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Let me see. Yeah. Ok, so that right. Hello. Good. Um, evening everybody. Um, and welcome to another session um, in the radiology series for junior doctors. And today we've got Doctor Alexander Yadi with, uh, teaching on trauma. And this is personally a topic I'm quite interested in because we didn't really get a lot of teaching in foundation on this and this is quite useful for junior doctors. So without much further ado I would let, uh, let doctor Yadi, uh, take over. Ok, thank you. Hi. Hello guys. Um, my name's Alex, one of the junior registrars based down in Southampton. Um, yeah, I've, I've done a talk that's mainly focusing on sort of major trauma, um, the role that, that plays, um, within the life of a, a radiologist and, you know, for the patient's perspective as well. Um, so let's get these slides going. Um, so the one thing I would say, first of all, there's, there's a link here that I've posted that hopefully you'll be able to get as a hyperlink, if not, it's also posted in the chat. Um, I suggest that people just click on that now just to make sure that's actually working. Um If you have joined on your phone and things for the talk, that's fine. Um But I recommend if you are able to quickly grab a laptop or a PC and turn that on, um, you'll get a bit more out of it if you're, if you're able to click on the link. Um It's a, a software that allows you to go through a, a trauma case. I've actually uploaded if you guys have a go scrolling through. So in terms of the session today, um I'm going to start with some of the sort of more dry bits, but they are quite important for you to have an understanding of really, especially within radiology, but also as a referral um about um the concepts of vetting and different CT protocols, um then talk a little bit about windowing and what we mean by CT windows and how that changes what we're looking at and how we change those for looking at certain things. Um I'm going to talk about um the Camp Bastian protocol, which is the, the common sort of trauma scan, full body trauma scan that we do. Um talk a little bit about what we call an on the table review or a hot review, which is um part of the role of a junior radiologist um along with what a hot report is. And so the key things to be looking for um then the second part of the session is going to be breaking the body down into, into its individual parts, I guess. Um, and talking through the major trauma based pathology that we're going to be looking for. Um, give you a few examples of what that um what that looks like. Um Hopefully that's all going to take about 40 45 minutes and then I'm gonna keep quiet for a little bit and open up this link again for you guys to individually have 10 minutes or so to be able to scroll through a real, real trauma case. Um That was one of my cases. Um I think two weeks ago um and give you about 10 minutes to try scrolling through identifying the injuries based on the bits that we've um we've discussed um and then we'll come back together and um go through it at that point. Um If there are any questions at any point, um feel free to pop them in the chat, um which should be working. I've just posted the um the link again just in case it didn't come up um pop questions in there at any point and I will try my best to answer them as we go. So, um little bit about vetting and, and CT protocols. Um Now it's quite common that uh you know, we get referrals like this every day. Um You know, a patient say 85 80 85 they've got abdominal pain. Um Now everyone knows that patients pretty much going to end up getting a CT scan. Um, especially if it's coming from a senior. It's very hard from our point of view to say actually, no, you know, I, I disagree. They definitely don't need a scan. Um, but actually there's quite a lot more to vetting than just saying yes or no. You know, if you're calling up to vet a CT scan at the other end, we're not saying, you know, just ticking your box to say yes, they can have it or no, they're not. Um You actually have to essentially prescribe a, a scan um with a few various parameters to look at and it's really tailored to be answering um a clinical question whilst minimizing the patient's exposure um to either uh radiation or to uh contrast media. And that's part of the reason that we, you know, we ask so many questions, it might seem like we're giving refer as a hard time. It's not that at all, it's actually um making sure we're doing the right scan for the patient. Um There, there are a few key things we need to be deciding, you know, what's the range of the scan? Um Are we just looking at the abdomen, are we looking at the abdomen and the pelvis or actually do we need to be looking at the chest as well? Um Is it a scan that needs IV contrast certain things like commonly AC TKUB, for instance, actually, doesn't need IV contrast. Um but actually quite a lot of imaging does especially abdominal imaging, um need to think about how much contrast do we need, you know, you only need a tiny bit or actually talking quite a he dose of contrast. And almost more importantly with that. Um what's the timing of the contrast going to be, you know, where the key with that really is? Where do you want the contrast to be when you take the scan? Um So for instance, if you're doing a CT PA, for example, to look for a patient who's got pulmonary emboli, um it does no good if the contrast is all in um the systemic arterial system or even in the venous system, what you need is that contrast to be in the pulmonary artery. So you can identify if there are any clots there. Um So the common phases we talk about is noncontrast um arterial phase, which would be early phase, late phase or pulmonary arterial um venous phase, which is normally going to be a portal venous phase, which is probably the most common that you may have heard of or a delayed venous phase. Um And the other thing is a ureteric phase. So that's about 10 minutes or so later, we give the contrast, the chance to um have been filtered out by the kidneys so that it highlights any ureteric bladder injuries, other things that are a bit less relevant for trauma but I thought I'll just mention briefly, um also need to decide a bit about oral or rectal contrast, which especially if we're looking at leaks and things or fistulas can be quite helpful. Um Anything we can do to reduce the dose. Um So as I mentioned a bit earlier, CTKB looking for kidney stones, um we actually don't need a really detailed scan. We just want a bit of, of gross data really to look at. Is there a big obvious stone there? Um Looking at the sli slice thickness depending on what we're looking at. Sometimes it's actually easier with a thicker slice than a thinner slice or sometimes with a composite of a bit of some thin, some thick um need to think about whether or not we're applying any reconstruction algorithms. And I'll show you a few of those a bit later on, particularly things like reconstructing algorithms to make bones appear a bit crisper to identify fractures um without having to do a separate scan specifically to look for that. And then the other thing to decide about, which is really a cardiac type thing um is what we call gating. Um Now, if you think you're, you've probably seen patients having a CT scan or see what a CT scan looks like, it sort of takes slice by slice as the patient works their way through. Um I know if you've got the beating heart, what you don't want to do is have one slice and then actually by the next slice down everything's shifted, er, two or three millimeters in one direction because the heart beats. Um So actually what gating is a way of doing is actually make sure every slice is taking at the same stage of the cardiac cycle. So that actually, you know, you don't get a step where things have suddenly shifted um between slices. Um The other thing to mention is a bit about windows. Now, I think you guys have had some abdominal um CT talk already. Um I'm not sure whether or not they covered windows, but I'll just go over it very briefly. Um Windows. It's a way that we view the images that have adapted to what we're specifically looking for a CT scan is essentially a gray scale display of density, partially manipulated with these of contrast media, but especially a non contrast, it's purely density and we give it what we call a hounds field unit or AC T number, which is how dense it is. Um And this is a scale that just give you a rough idea of where certain things lie. So on the really dense side, we've got things like bone, um fat at the lower end of your soft tissues and then air right down at the other end, um with air obviously being very black and bone being very white on a conventional um display. Now, the kicker is when we're recording this data depending on how advanced the scanner is, it records a value um of, you know, on a scale of um between 4000 different values and 65,000 different values. Um as I say, depending on how advanced and in detailed the scan is. Um and that essentially would equate to a minimum of 4000 different gray scale values um showing the difference in density. Now, the reality is most even medical screens that we use only display between 201,000. So actually, we need a way of saying how we're going to view what we want to see, especially given the human eye is actually a matter of several 100 different scales of gray that you can appreciate the difference to between. Sorry. Um So what we do with windowing is we take a section that we're interested in. So say we're thinking about bone. Um If we want to look at the subtle differences between bone, we say actually we want the difference between a white and a black to be between. Um hopefully, are you able to see my um my pointer here, does that display for people as long as you pop in the chat? Just to let me know. Oh been mixed. P let me try. Do do do I'll tell you what does it show clearly now? Cool. OK. Grand. So um if we're looking to the bone, for instance, we might say we want a window that's going between here and here. So we're actually only interested in things of a really high density. So what we say is everything less dense than that will just make it black because we don't care about it and everything more dense than that. So, metalwork, we just wait, it make it white. Cos actually, what we want to do is see the subtle difference between here and here, um, flips and if we're looking at the lungs, um we'll say actually, we want the, the sort of scale of gray between black and white to be between here and here. So we can see subtle differences and anything much less dense than that. Um We don't care about. So we'll just make that all black, anything more dense, we'll all make white. Um So there we go, right. Um So this is what I mean and when I talk about windowing, um so this is actually um the same scan, the same slice. It's a single acquisition that's been taken and this is all just displayed in a different way. Um So here, we've got what we call a brain window. We're actually looking at subtle differences between gray and white matter. Um not really caring about things like the differences between the cortex and medullary bone. So that's why that's all white. Um Then you gone to a bone window, we're actually saying, look, we're interested in the difference here between the cortex and medulla. So we can see that differentiation more clearly. Um But actually, you can't see any differentiation between gray and white because we're saying, well, we'll just make all of that of dark gray because we don't really care about that. Um And the final window just as an example I've put is a what we call a subdural window or blood window. And that's somewhere in between really? Because we're looking at actually, um, can we see a bit of blood coming out um from the inner table of the skull there? Um And each of these things will reveal pathology that you wouldn't be able to see on the other windows, which is why it's important to review scans in, in multiple different windows. Fine. So that's the sort of theory out of the way. Um Now we're going to start properly talk about trauma, but I think it's important you guys have an appreciation of that to understand why we do what we do. Um Now, um for anyone who doesn't know camp bastion is a large, um camp based out in Afghanistan, which was the, the UK base for a long time. Um And they actually devised the protocol out there, which was all about getting the maximum information for a patient with serious injuries um in the shortest space of time and with the lowest dose, um especially because we're generally dealing or they're generally dealing with very young patients. We don't want to overexpose them and they come up with what we call a dual phase, single pass protocol. Now, what that means is when I was talking a bit earlier, I mentioned about with contrast, we talk about what phase we want it in um dual phase means it's in two phases. So what we have is a portal venous phase and an arterial phase. Now, the way we do that is we inject a load of contrast into the vein and then we wait the best part of a minute, a chance for that re uh that contrast to get around the body. Um and um make its way into the venous circulation. We then immediately before we do the scan, we start injecting um contrast into the vein. Um and we put a little marker essentially in the normally in the aorta. Um And we do what we call threshold triggering. So we basically tell the CT scanner right, as soon as the density in the aorta gets above X value, that's when I want you to start the scan. And what it means from that is we get an image a bit like what we have on the right here. Um So this is the front of the patient here, back of the patient here. And we can see actually the aorta is full of contrast. So we can really nicely assess for any sort of arterial or vascular injuries. Um But you've also got portal venous enhancement of the spleen and the liver, which allows you to see the other injuries. Um I'm not sure. Does anyone think they can see any injuries on the, um, on the scan we've got here and if you can just pop them in the chat. But, ok, so hopefully that means you're going to learn something during the course of the talk. Um, we can see here's the spleen here and there's this sort of this dark defect of hypo attenuation just here. Um That's a, that's a laceration in the spleen. So actually, we can see the rest of the spleen is lighting up because contrast getting to it, there's actually this laceration here that's probably got a bit of, of more old blood there that's not getting in. Um And there's a similar but much more extensive um going on in, in the liver here coming around the, the liver hilum or this low density here um is large liver laceration. Um which again, there isn't an uh an aortic injury here, but if there was hopefully, you can appreciate that we'll be able to look for, look for injuries there whilst looking the rest of the body. Um One of the benefits of doing it is the split bolus is actually um it's generally um uh oh sorry, I've just seen the, the scan. So, yeah. Yes. It's a liver, liver laceration and a splenic laceration. Um The rest of the liver doesn't look too bad. There's possibly a bit of hematoma, subcapsular, hematoma just there. Um But this is really what we're interested in. This is a, a quite a big extensive laceration. Um I'll be talking a bit more about uh liver and splenic lacerations a bit later on. Um So, yeah, so part of the benefit of this is um it's actually a lower dose of contrast doing it this way than doing a, a separate arterial scan and a venous scan. Um The biggest benefit though um comes down to what we call the single pass aspect of it. So that's the idea that actually we're doing it all in one go. So we're getting the contrast where we need to and then in one go, sending the patient through the scanner and acquiring one lot of images. And that essentially works out to about half the dose of doing a scan with it in the arterial system. And then a scan in the portal venous system just to give you a rough idea of numbers. Um the dose about 30 um if we're doing um this dual face single pass and that equates to a lifetime risk of about one in 700 of a fatal cancer. Um Now, that doesn't sound like a terribly high number. Um but to put things, you know, um in perspective down at Southampton, we're probably doing um most days between five and 10 of these full body trauma ct scans um every day. So that actually equates to a few people a year um who essentially die from cancer because we've done um a we've done a trauma scan on them. Um So, you know, it's not to scare, you often say, don't request the trauma scans, but it's something that you do always need to balance, you know, nothing comes free. Um And getting that information from a patient following trauma does come at the risk of um irradiating them. But as I say, the dual phase does the, the single pass rather does mean we're actually able to halve the uh the radiation exposure, the patients have. The other thing that's important with that is actually, it means the patients in the scanner for less time. Um If you've got a really unstable patient with, you know, Anestis round, they've intubated them, they're on no adrenaline, they want to get that patient up to either theaters or itu as soon as possible. And actually by getting it all done in one go, we're able to facilitate that a bit better. Um Fine. Um So on the table review, um now this is something that happens in quite a lot of radiology. Um Obviously, I'm going to be talking about the, the trauma aspect of this. Um And it's essentially a way of actually, if anything needs to change from the scan based on the live stream of the images coming through, we're able to do that as we go um when we're scanning the, the head and the C spine in the context of trauma. That's pretty much the one thing where we don't actually need contrast because we're looking mainly for fractures, um, and bleeds. Um which in the first instance, you don't actually need contrast to identify them. So what will happen is a patient will have um, a scan of their, their head and their c spine and then they'll get the, the on call radiologist to, to have a review And this is a big part of my day to day job. Um as a junior. Um, so in this instance, we've got a, a section of, of the head, the side of the head, um with the ear just sat in here. Um, the eye is going to be within the, within the orbit which is over here. And there's this black oval, long oval shape here and this is um the carotid canal where the carotid, the internal carotid artery sits. And actually, if we look, there's a defect just where the arrow is pointing through, um through the bone there, which suggests actually there's a fracture involving the carotid canal. And this is the sort of case where actually we might have said, uh, you know, we just want a, a non-contrast head and c spine. But because there's an injury that could be involving the internal carotid artery, this would be an instance where we'd actually say, you know what, let's do an angiogram of the head and the neck vessels to make sure we haven't got a traumatic um arterial injury, um that's going to kill the patient before, you know, the, the splenic injury that we're, we're focused on. So once we, we've done that, we looked through the head and the c spine, um we then go on to do what we call a to gram. Now, um I never really knew what these were when I was a, you know, working in A&E and things. Um and as a medical student, um essentially, if we say we want to do a scan from the top of the liver to the letter trochanter, um A to gram is how or a scanno gram. Um is how the radiographers know exactly where to do the scans. They essentially throw the patient through quickly. Um You get this sort of low, low quality image that gives you a bit of an overview. And then they say, right, we're scanning from top of the liver. So we'll tell the CT to start here to the letter trach and stop here and that's how they sort of gauge the range that we've prescribed. Um But this can be a really important source of information. Um It's always worth having a look through with the main thing that we're concerned about with. Um this in context of trauma is actually do we need to scan the lower limbs? Um If we're happy that there's no obvious injury to the lower limbs, we can just stop the scan um at the lesser tracers around here. But actually if we're concerned of a lower limb injury, um we might want to extend that on. So we actually get an angiogram of the lower limbs to look for um, any vascular injury associated with, you know, really we're talking about big femoral or um or tibial fractures is the main thing. Um, can anyone see any obvious injuries on this, um, on this scam or this Tom? And again, if you can please just pop it in the chart. So it's a bit. Oh, perfect. Yeah, we've got, we've got a a fracture of the left neck of femur. Again, you appreciate, this is nowhere near the quality you get of a pelvic x-ray. Um You know, if you, if you just send them for, for an x-ray for a query off, um But actually we can straightway see that there is an injury there. Um Right thigh, soft tissue density uh this bit here. Uh Possibly, I think this to me looks more like this is just actually a bit of a skin fold. Um We've got a bit of the um uh the ischium um uh coming down here and then this density here, I think is just a skin fold that we can see coming through there. Um Again, you would see it more clearly if it was just a, a plain x-ray. Um the top ground really, we're looking for these big bony fractures. Um So in this instance instance, we wouldn't actually need to extend anything because we're going to be scanning down to the le canter anyway. But if we saw the femur down here was sideways, we'd say actually let's extend down to the knee so we can assess that properly. Um So once we've done that and we've seen, seen whether or not we need to continue the imaging down as far as the feet or anything, we can proceed and do the main um sort of body of the trauma scan, I guess, um which is AAA standard is gonna be a chest, abdomen and pelvis. Um And then there's the final part of the review for which is all about looking for further imaging. Um And that's looking for bladder imaging. I mentioned a bit earlier about the idea of a delayed phase scan. This is what the delayed phase scan is used for. So, in this instance, we've got um a scan which is probably just a portal venous rather than a split bolus. Um But there's a bit of added density just anterior to the um the bladder. So we've got the bladder is going to be just here, there is a catheter in it with a bit of darkness around it, which is just a catheter balloon. Um But this, we should have nice clean fat like we can see around the back of the gluteus muscles. We should be seeing fat around here and there's something a bit hazy, a bit unclear what that is. Um Actually, by just waiting for 10 minutes for the kidneys to have a chance to filter out that um contrast, we can then see that actually, it's filling up this, this gray thing we saw here earlier, it's filling up with the contrast, um which tells us that actually we're looking at a bladder injury here. So that's the, the the final thing really to be looking at in terms of the immediate review. Um Do we need to do this delayed phase imaging? So then we um once, once we're happy, we've got all the imaging that we need, we start what we call a ho ot report. Now, um I'm sure you've been in situations where you're, you're waiting for a report to come through. I is there anything urgent that, you know, you need to be dealing with whilst you wait for the, the radiology report to be put on the system? And that's what the hot report is there for. It's a way of um us as, as juniors being able to convey the important serious injuries straight to the clinical team um so that they can start immediate management whilst they're waiting for the formal report. Um I'd really like it. It's quite an exciting bit of the day. You know, you're in a room um staring at a screen and you've often got the surgical consultant, the E A&E consultant one of the itu registrars all crowding round listening to every word you say and watching you go through a scan saying, right? There's this here that there, the key to this is being really systematic with it. And as a lot of things in medicine, we take an ABC D approach. Um and when we're doing it as sort of a bit of a prompt, we actually have a performer. This is a copy of the performer that we use um to make sure we are identifying any, any of the serious injuries. Um So the first one, you got obviously the patient's details and your details in, we just check that you've reviewed the scanner gram or the um uh the trauma gram. Um see, is there any need to extend it to look at the lower legs? Um like we mentioned with the nasty femoral fracture for instance, and then we go through the ABC de So is there an endotracheal tube in there? Um And is it in the right place obviously, if you look and yes, they've intubated the patient, but you can see the ET tube is down in one of the main bronchi rather than satting in the trachea, you want to let them know straight away. Um Along with that, is there any evidence of airway obstruction or impending airway obstruction? Um A lot of trauma patients have, have vomited following the trauma and have aspirated and actually can get a load of debris in the airways that you want to let them know about. Actually, they want to start suctioning the patient. Um, the other thing is with nasty fractures or bleeding, you can get swelling around the airways. Um, that means that, you know, you've got an airway at risk and sometimes they really appreciate you letting them know and they decide, actually let's intubate them now, whilst we can still get a tube down if they're not tubed yet. Um rather than waiting until their airway is actually obstructed and then they're really going to struggle. Um moving on to breathing looking for if there are any pneumothorax, contusions, lacerations, hemothorax, things like that. Um And if they've got a chest train and again, give me a comment just on, does it look like it's in the right place? You know, actually, are you talking that there's a massive tension pneumothorax at the apex? Um And there's a lovely looking chest drain, but it sat right down at the base, not doing anything circulation in the context of trauma. Really. It's just bleeding we're talking about. So just a simple, yes. No, really. Is there bleeding in the thorax, the abdomen, the pelvis or any soft tissue bleeding. Um And I'll go through a few examples of each of those. Um And then you have obviously got a bit of space to, to leave some more notes on each of them as you need to um disability. Really? We're talking um about the sort of the nervous system really. Um So is there a big intracranial bleed, um nasty skull fracture, any midline shift, which I'll talk about in a moment, um a major spinal injury. So a reason why the patient might be paralyzed and do the team need to uh the, the D team need to take any spinal precautions when they're moving and handling the patient. Um And then also just, is there a major abdominal or pelvic injury they need to be aware of, you know, have they got a nasty looking splenic laceration that actually they need to be careful that they don't open up and get the patient to exane. So now, um has, has, has anyone got any questions just about that before I move on? Um because I'm going to then start actually going through examples of um traumatic injuries. No, fine. I will start heading on through then. So, um this is just the way that I review a scan, it's a sort of a top to toe thing bearing in mind those of the ABC D headers that we mentioned and it really just reflects the fact that we get the head and the C spine before we get any of the rest of it. So the first thing we want to be looking for when we're reviewing the head is, is there blood anywhere we're not expecting it to be to be um lots of places it could be extradural, subdural, subarachnoid, parenchymal contusions, subgaleal or sinus bleeding. Um you know, you can spend a long time trying to figure out actually, is that a subdural or an extra dual? Um at the end of the day, it doesn't really matter. Um what matters is, what's it doing? Is it tiny or is it a massive volume? Um you know, a massive volume, extradural or subdural are treated essentially the same way if they're causing significant pressure effect because actually it's the pressure that's causing the problem. Um, rather than specifically what kind of bleeding it is, something you do sometimes need to consider is when the history is a little bit unclear. Um It's not uncommon that we get, uh, you know, patients who've had a query, um, bike crash, um, you know, 80 year old out cycling and is then found at the side of the road covered in blood. Um, we've had a couple of them in the last week even. Um, well, actually there's a bit of a query. Is, is this someone who's been knocked off their bike or is it someone that's actually had a collapse? Um And that's what's caused them to crash. Um So there can be a bit of a chicken and egg, especially if you see a large volume of bleed. Um You need to be thinking actually, could this patient actually be having a hemorrhagic stroke? And that's what's caused them to have their trauma rather than it being a subarachnoid hemorrhage um as a result of the trauma itself. Um And if you think it could be that they've, you know, they've ruptured an aneurysm, that would be another um indication to actually go back and get your angiogram, intracranial angiogram. As I mentioned, the main thing, if you do see blood is, you know, trying to quantify, is it a small amount of bleeding or a significant amount of bleeding With the kicker? About what significant really being? Is there any mass effect? So can we see um all the midline structure of the brain being shifted across? Um Excuse me, can we see any coning? So the brain stem being forced down into the forum of magnum, those are the sorts of things we need to be letting the team know about urgently um so that they can get on and address them. Um Next, once we're happy with blood and we want to go and look at fractures. So this is why we want to go into our bone window, look for any fractures. Um and then try and identify where they start and finish and this could be a really helpful way as well if you think actually you haven't seen any blood, but there's a nasty fracture there. Um You can then go back and pop back into your blood window and look actually right next to that fracture. And often you'll find there is a bit of bleeding that you've missed. Um, so there are, there are a couple of other little helpful tips to help you identify a fracture that you might not see or maybe minimally displaced or even not completely undisplaced. Um One of the big things is blood in the sinuses. Now, all the paranasal sinuses should be full of air. Um, and actually in the context of trauma, if you see that they're, they're not full of air, they're, they're dark, sorry, lighter than they should be ie denser than they should be. And you need to think actually, it's either the patient's got nasty sinusitis and it's full of mucus or it's full of blood. In which case, it's probably a fracture extending into um the sinus. Um The other thing, pneumocephalus, if you can see there's air within the skull itself, um Unless it's obviously within a sinus, it's probably come out of a sinus, which is another sign that there's probably a fracture going through the sinus. Other thing is um especially with skull base fractures is this patient safe for an NG tube. Um I'm sure people have heard horror stories of things like this where actually your patients had a nasty skull base fracture. Um as someone passed a a nasal gastric tube in to decompress the stomach. Um But in this case, it's gone through um what looks like probably a fracture within the, the sphenoid bone, um which has allowed the tube to go down into the spinal canal, um which is obviously something we want to avoid. Um Last thing is just having a quick review of the, the eyes, ears, nose and teeth. Um for instance, if a patient is suddenly missing a load of teeth that we, you know, it's not known that they were missing loads of teeth to start. You need to think where have those teeth gone? Is there a chance they've inhaled them? Um Obviously that's a bit more relevant in terms of um, trauma that we're just looking at the head because hopefully, if they have inhaled a load of their own teeth, we'll be seeing that um, when we scan the chest. Other thing that's um, uh worth having a look at is the, the middle ear. So these are the bones of the inner ear, the malleus and the incus. Um, they often talk about looking a bit like a, a blob of ice cream having to put an ice cream cone. Um, but one of the injuries that can happen is this, which is called an incudo mada dislocation where the ice cream has slipped off of the ice cream cone. Um This is something that's actually quite a commonly missed injury. Um The patient then presents to, you know, ent um a long time down the line given what waiting lists are like, um, saying that, that they've never been able to hear since they had a head injury and it, it can be um, something as simple as this that was just missed. So, again, most of these slides I'm gonna be showing you of the traumas are actually my own cases when I've been on call. Um I can't remember the, the clinical stem for a, for a lot of them. I think this chap actually just fell over. Um And this is a scan on a bone window at the very top of the skull and we can see there's a large fracture going right the way through the middle of their frontal bone, um going on on uh on the back. You can see that it gets a little bit more wavy and what's happened here, this is actually a suture. So this is the sagittal suture, we can see other sutures here. Um And this is what we call diastasis of a suture. So the fracture has essentially opened up a suture that had sort of closed and this is quite an extensive injury. Um And then if we go down, we can see there's this large um extraaxial collection of blood um sort of um uh probable subdural hematoma um that's forming on the right side of the skull here. Um The important thing though about whether this is, as I say, whether it's extradural or subdural doesn't really matter what matters. Um Is if we look at the midline of the brain, which would be coming through, actually, I can draw it on with this. Can't I? Oh very softly, the midline of the brain is sort of going front to back through there. And we can actually see that the ventricles are being shifted across the left. So there is a significant pressure effect. Um So this is one that we need to get the neurosurgeon to involved very quickly. Um In this case, um the patient was actually in theater having that hematoma evacuated within 20 minutes of the the helicopter touching down at the hospital, which is is quite nice when things work out like that. Um This is another case, this was I think from an RT C. Um So road traffic collision um and straight away, if you look, we can see there's this big step in the frontal bone here. Um which if we follow it down over progressive um slices, we can then see this is our frontal sinus, half of it is full of air on the right. Um There's actually barely any air in the left at all, but these are both filled with something which is almost certainly going to be blood in the context of trauma. And we can see that little chip of fracture coming through there. Um As we continue down, we can see actually going through the the anterior ethmoid cells, there's a nasty fracture that's gone through there and blood filling all of these air cells um and blood as well in back here, which is your your um sphenoid sinus at the sort of back of the skull base. And hopefully, if you look carefully, you can, sorry, I just realize I'm pointing on the wrong slide. Um Sorry, the wrong screen. Um So, so what was it? So, yeah, anterior Ethmoid air cells here, full of blood um with our step there and you can hopefully see there's a very subtle lucent line passing through here. Um And that tells us that actually, this is a fracture line that extends from here all the way through the skull base um and comes out at the back here. Um If we go to the next slice down, um this is the, the Foramen magnum, which is where your spinal cord sits. And we can see that actually, that fracture line has gone all the way through into the foreman magnum um with a little bleb of gas just here, which would be something that would alert you to the fracture being there if you weren't already aware of it. Um You might have seen images like this before. Um This is a, a surface rendered reconstruction. Um This is something that could be really helpful for, for two reasons. One, with massive facial trauma where, you know, you're not really sure where to start, you can just see fractures going everywhere. You can, you can produce these, these take a couple of seconds to create. Um And straight away, you get a nice overview of actually the extent of the injuries. Um and it's also really helpful for the, the clinical teams. Um One of the really important aspects of, of radiology is anatomy and knowing your anatomy as you can describe injuries really clearly. Um But that's actually not that helpful if the people you're describing them to don't understand what you're talking about and sometimes actually just bringing this up and saying, you know, look that that will tell you more information than me writing a paragraph about it. So in this case here, we can see this is a big depressed frontal bone fracture and you can see it comes down and involves the nasal, the nasal bones into the orbit and into a bit of the ethmoid just on the right hand side there. So moving on to the spine, which is the other part of our the the first aspect, the non-contrast aspect of our scan. Um we often talk about the spinal columns, Dennis, spinal columns. Um and it's essentially a way of of separating the spine into different bits. So we have um the anterior spine here, posterior spine here and the spinal cord uh running through the spinal canal here. Um Essentially the reason for this is this all comes down to stability. Now, the conventional thinking is that um if you've only got one column involved, so you've got a fracture just here, it's probably stable where a a stable fracture is, the the spinal cord is not at risk. Whereas actually, if you've got two co uh columns involved. So, fractures has gone right through here and here there's potential for the, the core to be at risk. So it's an what we do mean unstable fracture. Um And that's about as I say, two columns being involved rather than one. Um However, there are some exceptions to that um or well, limitations I should say to that in terms of what you can and can't see um on a CT on a CT scan or an x-ray. Um this is a very particular type of fracture. Does anyone know what that's called? Um a fracture looks like that in the context of trauma that they can pop in the chart. So this is something that we call a teardrop fracture. And it looks like actually it's a tiny fra fragment of bone just come off of the anterior inferior corner of um C three. It looks like it's not actually a serious injury, but um this is what classically happens with a teardrop fracture. So it's often a hyper extension or hyperflexion injury of the cast, almost like a severe whiplash type in injury um of the c spine. And what you get is, although the bony fragment that you see is only small, what often happens is this, which is your interspinous ligament, which is the strong ligament that holds um the spine together at the back that holds the spinous processes together and the posterior sorry, the supra spinous ligament, which is this big thick one down here, they can both rip, which means that actually, although um you can't see it, there is instability of the posterior column which makes it a really worrying injury with the potential for spinal cord problem. Um And that's something that really needs assessment properly with an MRI the lungs. Um So on the, the top slide, so these, this is actually again, exactly the same slide one in a lung window. So um all the soft tissues are, are really bright and we can't really see them, but we can see the lung parenchymal detail a bit more clearly. Um And then this is a bone window. So we can see the bones more clearly and we can see there's a lot of air within the soft tissues here. So this is something we call surgical emphysema. Um and actually underlying, hopefully, just here you can appreciate, this is just completely black, there's no lung markings here. Um So we've got a small pneumothorax on the left with surgical emphysema on the left. And then if we look at the bone window straight away, you can see there's a displaced fracture of this rib here, um which is almost certainly going to be the cause of these two. in terms of when we see surgical emphysema anywhere, um it's essentially going to have come from two places. Um either there's penetrating trauma, so it's come from the outside in or it's come from a hollow viscous. So, um, or an air, um, air for viscous like the lungs and it's actually air that's escaped out into the soft tissues that way. Um, other injuries that can happen with the lungs is contusion. So this is essentially bruising of the lungs. So, this is all micro hemorrhage that's gone on filling the, um, the air spaces, the alveolar sacs up with, um, blood, um, which is why it looks darker than our sort of relatively normal right lung here. And we can see there are these um there's like locus of gas that are within the lung. Um These are things that we call pneuma seals, which are literally just pockets of air. Um And that indicates there's actually been a laceration um of the lung more common with penetrating trauma, but you can get a, a blunt force trauma causing a laceration. Um And these pneuma seals like that. Um Other things in the chest, not just the lungs. So, obviously the heart, um in this case, we got our left ventricle here, right ventricle here with our nice myocardium around the side and the dark line around the outside, a little bit of epicardial fat, sorry, pericardial fat. Um But then there's some added density around here, which is within the, within the pericardium itself. Um And this is going to be in the context of trauma, most likely hematoma. So, this is a patient, we need to be really worried about developing what we call cardiac tamponade. Um, the most common reason for seeing blood like this is, um, where there's been an aortic injury that's actually affect the aortic root, which is why the blood's got into the pericardium. The other thing is you can get um, actual injury to the, the, the heart wall itself. So in this case, we have, er, here, bit of right, er, right ventricle and there's a defect in the wall here and we can see, um, where there's that, um, probable blood, um, that's accumulated in the pericardium. Um, there's this new sort of contrast, filled blood through the time of the scan which has leaked its way out into the pericardium and tells us that there's active bleeding going on and a defect in the wall that it's going through. Um, other major parts of the chest really is the aorta. Um, I'm sure you, you've heard about the tennis ball sign, which is where you get this sort of appearance, um, of the aorta where it's dissected, um, can be spontaneous but it can be in the context of trauma. So that's something to look out for. And you have, um, this, the, the lower smaller bit is going to be what we call the true lumen where blood is actually flowing and then the bit superior to that is your false lumen and that's just filling with blood that's slowly, um, compressing and getting the, the true lumen, smaller and smaller. Um You can get aortic transection, which is essentially where the tube just tears. Um And there's all this added density around the arch of the aorta on both sides. And that's all just blood that's pooling um around the aorta because it's literally just torn through. Um The, these are often fatal um these injuries and the final thing is traumatic aneurysm. So, in this case, we can see where there's a, a bulge in the descending thoracic aorta here, um which is because there's been um a a defect to the the muscular layer and the intima um following trauma that's allowed it to all bulge out like this. Um Now, this slide is um just display the most common sort of a site sorry of aortic injuries, um which is just here, which is called the aortic isthmus. Um It's where the ligamentum arteriosus inserts, which is the, the remnant of your ductus arteriosus from your fetal circulation. Um Now, if you think of the aorta as a sort of floppy tube, um floppy curve tube is held together um held in place at three points. Um One is the aortic root, the aortic root at the, the, the heart, um which is quite a, a big sturdy attachment. Then the other end, you've got the diaphragm which again, is holding it, holding it nicely secure in place there. The only thing that's stopping it, flopping about about those two points is your ligamentum arteriosus. Um which means that if there's a sudden acceleration, deceleration injury, like what we see in a car crash. Um Actually, this ligamentum arterio pulls at the aorta and can tear it, which is why that's the most common site of aortic injury. Um moving on to the solid organs of the abdomen. Um Here we got a large liver laceration. We can see the hypodensity within the liver contrast is nicely getting into all the rest of it. But there's this big bit that's getting no contrast and it's probably filling with blood. Um If we look around the outside of the liver, there's a bit more hematoma forming around there as well and which suggest that this is bleeding into a subcapsular hematoma. Um There is the A ast which is the um uh that one of the trauma um societies of America that have created this grading system that can be used um to classify the extent of the trauma that just makes it easier to communicate to other people how serious it is and help guide the surgeons on management. Um Similar sort of injury in this case, this is the spleen. So the spleen probably normally would have sat about here in terms of size, but we can see there's all this added um nonenhancing, so darker density all around it, which suggests this is a massive splenic injury um and a large um subcapsular hematoma that's developed around the site of the spleen. Um, in this case, we've got a pretty normal looking liver. Um, this is actually a case from this more. No, um, this afternoon, um, that I just threw in at the last minute because it just shows really nicely, um, what a normal spleen looks like. But then with this defect, um, which is another splenic laceration, um, that we can see there, um, along with solid organ injuries, there's hollow organ injuries. Um So really the bowel should be full of gas, the stomach should be full of gas, but we shouldn't see, um, free air or pneumo peritoneum. But we can see here there's lo of air that's floated to the top of the abdomen. Um And that suggests that one of the hollow viscus of the abdomen has become ruptured, um, hard to see on a single slice, but I imagine it's this loop of bowel here that's, um, ruptured following trauma and, and opened up and is spilling air into the abdomen. The other thing is that you can have injury to the bowel that hasn't caused rupture. Um If I get, you just have a quick look over here, this is a bit of descending colon and that's quite normal. You can see it's thin walled, it's full of air. In contrast to these loops of small bowel here, you can see how they've got really fat walls. Um, and that's a sign that of traumatic injury. Um, so they've been probably squashed in some kind of trauma, swollen up and they're probably going to um, become ischemic and then rupture. Um, so that's a sign of an impending perforation. Really. Then we've got another sign here where rather than it being sort of generalized air at the top of the abdomen, there's a bit of air here which we see around the duodenum, which is labeled D, um, that suggests there's going to be a duodenal perforation here. Um, with a load of free fluid which could be blood could be stomach contents, um, just working its way around the abdomen here on the left and the right. Um, then moving on to the, the bladder. Um, we've got, uh, here, we got a nice sagittal section. Um, and we can see here there's a, the blad, the actual bladder itself is here. Um, this is a catheter balloon that's in there that's going to be full of full of water. Um, which will, it looks similar to soft tissues. Then we can see there's contrast that's leaking out. So we can tell that there's a bladder injury there. Um, we can see a little bit of air that's just sat or a bit of gas that's just sat at the anterior superior aspect of the bladder that's almost certainly come, been introduced during the catheterization. And actually, I suspect some of that air is leaked out and that's why we can see little bits of air, um, dotted around here. And air within this leaked contrast here. Um This is just another example of a bladder injury. So this patient's um, got a pubic ramus fracture that's actually gone through into the bladder. And again, we can see that contrast leaking out on a delayed phase. Um I think I'm nearly done with the slides now. So just bear with me for a couple more. Um This is um a pelvis, an actual view of a pelvis. And actually, we've got what we call the sacroiliac joints here and here. And we can see that on the left, it's massively widened. Um This is something that we call an open book pelvis because it looks like an open book, it's been opened up and we expect there are going to be some other injuries as well. But we can see, um, there's a definite dislocation of the left sacroiliac and probably, um a sort of slightly less pronounced, but, um, obviously it's a little bit wider on the right at the anterior aspect than it is at the posterior. One of the important things to consider with the pelvis and anywhere else that you've got a bony ring is what someone referred to as the Polo Mint principle. Now, if you took a Polo Mint, you'd find it's really difficult to snap it in one place, you're almost always going to get two breaks. Um So if you do see a fracture somewhere, uh like we have here, which a nasty fracture of the left iliac crest, iliac wing. Um There's also an additional fracture of that ring where broken in two places going sort of obliquely through the sacrum. Um This is another one of my scans from today that I just did some quick reformats of. Um and in this case, we've got what we call the obturator foramen um on the left and the right and we can actually see again that Polo Mint principle where we fractured through the inferior and the superior um on both sides, I appreciate the one up here is a little bit more subtle. Um but it is there. Um these are again, two individual polo rings that are both broken in two places. Um then just a bit more pelvic bleeding. As I say, you, you might see this and wonder where that blood's coming from. And actually, this is one of the instances where hopefully a portal venous phase is going to help you out because you can or an arterial phase depending if it's venous or arterial bleeding. Um But you look for some of the vessels and see if you can see contrast leaking out in there that's going to tell you the point of bleeding. Um Something that's important, not to forget is some soft tissue bleeding um uh as a as a site of collection of blood. Um So this is the anterior abdominal wall and we can see on the right, the patient's right hand side is nice and thin, the muscles of the anterior abdominal wall, there's this huge swelling um on the left. This is the same patient with it seen in, in Sagittal. In this instance. What we can actually see because this was done in an arterial phase is we can see contrast, um what we call contrast blush. So we can see contrast coming out of um the inferior epigastric artery just there. So we know exactly where that hematomas come from. Um I measured this one, it was about a liters worth of blood that was sat in this person's anterior abdominal wall. Um And in this case, the trauma was actually a low molecular weight heparin injection. Um Unfortunately, they had injected uh an anticoagulant straight into an artery, um which is why all this bleeding occurred. Um Finally, there's the extremities. Now, I'm not going to lab the point of this too much. Um Really you look at a bone, is it broken, try following the cortex down and see if it's a step in the cortex. Um This is another reconstruction that's done um after an angiogram. So we can see we've really nicely highlighted um the major arteries going down the leg, uh the superficial and the deep femoral arteries. Um And we can see that actually, even though it's a hideous fracture, it's actually stayed clear of um of the arteries and there's a pacification of the artery going dis