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Imaging intheStable Trauma Patient
BradleyS.Moat andNeilG.Parry
46
Abbreviations
ABC Airway, breathing, circulation
AP Anteroposterior
ATLS Advanced trauma life support
c-spine Cervical spine
E-FAST Extended focused assessment by sonography in
trauma
EMS Emergency medical services
FAST Focused assessment by sonography in trauma
Introduction
The hemodynamically stable trauma patient affords the
trauma team valuable time to consider a variety of treatment
adjuncts. Such patients are excellent candidates for a wide
arsenal of imaging modalities; however, thoughtful planning
of the types and sequence of imaging tests can minimize the
time spent in uncontrolled environments and facilitate transition to denitive care.
When considering appropriate imaging studies for any
trauma patient, the most important question to ask is: “Is this
patient hemodynamically stable?” Any patient showing signs
of signicant tachycardia, hypotension, or any other Airway,
Breathing, Circulation (ABC) concern should not leave the
trauma bay for imaging purposes and should never be sent to
the CT scanner. Being in the CT suite or in transit can be
very challenging if the patient deteriorates or needs ongoing
aggressive resuscitation.
B. S. Moffat
Department of Surgery, Schulich School of Medicine
and Dentistry, Western University, London, ON, Canada
N. G. Parry (*)
Departments of Surgery and Medicine, Schulich School
of Medicine and Dentistry, Western University,
London, ON, Canada
e-mail: neil.parry@lhsc.on.ca
In this chapter, we will review the imaging modalities
available for stable trauma patients. Further, we will discuss
strategies for a smooth and efcient transition from the
trauma bay to the imaging suite and nally to denitive care.
Imaging Modalities
Plain X-ray
Plain lm X-rays confer a major advantage over many other
modalities in that they are portable, can easily be performed
in the trauma bay, and are relatively inexpensive and widely
available compared to other imaging modalities. Many
trauma bays are equipped with ceiling-mounted X-ray systems which eliminate the need for bulky portable equipment.
Plain lm X-rays are an important adjunct to the Advanced
Trauma Life Support (ATLS) primary survey and include an
anteroposterior (AP) chest, AP pelvis, and occasionally lateral cervical spine (c-spine) [1].
The chest X-ray is a critical imaging study for all trauma
patients. Certain key ndings mandate treatment prior to
leaving the trauma bay. Patients with a clinically signicant
hemo- or pneumothorax should have a chest tube inserted
prior to leaving the trauma bay as these injuries can worsen
rapidly (Fig.46.1). With intubated patients, the chest lm is
also helpful to conrm adequate endotracheal tube position
prior to transport; however, it is important to remember that
a chest X-ray cannot differentiate between esophageal or tracheal intubation. Ultrasound can also play a key role in diagnosing and ruling out hemo- or pneumothorax. Additionally,
ultrasound can reliably detect esophageal intubation and
main stem intubation at the bedside, in real time.
The pelvic lm must be performed if there is clinical concern for a pelvic fracture, if there is any suggestion of hemodynamic instability, or if the patient is not going for CT
imaging (Fig. 46.2). With a clinically stable pelvis, it is
sometimes omitted if the patient is hemodynamically stable
and going for CT. With the clinically unstable pelvis, a
© Springer Nature Switzerland AG 2025
L. Marshall Gillman, S. Widder (eds.), Trauma Team Dynamics, https://doi.org/10.1007/978-3-031-86312-7_46
399
400
Fig. 46.1 AP chest X-ray— yellow arrow indicating left pneumothorax
Fig. 46.2 AP pelvis X-ray—open book pelvic fracture
binder should be applied and a pelvic lm should be obtained
prior to leaving the trauma bay.
The lateral c-spine plain lm has been largely replaced by
CT [2]. Even in centers where CT is not available, lateral
c-spine lms alone are often insufcient to clear c-spine precautions and may miss up to 55% of injuries [3]. However, in
select alert patients, c-spine precautions may be cleared clinically using a tool such as the Canadian C-Spine Rules [4]
(Fig.46.3). Most patients with a signicant mechanism of
injury will go on to have a CT c-spine and hence the plain
lm is not necessary. The cervical collar must therefore
remain on until the c-spine has been cleared.
Extremity lms may be considered as adjuncts to the
ATLS secondary survey as they can often guide the urgency
of orthopedic intervention(s) [1]. With limb-threatening
B. S. Moat and N. G. Parry
orthopedic injuries, pre- and post-reduction lms may be
necessary prior to leaving the trauma bay. Extremity lms
may also be helpful in guiding the astute trauma practitioner
to add extremity CT scans for injuries in which the orthopedics or vascular teams may require them (such as injuries
involving major joints or diminished pulse distal to the fracture). This can help eliminate the need for additional trips to
the radiology suite after the patient reaches denitive care;
however, timely transit to CT should not be delayed in favor
of getting extremity lms.
Focused Assessment withSonography
inTrauma (FAST)
As outlined in the preceding chapters, the FAST exam has
become a critical adjunct to the ATLS primary survey [1,
5–7]. While the primary function of the FAST exam is to
exclude hemoperitoneum and hemopericardium in the unstable patient, it remains a mandatory adjunct in the stable
patient as well. Stable patients with a positive abdominal
FAST should still proceed to CT scan. However, if a patient
with a positive FAST becomes unstable after leaving the
trauma bay, they can be quickly rerouted to the operating
room for denitive management (Fig.46.4). On the other
hand, stable patients with a positive pericardial FAST should
most likely proceed directly to the operating room.
Many trauma providers are facile with the extended FAST
(E-FAST) exam. In addition to the four abdominal views, the
E-FAST includes bilateral assessment for pneumothorax and
hemothorax. Like the standard FAST, the primary utility of
the E-FAST is to guide chest intervention in the unstable
trauma patient. The E-FAST views can still be a helpful tool
in the stable trauma patient where the clinical exam is equivocal, and the chest X-ray is either delayed or equivocal. An
important consideration to the use of E-FAST in the stable
patient is its high specicity; that is, the E-FAST may detect
small volumes of air or uid which are not apparent on chest
X-ray [8]. Such occult injuries in stable patients are often
managed conservatively, and hence chest tube placement
may not be required.
Computed Tomography (CT) Scan
CT is the mainstay imaging modality for the stable trauma
patient and careful consideration should be given to each
body area which may require CT imaging. Once the primary
and secondary surveys are complete, the patient may be prepared to travel to the CT suite. Mechanism of injury and
physical exam ndings generally dictate which areas should
be further imaged with CT.However, certain injuries warrant
special mention.
Adapted from Sell IG et al. The Canadian C-Spine rule of radiography in alert and stable trauma paents. JAMA. 2001;286:1841-1848.
46 Imaging intheStable Trauma Patient
401
Fig. 46.3 Canadian C-spine
rule
Any high risk factors?
Any of the following:
• Age > 65 years
• Dangerous Mechanism*
• Numbness or ngling in extremies
NO
Any Low risk factors?
Any of the following which allows safe
assessment of range of moon:
• Simple rear-end MVC**
• Ambulatory at scene
• No neck pain at scene or in ED
YES
Able to rotate neck
• acvely 45oto right and le
Liver
Kidney
Diaphragm
Fig. 46.4 Positive Focused Assessment with Sonography in Trauma
(FAST)—uid in the right upper quadrant
Much like with c-spine, the Canadian CT Head Rule helps
determine who requires a CT head with a clinically minor head
injury and mechanism [9] (Fig.46.5). All patients with moderate to severe brain injury (GCS <13) require CT imaging.
CT angiogram (CTA) of the chest has become the gold
standard to diagnose blunt thoracic aortic injury. This injury
can be highly lethal and should be suspected with any patient
involved in a sudden acceleration-deceleration type injury
(e.g., head-on collision or fall from signicant height).
CT angiogram of the neck is being used more frequently
to screen for blunt cerebrovascular injury (BCVI).
Historically, it was felt that BCVI occurred in less than 1%
of all major traumas; however, recent evidence suggests that
it occurs in up to 5% of all major traumas and that delayed or
missed diagnosis increases mortality [10–12]. Many authors
now recommend screening for BCVI in major blunt polytrauma patients [13–15].
*Dangerous mechanism:
• Fall from > 3 feet/5 stairs
• Axial load to head
• High speed MVC 9> 100km/h,) rollover, ejecon
• Motorized recreaonal vehicle
YES
• Bicycle collision with object
C-Spine
NO
NO
YES
immobilizaon and
imaging required
**Simple rear-end MVC excludes:
• Pushed into oncoming traffic
• Hit by bus/large truck
• Rollover
• High speed MVC (>100km/h)
No Imaging required
Trauma CT scans of the thorax, abdomen, and pelvis
require intravenous contrast but not oral contrast (Fig.46.6).
Good arterial phase images are essential to identify major vascular injuries (e.g., blunt aortic injury) and solid organ injuries
(parenchymal as well as contrast extravasation and/or pseudoaneurysm). Delayed lms for venous phase or to evaluate
urinary tract injuries may also be very helpful. Most stable
trauma patients with abdominal pain and/or a positive FAST
should undergo CT imaging of abdomen and pelvis. Phases of
scanning will be discussed further in the following chapter.
Many trauma patients undergo a “pan-scan” or “traumascan” which includes CT head, c-spine, chest, abdomen, and
pelvis. Early data suggested that there was a distinct survival
benet to patients who undergo pan-scan; however, the largest randomized control trial failed to detect any difference in
mortality [16–18]. CT pan-scans can detect additional injuries, up to 40%, of which 20% are clinically signicant when
compared to selective imaging [19–21]. This method also
allows one to radiographically examine the entire spine.
Prior to ordering a pan-scan, one must consider the longterm effects of undue radiation exposure versus the risk of
missing a signicant injury. Although this topic remains
somewhat controversial, CT pan-scans are frequently used
and should be considered for blunt polytrauma patients with
signicant mechanism of injury and/or decreased level of
consciousness.
Stable patients without obvious need for surgery (e.g.,
peritonitis, evisceration) sustaining penetrating trauma are
also candidates for more selective imaging. Consideration
must be given to the possible path of the missile, and all body
cavities at risk should be included if CT imaging is sought
[22]. Hemodynamically stable penetrating wounds to the
neck without hard signs for surgical exploration (e.g.,
402
Adapted from SellIG et al. The Canadian CT Head Rule for paents with minor head injury. Lancet. 2001;357:1391-1396.
B. S. Moat and N. G. Parry
Fig. 46.5 Canadian CT-head
rule
CT Head is required for paents with suspected minor head injuries (witnessed
loss of consciousness, definive amnesia or witnessed disorientaon with GCS 13-
15) and with ANY one of the following:
High Risk (for neurologic intervenon):
• GCS <15 2 h aer injury
• Suspected open or depressed skull fracture
• Signs of basal skull fracture
(hempotympanum, “raccoon eyes”, Bale
sign, CSF otorrhea/rinorrhea
• Voming > 2 episodes
• Age > 65
Medium risk (for brain injury on CT)
• Amnesia > 30 mins before impact
• Dangerous mechanism (
pedestrian struck by vehicle,
ejected from vehicle, Fall > 3 feet
or five stairs)
pan-scan is about 31 millisieverts (a standard CT head is
about 1.7 millisieverts) [27]. The use of CT in the pediatric
population warrants extra caution as it has been associated
with increased cancer risk, especially in young children [28].
While the CT pan-scan provides invaluable information,
consideration should always be given to cumulative radiation
exposure, especially in the younger patient. Imaging in the
pregnant patient also requires specic considerations which
are discussed in detail in Chap. 41.
Fig. 46.6 CT abdomen— demonstrates hemoperitoneum (blood
around the liver and spleen) due to a major splenic injury
impending loss of airway, active bleeding, expanding hematoma, hemoptysis, subcutaneous emphysema) are triaged
based on clinical exam and contrast-enhanced CT [23].
There are several approaches to the stable patient with
penetrating thoracoabdominal trauma; some of which are dictated by the mechanism of the injury (e.g., stab versus gunshot). Any injury to the thoracoabdominal junction needs to
be evaluated for diaphragmatic injury. While CT technology
is improving the radiographic detection rate, laparoscopic or
thoracoscopic evaluation of the diaphragm is usually warranted [24, 25]. Stab wounds to the anterior abdomen do not
require CT scans and can generally be managed by serial
physical examination [26]. Penetrating injuries to the ank
should undergo triple contrast CT scan (IV, oral, and rectal
contrast) as serial exams may miss retroperitoneal injury [22].
CT imaging may be warranted in blunt or penetrating extremity trauma based on clinical exam, and contrast studies are
often helpful to exclude major peripheral vascular injury.
The trauma practitioner is tasked with weighing the benets of CT imaging against the potential risks of radiation
exposure. The average radiation exposure for a single trauma
Other Modalities
Magnetic resonance imaging (MRI) is used in trauma but more
often after the patient has already been admitted to hospital.
Acutely, however, it may be used in the assessment and evaluation of spinal cord injuries. MRI is also helpful to aid with
diagnosis and prognostication of traumatic brain injuries.
Critical Thinking
There are a variety of important considerations when planning a trip to the imaging suite with a stable trauma patient
(Fig.46.7). Careful planning and clear communication are
key to ensuring a smooth process.
A chest X-ray and a FAST exam should be performed on
all trauma patients before they leave the trauma bay. Calling
for the X-ray technician early will avoid delays waiting for
plain lms to be obtained. Likewise, having an ultrasound
machine and a certied FAST user close at hand is a must.
If an inter-facility transfer is anticipated, advanced imaging (such as CT) should be kept to a minimum. The appropriate land or air emergency medical services (EMS) personnel
should be contacted as soon as a transport decision is made
such that delays in waiting for their arrival are minimal. Bear
in mind that CT scans performed at your hospital may not be
transferable to the receiving facility, may not use the same
protocols, and, as such, often end up being repeated when the
46 Imaging intheStable Trauma Patient
403
Fig. 46.7 Algorithm for
imaging the stable trauma
patient
Primary survey
Hemodynamically
YES
Consider CT
Secondary survey
Review imaging
Dedicated x-rays
ABC’s
stable?
imaging
NO
Proceed to CTProceed to CT
Treat life threatening injuriesTreat life threatening injuries
Call for CXR and pelvic XRCall for CXR and pelvic XR
FAST examFAST exam
Treat life threatening injuries
Repeat FAST
Call CT suite
Call Radiologist
Add dedicated x-rays &/or CT’s
Call definive care unitCall definive care unit
Treat crical injuriesTreat crical injuries
Call definive care unit
patient arrives [29]. Hence, scanning prior to transfer may
expose the patient to additional radiation and/or delays in
transfer. Only consider scans which may alter your management prior to, or during transfer.
Upon completion of the primary survey in a stable patient,
the trauma practitioner should start considering which CT
scans may be required. As soon as this decision is made, the
trauma team leader should immediately be in communication with the CT suite to notify them and nd out when they
can accept the patient.
Once CT has been notied, the FAST exam and the plain
lm X-rays should be in progress or already be available.
These studies should be carefully examined for any injuries
which may need to be treated prior to leaving the trauma bay
(such as a pneumothorax). The secondary survey should also
be completed at this point.
It is important to anticipate additional CT scans that may
be needed based on specic injury patterns. For example, if
there is signicant facial trauma on clinical exam, adding a
dedicated CT face to the initial trauma scans will save an
additional trip to the scanner later. Another common example is fractures involving major joints which often require
CT imaging prior to operative intervention. Clear and early
communication with consulting services can also help plan
such adjunctive imaging.
Transfer directly to
definive care unit
Before leaving for the scanner, it is important to ensure
you have the appropriate transfer equipment. Be sure to
bring standard resuscitation equipment as well as any analgesic and sedating medications you may need. At a minimum, a physician (ideally the trauma team leader) and a
nurse should accompany the patient at all times until they
reach denitive care. If the patient is intubated, a respiratory
therapist should also stay with the patient at all times.
Another important consideration before leaving the
trauma bay for the CT suite is where the patient will go
after their scans. If the patient is being admitted, the trauma
team leader should decide what level of care is required as
soon as possible. It is critical to give the oor, observation
unit, or intensive care unit as much notice as possible to
ensure a bed is available and staffed. Frequent communication with those in charge of these beds is important. The
goal should be to transfer the patient from the trauma bay
to the scanner and then directly to denitive care. This
avoids unnecessary time spent in transit and in the ER and
further minimizes the time spent in uncontrolled environments. After the bed request is made, it is helpful to touch
base when leaving the trauma bay to the CT suite, and again
when leaving the CT suite to ensure the bed is prepared and
the denitive care team is ready to transfer care as soon as
the patient arrives.
404
Key Points
• Always ask: “Is this patient stable?” If not, do not
transfer them to the CT scanner.
• Ensure all trauma patients have a chest X-ray and
FAST exam done prior to leaving for the scanner
and act on any injuries which could progress.
• CT scan with a low threshold for pan-scan is the
modality of choice for most stable, blunt trauma
patients.
• Carefully consider which scans are needed urgently
and anticipate additional scans which may be
required by consulting services.
• Communicate early and clearly with the CT suite
and the denitive care unit to ensure a smooth transit for the patient.
When caring for the stable trauma patient, astute planning
and a smooth transfer from the trauma bay, through the
imaging department and nally to denitive care will
improve patient care and maximize efciency.
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Advanced Considerations
inCross- Sectional Imaging inTrauma
SignyHolmes
47
Introduction
CT and MRI have progressed dramatically since the early
days of cross-sectional imaging and continue to advance.
While the radiologist should ideally serve as the ultimate
resource for determining the next best step in imaging for
a given trauma patient, several advances permit more
general approaches for common questions in trauma
imaging.
Once the decision has been made to proceed to crosssectional imaging, there are various considerations to
optimize CT protocol selection for any particular
patient. There are also a number of options for problemsolving around questions remaining after initial imaging, which integrate additional techniques and
modalities. This chapter is intended to review several of
these techniques and the contexts in which they may
prove most helpful in guiding decision- making during
trauma resuscitation.
Initial Trauma CT Protocol
Many of the considerations in initial imaging of the hemodynamically stable trauma patient have already been
reviewed (see Chap. 46). With increased capabilities of
modern CT scanners, however, the question of which
body parts to image is now supplemented by the ancillary
question of how best to image those regions. The overall
guiding principles in both questions must include gathering enough information to guide appropriate management, mitigating unnecessary exposure to ionizing
radiation, and minimizing harm related to iodinated contrast administration.
S. Holmes (*)
Department of Radiology, University of Manitoba,
Winnipeg, MB, Canada
e-mail: sholmes@hsc.mb.ca
Iodinated Contrast Administration
Iodinated contrast can be critical for detection and characterization of injury as well as road mapping for potential transcatheter therapy by Interventional Radiology. The principal
risks of iodinated contrast material administration fall either
under nephrotoxicity or under allergic and allergic-like reactions. Recently updated guidelines have deemphasized the
nephrotoxic risks of iodinated contrast in underlying renal
dysfunction [1]. Contrast-induced nephropathy is not uncommon in trauma patients with incidence in some cohorts
reported as high as 14.7% but has not been demonstrated to
contribute signicantly to morbidity or mortality when controlling for confounding factors [2, 3]. Therefore, while the
decision to proceed with contrast-enhanced imaging in
patients with known or suspected renal disease should be
based on the level of concern for signicant injury and on
discussion with the radiology department, intravenous contrast is almost always warranted when clinical concern for
signicant injury is high. Similar principles should guide the
decision whether to delay imaging for results of serum measurement of renal function [4]. Of note, the total volume of
iodinated contrast material administered is directly associated with risk of contrast-induced nephropathy [5]. Repeated
contrast administration should therefore be avoided where
possible and optimal imaging strategies used the rst time.
Up to 1in 2500 patients may develop a severe and potentially life-threatening reaction to injection of iodinated contrast [6, 7]. The strongest predictor of these reactions is
history of previous reactions, with re-exposure rates of reaction reported at 31.1% in the absence of premedication [8].
Hemodynamically stable trauma patients with known history
of allergic-type reaction to iodinated contrast and low to
intermediate suspicion for signicant injury may undergo
premedication prior to imaging. While this will potentially
delay initial cross-sectional imaging, emergency premedication protocols can be administered where risks of incomplete
CT imaging outweigh the risks of breakthrough reaction [9].
The protocol we use at our institution includes methylpred-
© Springer Nature Switzerland AG 2025
L. Marshall Gillman, S. Widder (eds.), Trauma Team Dynamics, https://doi.org/10.1007/978-3-031-86312-7_47
407
408
S. Holmes
nisolone 40mg IV or hydrocortisone 200mg IV 4h before
the scan followed by diphenhydramine 50mg IV 1h before.
Premedication is not required in patients with a history of
mild reaction [8].
Planning anInitial CT Protocol
As previously noted in Chapter 46, most widely utilized
trauma protocols include noncontrast imaging of the brain
and cervical spine as well as contrast-enhanced imaging of
the chest, abdomen, and pelvis. Selective imaging may be
appropriate in penetrating injury and in some cases of blunt
trauma in younger patients more vulnerable to lifetime risk
of radiation-induced cancers but has been found to result in
only minimal decreases in radiation exposure (20.6 vs.
20.9 mSv) and may result in delayed imaging as well as
missed injuries [10, 11].
Imaging of the chest and abdomen should be timed for
peak arterial enhancement in order to optimize vascular
assessment. In the chest, there is very little downside to
obtaining only arterial phase images. In the abdomen and
pelvis, multiple phases may be required for adequate detection and characterization of injury. For example, identication and accurate classication of splenic injury is of great
importance given trends towards nonoperative management
and need for angioembolization [12]. Arterial phase imaging
is required to roadmap vascular supply and identify small
bleeds, while the background spleen enhances with sufcient
homogeneity to allow detection of small lacerations only
later in the portal venous phase. Comparison of both phases
is required in many cases to differentiate active bleeds from
pseudoaneurysms (Fig.47.1).
Some trauma protocols include both arterial phase and
portal venous phase imaging of the entire abdomen and pelvis. To reduce total radiation dose, the total craniocaudad
extent of imaging in either phase could be reduced, although
this carries its own risk of missed or incompletely characterized injuries. In particular, if an institution does not routinely
include arterial phase imaging of the lower abdomen and
pelvis, the radiology department should be informed of any
major penetrating abdominopelvic trauma, particularly gunshot injury, and of suspected pelvic fracture or unstable pelvis to ensure caudal extension of the arterial phase. Potential
renal injuries also merit extension of arterial phase imaging
as accessory renal arteries can arise anywhere from the
abdominal aorta. Additional delayed phases may be indicated in the setting of suspected renal or bladder injury, further discussed below.
Arterial phase imaging of the neck is indicated in the case
of penetrating injury or in suspected blunt cerebrovascular
injury (BCVI). This may be included routinely in cases of
high clinical suspicion, added following on-table review of
noncontrast imaging of the cervical spine for fracture, or if
necessary performed as a separate follow-up examination
requiring an additional contrast bolus.
Fig. 47.1 Multiphase
imaging in MVC trauma. A
round focus of extraluminal
contrast on arterial phase
imaging through the spleen
(closed arrow, a) is unaltered
in morphology on portal
venous phase imaging (closed
arrow, b) compatible with a
pseudoaneurysm. Smaller foci
higher in the spleen in the
same patient (open arrows)
are punctate on arterial phase
imaging (c) and demonstrate
blooming on portal venous
phase imaging (d) compatible
with areas of active arterial
extravasation. The patient
underwent nonoperative
management with transarterial
embolization. Extensive liver
lacerations were also present
in this case
a
c
b
d