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Radiology. I'm a radiology consultant. Sorry, let me just click that this is okay. Now it's got stuck on my screen. Uh Seconds. There we go. There we go. Right. Welcome over your verdict. My name is David Delius. I'm radiology consultant at King's College Hospital in London. I'm just going to talk to you about CT imaging, a major trauma. Um And uh this talk was actually prepared for our own medical students by a couple of our uh really excellent radiology registrars. Um David Nicholson Thomas and Archie Keeling. So just to give them the credit for that at the beginning. Um uh but they've used this for a while for our, just for our own medical students. Um So uh I'm just going to go through this but do feel free to uh kind of put uh comments or questions in the chat as we go. Um I will kind of ask questions as we go. So feel free to kind of unmet yourselves. Um And just, just jump in. Um So if I can make this work, yeah, there we go. All right. So what we're going to cover is uh Hugh. And when do we image in trauma, we're going to talk about uh protocols in CT. Um And we're going to introduce the concept of contrast phases, which is uh sort of quite important to understand. Um And we'll talk about a little bit about different patterns of injury and blunt versus penetrating trauma and we'll show a few cases um uh to, to demonstrate some of these injuries. Um hopefully you'll start to uh this will help you become aware of what sort of patient's to scan in the trauma setting. Um And to understand what what's meant by different phases and ct scanning, um and appreciate patterns of injury based on trauma mechanism, which is an important concept um to kind of get together and hopefully we'll see some examples of traumatic injuries. Um So, um, just to say, first of all, we're, we're, as you saw in the first slide, probably that was actually a view of the helicopter pad. Um It's not going to go back now, that was the view of the helicopter pad on top of the hospital at King's. Um, we're a level one trauma center for the region and um uh most of the trauma that we receive um is blunt trauma. We don't get uh sort of massive amounts of penetrating trauma, most of its blunt trauma for and road traffic accidents really. Um We do certainly get some, some penetrating trauma with stabbings but gunshot wounds. Actually, we don't see very often. Uh I guess, depending on where you are, obviously, you're gonna have very different sort of patterns of injury. So just first of all, how can we define what major trauma is? It's generally defined using the injury severity score. Um, and, um, uh, that gives you, uh, it provides an abbreviated injury scale, um, assigned to one of six body areas and then you take, um, uh, top three scores that it gives and, and, and it produces a score out of 75 major trauma is defined as an injury severity score of more than 15. Um but when trying to decide who needs CT imaging, it's really based on suspected uh injuries and according to mechanism of injury and primary clinical survey findings. Um so whether um uh where the mechanism of injury is, is significant for most patient's, we would end up taking them straight to CT at King's. So we generally use a sort of straight CT approach for life threatening or potentially disabling injuries. Um We have lots of other imaging modalities and radiology. Um We use them not that much in the context of major trauma, um plain films, um really kind of introduced delay. Um They kind of end up being a sort of unnecessary radiation exposure and and more more important that just adding delay in evaluating most of these patient's um ultrasound, uh certainly has its place and you, you may be familiar with a sort of focused um uh abdominal ultrasound and trauma, which uh is really designed to pick up free intraabdominal fluid. Um, but it's not helpful in pretty, picking up a cute um solid organ injury in the context of major trauma. It's got a high, very high false negative rate and it's also very operator dependent. Uh and so it's really, we don't, we really don't use that very much at all. Um, MRI also has its place, um, certainly not in the unstable patient. Um, the MRI scan, er, is a very uh dangerous environment for, for an unstable, for an unstable patient's. Um, it's hard to get patient's I/O of the MRI scan. Er, there's obviously all the issues with um uh bringing in equipment into the M R scan, er, that is Ferro magnetic, um that can be very dangerous. So everything has to be obviously EMR compatible. Um and patient's who go off inside the MRI scanners are actually uh of course, that sort of great risk. So, um really, MRI doesn't particularly have a place in major trauma, um except in the uh sort of stable um human, dynamically stable patient's who have um known or suspected um uh neurological injury where you need to uh where you need to assess cord compromise and then those patient's where you will do MRI, but at a later stage, once they're stable, um but before you get to the CT scan, er, you've got to remember that the priority is to treat the patient's so they need resuscitation using an A B C D approach. That's not something I'm going to talk about. Um, a radiologist. You'll, you'll pick that up from your clinical lectures. Um, you need to be aware that for, for the CT scan, the patient, although the scans themselves very fast, um, and you'll probably be, you probably have seen that the CT scanners will scan from head to toe, um, perform the actual scan from head to toe, uh sort of in a matter of, you know, sort of seconds, maybe sort of 10, 10 seconds or so. Um, but it does take several minutes to uh set the scan up. Obviously getting patient's especially trauma, patient's on and off CT tables is not a simple process given all the lines and tubes and everything else. And so, um in practice, patient's will have to lie flat for several minutes to have a scan. Um So the airway and analgesia and aesthetic considerations are all very important. Patient's need to be still to have a CT scan. And therefore, um they, they need to be appropriately analogies or anesthetist if necessary. Uh in order for that to work. Um So, um if patients are unstable and there's a clear and there's clear evidence of significant abdominal injury, then patient's need to go to theater, you don't need to, um, you shouldn't be delaying that in a, in an unstable patient, you need to not human dynamically unstable patient, you need to not delay um their life saving treatment by going to a CT scan in that situation. So, we're going to just introduce this um concept of different contrast um phases in CT. So, uh we use um iodine based uh intravenous contrast for CT. Um and it's very important to uh use that in trauma CT in order to get good views of uh the organs that we want to look at. Um the way you administer is via uh via an intravenous cannula. It can be, you can use um uh central, a central line of the patient's got one. Um The problem is that what you really need to do is to actually give your bonus of contrast. Um ideally in a trauma situation in quite a specific way. So you need to be able to give it at a very specific flow rate um uh quite quickly. Um and to be able to time it quickly. So we don't give it just by hand, what we do is we use uh mechanical power injectors that can time the contrast administration. And the idea of doing that. And by the way, you generally can't use power injectors with central lines. So you usually have to have a decent peripheral cannula in order to be able to do it. Um the purpose of this is to be able to time the scan correctly so that you will optimally have the, the bolus of contrast in the part of the circulation that you want it. So the phase of the scan describes where the contrast is mostly distributed. And this will depend on the timing of the scan relative to the Bolus administration. And the three phases that we think about are basically the arterial phase, which is around around 15 seconds after Bolus administration, the venous phase, which would be around 90 seconds and a delayed phase which come, which will be around about 15 minutes. And we'll show some examples of this and what this does. Um the in terms of these timings though, um clearly you're, if you're injecting into a a vein in the anti cubital fossa in the elbow, uh and it's a decent Kanye and decent vein. Um and the patient is young and fit, then these timings will probably be about right. So it'll be about 15 seconds for the contrast to work its way through into the arterial side of the circulation about 90 seconds to get into the venous side. If however, you have a patient who is elderly in heart failure, um then the time it takes for contrast to get into those parts of the circulation may be significantly delayed from that. And also if you're using a sort of dodgy cannula in a foot, for example, if you can't get a decent vein, then obviously that's going to affect the timing as well. So these are all a little bit variable. But here you can see um an example of a CT scan done after intravenous contrast and you can see the bright white contrast on this abdominal ct section. So just the anatomy, you can see the liver here um on the right side and you can see the spleen there. Um And this uh structure here is obviously the aorta. Um and that's the portal vein here coming into the liver. And you can see if you look at the density of contrast within the aorta, it's very dense at that point. And that's because there's an arterial phase scan and the density within the aorta is much higher than the density within the portal. They between in the portal vein at this phase of the scan if you then scan later. So that was around about sort of 15 or 20 seconds. If you then scan later at around 90 seconds. After bolus administration, you can see that that um contrast density is reversed. Um And that's because most of the contra this is now in the venous and portal venous um uh circulation. So there's the portal vein, you're beginning to see veins within the liver, which you couldn't see at all before you can see density in the portal vein. You can see that the contrast density in the aorta is much uh is much less is much reduced because it's now washed out mostly from the, from the arterial circulation. And I also want to draw your attention to this stretcher here, which is the spleen. Um And you can see that in the arterial phase, it has this very um uh sort of uh sort of splotchy appearance. Um It always has this appearance on an arterial phase scan and you could be forgiven for looking at that and thinking that maybe they've got a splenic uh sort of splenic injury with lots of splenic lacerations. But in fact, we always see this on the arterial phase in the spleen specifically. And if you wait for the venous phase, it becomes much more homogeneous lee enhancing. Okay. So they were just showing um and sorry, the other thing to just point out, of course, as if you look at the overall density of the liver, you can see that it's relatively low density there on the arterial phase. But once the contrast gets through into the venous phase, you can see that there's generalized diffuse enhancement of the whole of the liver. So you're, you're seeing the parenchyma of the liver much better there. Um All right. So what about the delayed phase? We haven't really spoken about that. Um So that's sort of done separately. Um And um the reason for doing that generally is because um you get that there's a sort of slow clearance of contrast through the kidneys. Um And therefore, if you wait for that clearance to occur, you'll get nice views of the urinary tract from the renal keyless is into the ureters and down into the bladder. So here's an example just to look at this. So this is a corona well reformat um of an abdomen of a patient who you can see has got all these um uh large renal cysts, which don't worry about those, but there's a sort of big renal cyst there on the left, lots of renal cysts there on the right as well. Um And you can see in this um relatively arterial phase scan, um that there's a very dense aortic um contrast there. You can also see if you sort of ignore the cysts, you can see the renal parenchyma there, which is markedly enhancing within that arterial phase. But if you wait for 15 minutes later, you'll notice that the aorta now um has completely lost all its contrast. Um And you'll notice that the renal parenchyma as well on each side has, has basically lost all its contrast. But you're now seeing um contrast within these sort of spindly um uh callouses within the right and the left kidney. Um, you can see a little bit coming down into the ureter there on the left and you can see that the bladder, which previously was of quite low attenuation has now filled up with contrast. So you can see how the delayed phase and this is about 15 minutes later, is quite useful in patient's who you might be concerned about renal tract or bladder um injury, oops just going to check in the chats. Um Make sure there again, that's fine. All right. Um So if you have a leak uh in a trauma patient from a ureter or the bladder, then you'll see um uh contrast enhanced free fluid, which wasn't present on an earlier phase imaging. Um The problem with this is you probably realized is you've got to wait around 15 minutes um in order for this to happen for enough contrast to um to, to hit the collecting system, for it to be useful. Um And obviously, if patient's are a little bit unstable, that might be uh an issue. So we tend to review the scans at the time of imaging and we review the arterial and venous phases um and determine whether we think that there is a likelihood of renal tract injury and if that is the case and if the, if the patient is stable, um then we will um keep them on the table for 15 minutes to do the delayed scans. So basically, um the key thing is, are there any injuries that threaten the bladder? And in particular, you're going to be looking for uh in particular, in that context, you're going to be looking for pelvic injuries. We sometimes see this especially with a so called open book pelvis where the pubic synthesis is widened. Um That might be a sign that the there might well be a bladder injury. Um uh or if there's a kind of a penetrating injury local to the renal track that might be significant, obviously, or if there's a suspicious amount of pelvic free fluid without another obvious cause for it. And obviously, if the patient's stable enough to stay on the scan, er, then we'll keep them on and do a delayed phase scan. And it's quite important to assess the different scan phases um, in conjunction with each other because, um, what you'll find is a change in density um of the contrast between the arterial and venous scanning phases. Um And that will give you information about whether there's active bleeding or a pseudoaneurysm or think that sort of thing. So I'll show you some examples of that, say here's um just uh an example case, this was a patient a, a young man who was stabbed in the right upper abdomen. Um and you can um see hopefully. Um uh well, first of all, let's just have a look at what the two scans are showing. So these are two scans through the upper abdomen. Um And what I want you to do, first of all is not worry about the injuries for a second, but just try and work out um what phase of scanning each of these two um images show. So does anybody want to, you can either put it in the chat? So you've got the left hand panel here and the right hand panel here. What phases do you think those are showing and we'll worry about the injuries in a second. Yeah. So, so the left hand panel is which actual face? Yeah, exactly. So the left hand panel is the arterial phase. You can see how dense um the aorta is there. And, um, you can see that there really is no contrast in the inferior Vena cava, which is sort of sitting just here. Um, and on the right hand panel that's going to be the Venus face, that's gonna be a venous phase. Exactly. So now you can see that there's quite a lot of contrast on the venous phase within the uh within the inferior vena cava, which there wasn't before you can see that the contrast has faded within the aorta. Um And if you look at the renal parenchyma as well, so just look on this kidney to begin with. Um You can see that on the arterial phase, you're getting all this sort of cortical bright cortical enhancement, which we see in the arterial phase in kidneys and on the later phase, um it kind of runs all through that the renal parenchyma sort of more diffusely enhancing it. So that's the sort of different phases. You can also see you haven't really got the spleen on this image on the left, just a tiny bit of it, but you can see the spleens quite uniformly enhancing on the venous phase on the right hand image and also the liver. Um you can see that the liver, which was sort of quite low attenuation there on the arterial phase becomes much more, much higher attenuation and more diffusely enhancing. So now the next question is, of course, what is the injury? So there's arterial and venous and the question is, what's the major abnormality? So anybody wants to, uh, has it, I guess you put it in the chat or if somebody wants to say what they think somebody's put their hand up. Actually, I can't see everybody's name. That's, I think as that, let's put their hand up. As I, what do you think? I think it's operation. Uh Do you think it's what, uh due to the stabbing, the population has a good and it is getting accumulated inside the, inside the Dominica? Okay. So, um, I think what you're saying is that sorry, it's a bit a bit fuzzy the sounds. But anyway, I think what I'm hearing, hearing you say is that there's some gas, uh maybe perforation. So I certainly agree that there's gas. The question is where when, when you say perforation, I assume what you're talking about is, would be a uh entry, so penetrating injury, right? So not, we're not. Yeah, so not bowel perforation. Um So no, I think that's right. So you can see that the patient's must have been stabbed here in the flank. There are lot cules of gas tracking through the muscle tissue there. Uh, and into uh, and and uh, sort of through the, uh, sort of abdominal wall just really below the costal margin. Um, okay, what else? What else can we see? Any other idea? Any, anything else you can see, uh, the enhancement of the space and the anterior side of the abdomen. Uh, you can see three black. Yes. Okay. So, what we're looking at these are normal bowel loops. All right. So these are normal Gassville bowel loops. So, um, gas, you can see sort of outside of the abdomen, gasses black, uh and gas within the bowel is, is black. Also these little lock cules of gas are also black. So these are just normal loops of bowel that are kind of curling up and down through that CT slice. So these are normal bowel loops, think a little bit about the mechanism of injury and the direction that it's going in and think a little bit about what you expect is going to be injured. Given that we've seen the trajectory of the penetrating injury just here in the right flank. It will be a penetrating injury to the liver. Yeah, absolutely. So, can you see how this, we're sort of cutting through the lower part of the right lobe of the liver? And can you see how this part of the liver is really quite nice and homogeneous? And actually at this point here, there's a sort of low attenuation area and then a very, very bright area. Well, that shouldn't be there. And if we look at it on the arterial phase, you can see that there's, there's this sort of low attenuation here. It's a bit harder to see, but there's a very, very bright thing here, sort of sitting in the liver. So, the outline of the liver here is this. Yeah, you can see that. Hopefully can, can you actually see my cursor when I do this? Maybe you can see it. Can you see it? Yes, you can see it. Yes. So that's the outline of the liver. So all this part of the liver looks fine, but this bit of the liver certainly doesn't. And there's an area that's not enhancing at all. So this is a liver lacerations. But the question is, what's this bright thing? Um That's sort of sitting in there on both the arterial and the venous phases. What do you think that might be? That's what is the, that is the uh I think one of the hepatic countries might be cut it. So instead of going to the venous arterial phase, it's dripping in the abdominal cavity. And right. So this is a site of active bleeding, okay. Um And you can see that it's bright on the arterial face as you, I think you just said, um it suggests that it's arterial bleeding bleeding, which it is um so because it's, it's um this is not a normal vessel, this is a, a bit of a little area of arterial bleeding within the lacerations and look what's happening to it between the arterial and venous phases. The point is it's not getting, it's not staying the same. It's not getting smaller, it's actually getting bigger. So this contrast which is blue bleeding out on the, when it's in the arterial phase of the circulation, it's bleeding out of the artery and then it's pooling there. And therefore, when you come to the later venous phase, there's a bigger pool of contrast sitting there than there was in the arterial phase. So this is an arterial bleed that's pulling within the, within the liver lacerations in. Now, what other organ has been injured? And again, just look at the track of where the knife has, where the blade has gone deliver is obviously. But I think it's also possible with that with you, uh the outer surface of the right give me particle right on the surface of the cortical people might also be because if we see in the industries, we see the uh like three bombs up and down. Same thing was in the actual face and you would like to give me as well. It's not perfect. Absolutely. Right. So, yeah, so what you're doing is you're sort of thinking, well, we can see the track of where this knife is going. I'm going to be looking really hard to see if there's a kidney. We, we know that it's come through the skin here and it's gone through the liver. There were going to be looking really hard at the kidney that's sort of sitting in between the two. Um, to see where, yeah, that's been injured or not. And actually you've got a sort of normal kidney on the other side to compare with, which is a bit helpful. And you're just kind of cutting through the lower part of the kidney here. So you're obviously not seeing the whole kidney. But can you see several things to notice? One, is that the surface of it, which is nice and smooth around here, which I think is what you're pointing out. It's nice and smooth around here and on the other kidney, it's kind of nice and smooth all around. Yeah, nice and smooth, all around there. But here it's got this very irregular sort of jagged edge to it. So that looks like a, that's not a normal surface of the kidney that's all lacerated. And then also look at the position of the kidney. So what do you have on the, on the normal side? There's the kidney, what's this structure here? Which is sitting just between the kidney and the vertebra. What would you expect to be there? What's that normal structure going to be? Was major muscles? That's the, so as major muscle. Exactly. That's what that's what you expect to be there. But have a look on this side, look at the position of the kidney, it's actually nowhere near where the other kidney is. It's kind of moved along anteriorly. Yeah, it moved a long way anteriorly. It's also moved laterally. And this all this, you've got all this tissue here, that's not a normal. So as you can see what the normal cells looks like on this side, this is all a massive human toma that's sitting in the perirenal area and just pushing the kidney out of the way. So, uh so this is a patient who's got a renal and a liver lacerations with active arterial bleeding within the, within the liver lacerations. So the question is, um, so there you go. So that's the answers. But the question is, what are you going to do? Um, next. So that's my question. What, what are you going to do next? Who you're sitting in the scan? Er, okay, everybody's gone home, they've all gone to have lunch and you're sitting there on your own. They said, you know, just go and scan this stab stab victim, go and sit in the scan, er, just to make sure everything's all right and the scan comes out and you see all these things, uh and your boss has gone home for lunch and uh and you're kind of like left looking at this actively bleeding, um, liver, what are you gonna do? Patient's kind of uh theater or the surgeon? So, theater, yeah, theater insurgents is certainly an option. I mean, I think the first thing you've got to say is what? Oh yeah, somebody's raised the first three clean level and we stop the bleeding. I don't think you're going to be able to do that to be a long way in to kind of stop to clean the wind. And maybe you can give, maybe you can give fluid since patient has IV Candida, you can start giving fluid. Okay. So I, I absolutely agree with that. I think, I think yeah, urgent things are urgent. So, so resuscitate the patient. Okay. You need airway breathing circulation. You need to any question like that? You ever get asked in an exam? You need to start with the emergency thing. So it's going to be airway breathing circulation. You need to, yeah, you need to set up fluids, um etcetera. And what's the, what who you gonna call? I think uh somebody had their hand up patiently or have disappeared. Now, where are they? Um I can't see, I can't see it. Was it Yazid again as, as there you go. As I think I had your hand up. Yes. Uh Who you gonna call? Who's going to sort this out for you? Yeah, so you're right. Uh emergency, especially uh especially uh one of my colleagues. Uh yeah, emergency surgery or emergency trauma. Okay. Okay. So certainly the surgeons could take them to theater and do that. Let me see. Somebody else put their hand up and then it went down again. Was it Christie. Christie, did you have, I was going to say whether interventional radiologist would be able to help interventional radiologists. Um That would be, if you've got them available, that would be a, be a great option, wouldn't it? Because you can deal with this arterial bleeding point very directly. So that's what happened in this case. Um Can you see what can you see what's done here? Can you see where? Um So this is a, can you see the catheter? Yeah, it comes in there. It's going in, um, uh, through the, it's a hepatic artery angiogram. So it's coming in through the, through the groin, groin puncture into, it's the femoral artery. All right, the catheter comes up into the aorta, um, and then into the celiac axis and into the hepatic artery. Yeah. And this is, these are the branches of the hepatic artery. And can you see, um, uh, what, what, what's this, by the way? What's that outlining? Do you think? Would that be an extra visitation? Uh No, actually that's, that's just outlining the, the gallbladder. They're all right? Okay. But you can see this is, uh, can you see what you see what's been circled there that, do you know what that is at the artery, which is in June? Yeah. What, what is actually, what's there though? You know what that is? Yeah, that's a coil that's a coil that's been put in, um, to, to treat that patient. So that this is the same patient, they went to interventional radiology and they, they put a coil in and stop the bleeding. There you go. Another life saved. That's all good. Um, all right. So that was sort of all, uh, discussion about, uh, sort of contrast phases. Um, and, uh, what when you're, I don't know if you've sort of spent any time, sort of sitting in a CT scan, er, but you'll notice when you do a CT for anything that the, the radiographers always start out with what's called a scan A gram, which is sometimes called a scout image. And it sort of gives you a basically just a, a quick uh sort of X ray tight image of the area of the patient that you want to scan. And the purpose for doing it really is to allow the radiographers to plan um the actual scan. So they'll do this and then they'll uh they'll put like a line across it where they want the scan did start and line across where they want the scan to end and then they can plan the actual CT from it. But it's very helpful because it sort of gives you an extra sort of free image um of the entire body. And um what we tend to do at King's is we tend to make sure in trauma patient's that we do a scan a gram really all the way um from uh from head to toes because even if you're not going to scan, uh, sort of that much. I mean, you may just be scanning sort of chest abdomen pelvis and not the lower limbs, but it's helpful to do this. It's not a huge radiation dose and what it can do sometimes is pick up injuries, um, sort of quite easily. So the sort of injuries that you might pick up. Well, let's see, what, what, what can you, what can you see on this? I'll just zoom up on this a little bit. Um, there we go. Ok. Anyone spots anyone spot any injuries on this, right? Humans. Yeah, there's a right humeral fracture. Shocked. Yeah. Mid right humeral shaft. What's that? What's the most difficult fracture to pick up ever? Mhm. Be shoulder. The answer is the second one. The answer is second. Yeah. Why are you doing anything? Uh You know why that is right? Because whenever we see something, we see a fracture, then we get so excited, we pat ourselves on the back and then we go home for lunch. And what you have to remember is that when you've seen a fracture always look for the next fracture. Okay. So, so the is always, is always, there is always too tempting to stop looking once you've seen a fracture, right? So you always look for the next thing. Um, so here we go. So you're right. You've spotted the right mid humerus fracture. Can anyone spot the second one? Yeah. So, I don't know, it's probably one that the surgical neck is structured as well in the same, you know, on the left side, on the left side, can you see that? You see how distorted that is anyway. So, yeah. So there is a, there's a fracture on the left side as well. Okay. Good. So, the other advantage of the other thing, the use of the scan, a gram of course, is to sort of pick up if there are sort of tubes or artefacts or whatever that are going to, we need to be removed that we haven't spotted um that are going to cause artefacts on the scan. So that's quite another helpful thing to look at for the scan A gram. Okay. So let's look at blunt trauma. Um So um common um oh sorry, let me just get back. That's fine. Sorry. Um Common blunt trauma mechanisms of injury are going to include red traffic accidents, um uh falls from height, um or blunt trauma, assaults as well. Um And um the scan a gram, as we said, as I said, is done is done really from, from head to foot. Um And then in terms of the order of scanning, you're gonna generally do the head CT first. Um That's partly because um that's partly because the reason, the reason for doing the head CT first is that we do the head CT and trauma without contrast. So we do the head CT first because we don't want any contrast there because you want to just be able to look for blood, which is bright. Um uh and then you'll then scan the, the cervical spine. Um and then you and, and thorax, abdomen and pelvis following contrast in arterial and venous phases. Um And if there's a suspicion of renal or your rhetorical bladder injury, you'll scan, you might do a delayed phase scan as well. Um When you're looking at patient's, you've undergone blunt trauma, you want to just think about the the where the force has gone and try and look for injuries that are going to be associated with each other. So in the brain, um if uh patient's been struck on the back of the head, then you might see injuries posteriorly, but you also might see contra q injuries anteriorly where the brain strikes the frontal bone si belt injuries are sort of good example. So here you can see a corona reconstruction from a young female and a high speed road traffic accident. Um And um can you see what's what looks abnormal about this? So actually the interest of time, a slight line just completely bruising and the, yeah. So can you see? So this is, this is bowel. Yeah, this is all bowel, but it's in a very funny place because if you look at it, it's actually coming outside of the abdominal wall. Um And can you see the line of it like, what does that make you think of this? This? So you have been a seatbelt. Yeah, that's where the seatbelt is going to be worn, right? So this actually is a, is a herniated bowel. That's actually, it's just, it's torn, the abdominal, the seatbelt injury has torn the entire abdominal wall and the bowel is just herniated out through that abdominal wall, hernia just along that line of the seatbelt. So this is the hernia that we saw before. So this is a sagittal reconstruction. Now, you can see all the abdominal content here and this sort of slice through that herniated loop of bowel. But now think we've seen what we'll think about the mechanism of injury. And can you see anything else that might be sort of in the line of that injury that might be associated with it, any one spot, anything else on this image, think about the injury. So the seatbelt is going to be um, is a clearly across the abdomen. Um So it's stopping that part of the abdomen from going forwards at the time of the collision. But the body above is or the body below, there's going to be pretty fixed to the seat, the chest above that level is going to be sort of driven forward. So there's going to be a sort of flexion really across where the seatbelt is. Can you think what else there might be that might be going on? And can you see something else on that scan. That worries maybe the shift. Uh Yeah. Good. Right. Can you see how, look at all the vertebrae? Oops, I'm losing my curse up. There we go on one second. There we go. Right. So look at all the vertebrae. Can you see how they're very nicely spaced? This space is all the same, all the same, all the same. And suddenly this, this space is just too wide. There's a little fragment just sitting there and look, there's a fracture right through the spinous process there to look all these spinous processes. And then suddenly there's this, this one which is a fracture. So this is a horizontal fracture really through the disc and through the spinous processes, a chance type fracture and that force has gone straight through. Um it's affected the anterior abdominal wall causing this massive hernia and it's also caused the chance fracture through the spine. So be systematic, make sure you've looked at everything. I mean, look, look carefully through expected areas for injury, but make sure you've looked through the lungs, the mediastinum, the heart, the bones, spine vessels, solid organs bell is an awful lot to actually look through penetrating trauma. So this type of trauma obviously would include stabbings or gunshot wounds. Um And um imaging is going to be specific to the actual site you're looking at and so it can be targeted to the site of interest. This is obviously a patient who has undergone a gunshot wound. Um, uh, none of these pellets have actually penetrated deeply. They're all quite superficial as it happens. Um, think about the path of the penetrating wound and the structures that are going to be at risk along that including arteries, lungs, heart, liver, spleen, bowel, everything else, remember the standards. And we saw earlier there was the trajectory that we were looking at okay and beware of multiple wounds because often there may be more than one. So um have a think about some of the injuries that you might see in penetrating or uh in penetrating trauma in each of these following areas. So here, um so in the thorax, for example, um what what sort of injuries might you see in penetrating trauma? Commonly? Uh pneumothorax, pneumothorax. Absolutely. Hematoma, hematoma. Yeah, maybe within the lung. Yeah. Well, where, where else direct penetration injury to the heart? Yeah, injury, true injuries to the heart. I think it's just the diaphragmatic injury. Absolutely. So don't, yes, a hematoma uh sorry. Uh herniation, herniation. Oh yeah. Ok. Diaphragmatic herniation. So, diaphragmatic injuries. Absolutely. When you said hematoma though, I assume he meant in the lung, but don't forget also pleural. Yeah. So, so hemothorax as well as pneumothorax. Okay. So um think about all those things so poorly hemorrhage, cardiac injury. Okay. What about the abdomen? Well, obviously all the solid viscera. So liver spleen, pancreas, kidneys, what else? Maybe bowel perforation? Yeah. So hernias and evisceration is just like we saw. So don't forget. Um uh, so with bowel perforation, it's often, um, not so easy to see on CT we, it's one of the things that we can miss is bowel injury, but one of the things to sort of look out for carefully is if there's any free intraperitoneal gas because that will be a very good sign at bowel perforation. And then of course vascular injuries to look for active bleeding, pseudoaneurysms and transactions. Okay. What about head trauma? What types of intracranial bleed can you think of? Yeah, extra. Yeah. So extracranial, I suppose is one. Yeah, I really thought don't really put that in. But anyway, extradural. All right. So running between the dura and the industrial layer of the skull subdural which would be between the juror and the Arachnoid March and subarachnoid. Yeah, between the sub arachnoid membrane and the peer martyr. But also parenchymal I in the in the brain parenchyma itself. All right. So all of these can be related to trauma. Um and these can all cause complications including which are really pressure effects. So you look for a shift of the midline, you look for cerebral herniation and hydro catalyst. These are all pressure effects due to intracranial bleeding because you're bleeding inside of a fixed um box which is the skull. Um All of these obviously need urgent neurosurgical opinions. So the 48 year old male red traffic accident hemodynamically stable. I don't know, I hope you've got a reasonable sized screen. The image might be a little bit small, but here's the ct what types of hemorrhage can you see on this image just in the interest of time? Because I think I know we want, we wanted us to stop it a bit early. Um The answer is actually all of them. All right. So I don't know if you were there already, but you were all right. So you can see subdural hemorrhage. So this is the this midline straw to here is the folks and that should normally be a very thin, a very thin membrane in the center coming through the center of the brain. And you can see that actually it's very thick and all irregular and that's subdural blood which is layering along that you can also see parenchymal hemorrhage. Yeah, which is there in the brain parenchyma. You can see suburb sorry extradural hemorrhage, which is here, which produces this sort of by this, this sort of uh which uh which produces this uh this, this sort of convex density here. Um And you can also see some subarachnoid hemorrhage, which is a little bits of hemorrhage just tracking into the um uh just sort of tracking into the um uh into the sulk I uh just there. Um So what will you do this patient again? Of course, airway breathing circulation and then discuss with the neurosurgeons. And the question is, where is the patient's, I where is the patient's right eye? Can anyone see it? So, I'll show you where the left eye is. The left eye is just there. I don't if you see my cursor or not actually, but the left eye is just there. Can you see my cursor now? Yes. The left eye is just there. Where's the right eye? It looks like there is no right. I, well, there is but it's not where it should be there. It is. Look uh see that there's the lens just there. It's kind of dislocated out of the orbit. Okay. All right. Um So, um what sorts of trauma might be sustained in the chest? Uh Well, let's skip through this just in the interest of time but obviously, injuries to the media steinem um uh with sort of cardiac injuries, pericardial hematoma, myocardial contusions. Um uh don't forget esophageal rupture as well. Lung contusions and lacerations, obviously fractures and dislocations of bones and hemothorax. All of these could be in the chest. Him, authorities and pneumothorax. Just a question. What's the complication of multiple rib fractures? Do you know any complications of multiple rib fractures? I mean, normally we don't get too worried about them in major trauma really, but they certainly can be painful, but there's a particular complication. They can have um uh flail chest, deliberate fail, chest. Yeah, that's what we were thinking of really. So flail chest. So a flail chest is defined radiologically anyway, as when there's three contiguous ribs fractured in two or more places. Um And in a, in a nonventilated patient, you might see paradoxical movement of the flail segment. And this is a big problem in trauma because when you try and ventilate them, it causes all sorts of difficulties. So that can be an issue. So that's certainly something to pick up. Okay. What four injuries can you see on this chest ct? So you notice the windows are very different. Um And these are sort of windows which are altered to in order to be able to look at the lung really, um uh which is very different to the windows that we use to look at the soft tissues. But what, what can you see? What are the 44 injuries you can pick up on this film and this slide? Any thoughts there'll be pneumothorax? Good. You can see a pneumothorax. I agree. What else? And so that's here. Can you see, you can see the lung edge here and then there's gas around it, which they shouldn't be and see the lungs all way to the edge on this side. But here there's a pneumothorax. Okay. What else? They'll be? Subcutaneous emphysema, there's subcutaneous emphysema. Good. You can see all that there. Okay, in the interest of time, I'm just going to speed on. So there are also rib fractures. Can you see how the shape of the rib there? It's not in the right place. Really? Did you see that just here? Um And also there's a, a small hemothorax. Um So there's another road fracture on that side actually. And there's a small hemothorax that's just, do you see that sort of layering at the back there? There's a small hemothorax. Okay. So, what are you going to do in terms of specific treatment? Well, you're all gonna say airway, breathing circulation good. Um What needs treating first, out of what we can see here. You strike and the eating the new Kerekes. Yeah, the pneumothorax. Absolutely. Right. Now, my question is which side you're going to put the chest drain in. So, do you know which side is which on a CT scan? Which side do you put the chest drain in? Uh left one? Right. Nope, right side. It's the right one, the right one. All right. So will you, you need to remember this? Okay? Don't get into trouble with that. So, basically, the scans are all conventionally um displayed, um as if the patient is lying on their back with their feet towards you. Right. So you're looking up the patient. So this is the right side and this is the left side. All right, you will get used to it, but you mustn't get that wrong. Okay. And if you're a bit, if you're a bit, not sure, then what, so long as they've got normal anatomy, you can use the order if you like there's the aorta you see okay, which is obviously on the left side. Okay. Talking the aorta around 80% of patient's with thoracic aorta. Uh aortic injury will die on the scene. Actually. Um for those who make it to hospital clinical diagnosis is difficult. Um and relies on good imaging, um there can be different types of aortic injuries, so minimal aortic injury, um so lesions involving the intima of the vessel wall, aortic lacerations which extend through the vessel wall transactions, which were all three layers and sued aneurysms, which is in a contained aortic rupture and also an intramural hematoma. Um So you'd normally do a CT angiography. Um and you're going to be looking for sort of hematoma around the aorta and a flap, uh an extra visitation of contrast. So here, for example, is a motorbike accident. This patient had a, had a chest X ray initially um which obviously, as we said, right at the beginning, we wouldn't normally do. But anyway, this in this case, they did. And what you may see on here is that there's actually quite a lot of widening of the upper mediastinum. Do you see how big that is? It's really, really fat width of the upper mediastinum just there, there's also avail like capacity across the left chest. You see how dense it is compared to the other side. Okay. So widened mediastinum, there's a deviated trachea. Can you see the trachea there? So that should normally be much more in the midline, the film's not really rotated, but the trachea is deviated across all this is telling you is that there's a big hematoma in that mediastinum there. So, depression of the left main bronchus, that's another sign. Uh There's the left main bronchus which is pushed down again by this sort of big hematoma. So this is a patient where you're really worried. There's a traumatic chaotic rupture and here's the CT. and can you see this very large hemothorax there on the left and there's the aorta, it's not like any of the orders we've seen so far. It's a very odd shape and you can see a flap um sort of through it there. Um And this is it, this is a pseudoaneurysm sitting there in the aorta. Uh And this patient is very lucky to have survived so far and needs to uh that needs to be treated and you can see all this massive hematoma around it, all this soft tissue. Okay. Um So there we go. Um abdominal injury, I think we are. We've sort of run out of time really. Um I mean, I'm happy you. Um uh I mean, you know, maybe we could sort of carry on on another time. Uh But I I'm consciousness taking, it's obviously been taking a bit longer than I thought it would. Um Should we? So perhaps we better stop? Yeah. Okay. We can uh we can try and book in another, another another session. Yeah. Okay. Yeah, that's fine. All right, thanks. All take care. Thank you. That.