Abdominal CT-Scan in

Trauma
EMG Team

Introduction
Trauma is the leading cause of death < 40
y.o.
Abdominal trauma is responsible for 10%.
The findings to look for in abdominal trauma
are the following:
Hemoperitoneum
Contrast blush consistent with active
extravasation
Laceration: Linear shaped hypodense
areas
Hematomas: oval or round shaped areas
Contusions: vague ill-defined hypodense
areas that are less well perfused
Pneumoperitoneum
Devascularization of organs or parts of
organs
Subcapsular hematomas

Introduction
Sign of shock in CT-Scan :
Collapse of inferior vena cava
Small aorta
Persistent nephrogram without excretion
Hypodense spleen, without enhancement and
normal vascular pedicle
Increased enhancement of the small bowel wall
Increased enhancement of the adrenal glands
Sometimes findings of right cardiac
insufficiency with reflux into the hepatic veins

Introduction
Systematic
approach :
1.Crania caudal
2.Superficial deep
3.One organ other
organ in one plane

Introduction
Initial evaluation :
Blunt trauma
Penetrating trauma

Follow up evaluation NOM

Rule out injury negative
predictive values

Trauma Protocol
Blunt injury
Simple protocol
The portal venous phase ~ 70 secand
Delayed scan ~ 3-5 minutes later injury is
detected on the initial scan.
No oral contrast is administered.
Penetrating injury
Same as blunt injury
risk injury : flank great risk for bowel perforation.
No reason for immediate surgery (initial scan)
additional scan after the administration of rectal contrast
(50 ml contrast in 1000 ml saline).

Introduction

Hemoperitoneum
Hyperdense intraperitoneal fluid collection

020HU

Preexisting ascites
Bile
Urine
Digestive fluid
Diluted or old blood

3045HU

Free Unclotted
intraperitoneal blood

4570HU

Clotted blood/sentinel clot

sign hematoma

>100 HU

Extravasation of contrast
medium
(vascular or urinary)

Spleen
Spleen most
commonly injured
(25%)
AAST grading limited
value not predict the
succes rate of NOM
Contrast extravasation
(not part of grading)
active bleeding
failure of NOM (80%)

Splenic CT Injury Grading Scale

Grade I Laceration(s) < 1 cm deep
Subcapsular hematoma < 1cm diameter
Grade II Laceration(s) 1-3 cm deep
Subcapsular or central hematoma l-3cm
diameter
Grade
III

Laceration(s) 3-10 cm deep

Subcapsular or central hematoma 3-10
cm diameter

Grade
IV

Laceration(s) > 10 cm deep

Subcapsular or central hematoma >
10cm diameter

Grade
V

Splenic tissue maceration or

devascularization

Parenchymal Contus

Hypodense
intraparenchymal area

Parenchymal Laceration
Superficial, linear
hypodensity, usually
less than 3 cm in
length
Fracture - involves
two visceral surfaces,
or if its length is
more than 3 cm
Multiple fractures Scattered spleen

Subcapsular
Hematoma

Crescent-shaped perisplenic
Compresses the splenic parenchym

The findings are the

following :
1.Multiple poorly defined
areas of decreased
attenuation not linear
not laceration
(Contusions)
2.Rib # + subcutaneus
emphysema
pneumothorax
3.No contrast
blush/hemoperitoneum

The findings are the following :

1.Linear hypodense lacerations
2.Round and oval hypodense
areas intrasplenic hematoma
3.Hemoperitoneum

Spleen
The shortecommings of
this grading scale are :
Often underestimates
injury extent
Significant
interobserver variability
Does not include :
Active bleeding
Contusion
Post traumatic infarcts

No predictive value for

NOM

The findings are the

following :
1.Hemoperitoneum
2.Oval or round shaped
areas in the spleen
hematoma
3.Linear hypodense in the
anterior part of the spleen
laceration
4.Anteriorly & medially of
the spleen
extravasation

Liver
Second most common
solid organ injury
Most common death
more vessels
Posterior segment of
right liver lobe
frequently injured
retroperitoneal
bleeding

Liver
The findings are :
1.Green arrow : oval
shaped hypodense
hematoma
2.Yellow arrow : linear
shaped hypodense
laceration
3.Blue arrow : vague ill
defined hypodens
contusion
4.Fluid around the liver
5.Transection of the
liver

Liver
Shown to be
unreliable in
predicting need for
surgery
Helpful in guiding
management
Positive correlation
between grade of
injury vs likelihood
of failed NOM

Classification
(AAST)

I-Subcapsular hematoma<1cm,
superficial laceration<1cm deep.

II-Parenchymal laceration 1-3cm deep,

subcapsular hematoma1-3 cm thick.

III-Parenchymal laceration> 3cm deep

and subcapsular hematoma> 3cm
diameter.

IV-Parenchymal/supcapsular
hematoma> 10cm in diameter,
lobar destruction,

V- Global destruction or
devascularization of the liver.

Liver
The findings are
the following :
1.Complete
devascularization
of the right lobe
2.Contrast blush
intraparenchymal
at lateral margin
and lower level
3.Hemoperitoneum

Liver
The findings are the
following :
1.Subcapsular
hematoma > 10 cm
2.Contrast blush
3.No hemoperitoneum
Lacerations can be :
Stellate
Branching

Small zone I (central)

retroperitoneal hematoma

Large zone I (central)

retroperitoneal hematoma with
active extravasation

Large zone II (lateral)

retroperitoneal hematoma

Renal
90% due to blunt trauma
Renal is the 3rd most common organ
involved in blunt trauma
10% of solid visceral injury
Evaluation for :
Parenchymal injury
Vascular injury
Collecting system injury

Renal criteria for performing CT

in abdominal trauma
Macroscopic hematuria
Microscopic hematuria with shock
Important renal ecchymosis or fracture of
the lumbar transverse process
Open trauma involving the retroperitoneum
Mechanism of deceleration (risk of pedicle
injury)
In children all types of posttraumatic
hematuria

Computed Tomography
Early and delayed CT scans through the
kidneys are necessary
Excretory-phase contrast (3min)
The preferred technique
Helical CT performed from the dome of the
diaphragm

Scanning parameters include

Collimation of 7 mm,
Pitch of 1.3,
Image reconstruction intervals of 7 mm.

Subcapsular hematoma
(category I)

Crescent shaped hyperdensity,

located in the periphery of the

Laceration
Hypodense, irregularly linear areas,
typically distributed along the vessels
and filled with blood.
They are best analyzed at arterial
phase
Superficial (<1 cm from the renal cortex)
Deep (>1 cm from the renal cortex)
Renal medulla
Collecting tubule system

Simple renal laceration

(category I)

Major renal laceration without

involvement
of the collecting system
(category II)

Major renal laceration

involving the collecting
system (category II)

Multiple renal lacerations

(category III)

Shattered kidney (category

III)

Segmental Infarct
Triangular parenchymal area, with a
widest part at the cortex, which is
not enhanced during the different
phases, with clear delineation

Segmental renal infarction

(category II)

Traumatic occlusion of the

main renal artery (category III)

Traumatic
occlusion of the
main renal
artery
(category III)

Active arterial extravasation

(category III)

Laceration of the renal vein

(category III)

Urinoma/Urohematoma
Presence of a more or less significant
breach of the collecting tube system,
with urine escape reflected by
extravasation of contrast medium on
delayed imaging, in an extrarenal
location

Avulsion of the ureteropelvic

junction (category IV)

AAST organ injury severity scale grading system

for kidney injury
Grade 1

Contusion or contained and non -expanding

subcapsular haematoma, without parenchymal
laceration; haematuria

Grade 2 Non -expanding, confined, perirenal haematoma

or cortical laceration less than 1 cm deep; no
urinary extravasation
Grade 3 Parenchymal laceration extending more than 1
cm into cortex; no collecting system rupture or
urinary extravasation
Grade 4 Parenchymal laceration extending through the
renal cortex, medulla and collecting system
Grade 5 Pedicle injury or avulsion of renal hilum that
devascularizes the kidney; completely shattered
kidney;
thrombosis of the main renal artery

Renal
The findings are the
following :
1.Extravasation and fluid
paracolic gutter
peritoneal violation
2.Hematoma perirenal
space
3.Violation of the
collecting system

Renal
Some final remarks on
renal injury :
CT has facilitated shift
toward NOM
98% renal injuries
NOM
Injury delayed
imaging evaluate
collecting system
Penetrating trauma
rectal contrast
bowel injury

Pancreas
Uncommon injury
0.4% overall
incidens
1.1% in
penetrating trauma
and 0.2% in blunt
trauma
Rarely an isolated
injury

AAST GRADING OF PANCREAS INJURY

Grade

Type of
Injury

Description of Injury

Hematoma

Minor contusion without duct injury

Laceration

Superficial injury without duct injury

Hematoma

Major contusion without duct injury or

tissue loss

Laceration

Major laceration without duct injury or

tissue loss

III

Laceration

Distal transection or parenchymal injury

with duct injury

IV

Laceration

Proximal transection or parenchymal

injury with probable duct injury (not
involving ampulla)b

Laceration

Massive fragmentation of pancreatic

head

II

Laceration of the pancreatic

neck without duct injury

Pancreatic transection (neck)

with duct injury

Subtle pancreatic contusion

Pancreas
Typical left sided package
injury
Pancreatic tail injury
Renal Injury
Pneumoperitoneum

Pancreas
Right sided
package
injury
Liver
laceration
Transection
of the
pancreas

Bowel
The findings are the following :
1.Hypoperfusion of the spleen
(yellow arrow)
2.Multiple area of contrast
extravasation (green arrow)
3.Hemoperitoneum
4.Pneumoperitoeum (blue arrow)

Bowel
Pneumoperitoneum uncommon
findings if bowel injury present
Known false positive :
Peritoneal Lavage
Foley insertion intraperitoneal bladder
rupture
Translocation from thorax diaphragm
injury

Small Bowell
Most common findings :
Unexplained non-physiologic free air fluid (84%)
Diffuse wall thickening :
Hypoperfused shock bowell active bleeding
Focal thickening :
Direct injury usualy non-transmural injury
Spesific findings :
Oral contrast/bowel content extravasation
Focal bowel wall discontinuity
Other findings :
Mesenteric stranding
If in combination,
Focal bowel thickening
very suggestive
for bowell injury
Interloop fluid

Traumatic duodenal intramural

hematoma

Periduodenal hemorrhage

Bladder
If # pelvic bladder
rupture only 10%
If bladder rupture
almost always #
pelvic
1/3 rupture at site
of # due to pelvic
#
2/3 rupture
opposite site
shearing force

Bladder
The findings are the
following :
1.Contrast in the
bladder surrounding
foley catheter
2.Extravasation of
contrast in pre-vesicle
space
Molar Tooth Sign
extraperitoneal bladder
rupture

Bladder
Have good
distention of the
bladder
Do not administer
contrast in the
bladder and I.V
contrast at the
same time
bladder rupture or
active bleeding

Thank You