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Laurie A. Romig, MD, FACEP Executive Medical Director LifeNet Florida Medical Director Pinellas County (FL) EMS PowerPoint Presentation
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Laurie A. Romig, MD, FACEP Executive Medical Director LifeNet Florida Medical Director Pinellas County (FL) EMS

Laurie A. Romig, MD, FACEP Executive Medical Director LifeNet Florida Medical Director Pinellas County (FL) EMS

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Laurie A. Romig, MD, FACEP Executive Medical Director LifeNet Florida Medical Director Pinellas County (FL) EMS

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  1. Shades of Black and White Reading Trauma X Rays Laurie A. Romig, MD, FACEP Executive Medical Director LifeNet Florida Medical Director Pinellas County (FL) EMS

  2. Objectives • Most common initial X rays in the adult trauma patient • Normal and abnormal findings on: • cervical spine • chest • Examples of some ancillary studies

  3. Why should you know about all this stuff?

  4. Why should you know about all this stuff? • Flight and critical care crew members might intervene based on X rays • Feedback on your clinical patient evaluation • Catch some problems early (even before the doc) • Makes you a better trauma team member • Impress almost anybody

  5. “The BIG3” • Cervical spine films • lateral • AP • odontoid (open mouth) • Supine chest film • AP pelvis film Some trauma teams routinely include a lateral lumbosacral spine film, to make the BIG 4

  6. Ancillary Radiographic Studies • Extremity X rays • Other plain films • Retrograde urethrogram • Abdominal ultrasound • CT • Arteriography

  7. Approach to Reading X rays • Know what normal anatomy looks like • Always take a systematic approach • A little distance can be a good thing • Experience counts

  8. A Systematic Approach

  9. Cervical Spine X rays

  10. The Lateral Film • Is the film satisfactory? • Nothing obscured by jewelry or other opaque objects? • Penetration OK? • An adequate film?

  11. A-O junction obscured by nameplate • Occiput and palate not seen • At least the top edge of T1 should be seen Not an adequate film!

  12. Curves to Follow

  13. Abnormalities in Curves • Malalignment of post. vertebral bodies = more significant than ant. • Spinal canal diameter is significantly narrowed if < 14 mm • Anterior subluxation caused by facet dislocation • < 50% VB width = unilateral • > 50% VB width = bilateral • widening interspinous spaces

  14. Symmetry • Symmetry of bones • Intervertebral disc spaces

  15. Often due to compression Compression of > 40% normal VB height usually indicates a burst fx with possible fragments into spinal canal Anterior compression may cause a “teardrop” shaped fx Abnormal Symmetry

  16. Measurements • Soft tissue spaces • Retropharyngeal space • 7 mm at C2 • < 50% of width of VB at C4 and above • may be 100% width of VB below C4 • Retrotracheal space • 22 mm at C6 • 14 mm in children

  17. Soft Tissue Measurements C 2 C 4 C 6 Abnormal measurements may indicate soft tissue swelling from obvious or occult fxs, hematomas, or abscesses

  18. Ant. A-D Interval C 1 C 1 Dens (C 2) Anterior Atlanto-dens Interval • 3 mm in adults • 5 mm in children • >3.5 mm = T. L. injury • > 5 mm = T.L. rupture & instability

  19. Intervertebral Disc Spaces • Decreased IVD space may indicate herniated disc

  20. Atlanto-Occipital Distance • Distance from atlas (C1) to occiput should always be < 5mm • Increased distance may indicate atlanto-occipital dislocation

  21. Spinous Processes Anterior-Posterior View • Symmetry/size • Alignment of spinous processes • Smooth, rolling lateral edges

  22. Odontoid (Open mouth) View

  23. C1 lateral mass C1 lateral mass Dens C2 Odontoid View Close-up

  24. Abnormal Cervical Spine Films

  25. Normal Atlanto-occipital Disassociation & Fx C1

  26. Unilateral Facet Dislocation Bilateral Facet Dislocation

  27. Odontoid (C2) fx

  28. Shades of Black & White

  29. Lateral view of odontoid fx on CT C1

  30. C5 compression fx C5 compression fx

  31. C6 burst fx/dislocation

  32. C 5-6 fracture/dislocation on CT

  33. C4 Teardrop Fx

  34. Chest X rays

  35. A Systematic Approach • The systematic approach involves evaluating: • adequacy of the film • bony structures • mediastinum/major vessels • lung fields • soft tissue • diaphragm/portion of abdomen visible

  36. Adequacy of the Film • Do you have it hung up right? • Appropriate X ray penetration • Too light, can’t separate out subtle changes • Too penetrated, can’t evaluate lung fields well • Able to see both costophrenic angles and both apices

  37. Bony Structures • Ribs • Fx of first and second ribs imply great force and potential for underlying great vessel, lung and airway damage • Sternum • Clavicles • Scapula • Fx may also imply great force and underlying injuries • Cervical and thoracic spine

  38. Mediastinum and Major Vessels • Width of mediastinum • Aortic rupture • Size of cardiac shadow • Hemo or pneumopericardium • Underlying medical problem • Air in mediastinum • Trachea • Tracheal shift

  39. Lung Fields • Pneumothorax/Tension Pneumothorax • Hemothorax • Pulmonary Contusion • Atelectasis • Infection • Pulmonary Edema

  40. Soft Tissue • Subcutaneous emphysema • Foreign bodies/impaled objects

  41. Diaphragm/Abdomen • Diaphragm position • Position of gastric air bubble and/or NG tube • Ruptured diaphragm • Free air under the diaphragm • Ruptured abdominal viscous organ

  42. Normal Chest X ray • Adequacy • Bones • Mediastinum/major vessels/trachea • Lung fields • Soft tissue • Abdomen

  43. Abnormal Chest X rays

  44. Bony Abnormalities • Rib fx’s • Mediast. OK • Pulmonary contusion • Subcu air • Chest tube • NG tube

  45. MVC victim

  46. Scapular fx Pulmonary contusion