BOWEL PERFORATION TRAUMA BLUNT ABDOMINALT RAUMA Spleen, Hepatic, and pancreas
CT SCAN USG - FAST Plain Abdomen Film

Abdominal aortic aneurysms

Radiological features
Abdominal X-ray (AXR): Look for curvilinear egg shell type calcification Ultrasound (US) can accurately determine size.Limited use in assessing rupture. CT is accurate in assessing aneurysm rupture as well as visualising adjacent structures.

(up)Ruptured aortic aneurysm. The arrowheads denote the breach in the wall of the aneurysm (A), with extensive associated retroperitoneal haemorrhage (H).

(Left)Calcification in the left lateral wall of an aortic aneurysm (arrowheads).

Obstruction-SBO

Radiologic Features: AXR (3pos.)

Dilated small bowel, multiple airfluid level Bowel wall Thickening, Herring Bone appearances Little gas in colon, especially rectum

Key: disproportionate dilatation of SB, bowel sound Causes : Adhesions,Hernia, Volvulus, Gallstone ileus,Intussusception

Mechanical Small Bowel Obstruction

Supine

Erect

Cross Table

Obstruction-LBO

Radiologic features
Dilated colon to point of obstruction Multiple air fluid level=Step Ladder Herring Bone appearances Little or no air in rectum/sigmoid Little or no gas in small bowel, Ileocecal valve remains competent. Distended small bowel shows incompetent ileocecal valve

Large bowel Obstruction

Perforation
Perforation of an air containing hollow viscus will result in free intraperitoneal air Radiological features

CXR : free sub-diaphragmatic air

AXR : Left Lateral DecubitusAir will then outline the lateral edge of the liver

Perforation

pneumoperitonium

AXR , LLD position

BLUNT HEPATIC TRAUMA

The third most common organ injured in the abdomen.

The need for surgery is determined by the size of the laceration, the amount of hemoperitoneum, & the patients clinical status.

Ultrasound findings: - Laceration (right lobe > left lobe)

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- Intrahepatic hematoma: * Hyperechoic in the first 24 hours * Hypoechoic & sonolucent thereafter
- Subcapsular hematoma: * Unilateral, along the area of laceration * Anechoic, hypoechoic, septated lenticular, or curvelinear (DD/ascitic fluid) - Capsular disruption - Intraperitoneal fluid

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Ultrasound findings

A crescent-shaped hyperechoic collection along the right lateral aspect of the liver consistent with subcapsular hematoma.

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BLUNT HEPATIC TRAUMA

CT grading (blunt hepatic trauma) Grade I Capsular avulsion, superficial laceration (s) (<1 cm deep), subcapsular haematoma (<1 cm thick), isolated periportal blood tracking Parenchymal laceration (s) 1-3 cm deep, central/subcapsular haematoma (s) 1-3 cm Laceration (s) > 3 cm deep, central/subcapsular haematoma(s) > 3 cm Massive central/subcapsular haematoma (> 10 cm), lobar tissue destruction (maceration) or devascularisation Bilobar tissue destruction (maceration) or devascularisation

Grade II

Grade III

Grade IV

Grade V

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BLUNT HEPATIC TRAUMA

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BLUNT HEPATIC TRAUMA

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SUBACUTE SUBCAPSULAR HAEMATOMA OF THE LIVER

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BLUNT HEPATIC TRAUMA

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Liver laceration with extravasation. An enhanced axial CT scan of the upper abdomen shows a large laceration through the right lobe of the liver (blue arrow), blood in the peritoneal cavity (black arrows) and active extravasation of the intravenous contrast (red arrow). The stomach is labeled "S."

SPLENIC INJURY

Most commonly injured Ultrasound findings: - Splenomegaly, with progressive enlargement - Irregular splenic border - Intrasplenic hematoma - Contusion (splenic inhomogeneity) - Subcapsular and pericapsular fluid collections - Free intraperitoneal blood (disappear 2-4 weeks) - Left pleural effusion - When the spleen returns to normal small irregular foci /normal parenchyma

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SPLENIC INJURY

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SPLENIC INJURY

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HAEMOPERITONEUM (FRAGMENTED SPLEEN)

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BLUNT PANCREATIC INJURY

CT grading (blunt pancreatic injury) Grade I Grade II Grade III Grade IV Minor contusion or laceration without duct injury Major contusion or laceration without duct injury or tissue loss Distal transection or parenchymal injury with duct injury Proximal transection (to the right of mesenteric vein) or parenchymal injury involving ampulla Massive disruption of pancreatic head

Grade V

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BLUNT PANCREATIC INJURY

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Extremities
Trauma : Plain X-Ray, CT Scan, MRI Rule of two (Plain X-Ray)

Two views Two joints Two sides

Clavicle fracture

AC Separation

Scapular Fracture

AP position Lateral position

Galeazzi Fracture

Monteggia Fracture

Posterior hip dislocation

Left Acetabulum Fracture- CTScan 2D -3D

Shentons line

Left femoral neck Fracture

ANY QUESTIONS??

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