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ACS TQIP BEST PRACTICES GUIDELINES IN IMAGING AS ER 1988 THE AMERICAN SOCIETY OF Released October 2018 Table of Contents Introduction ............................................................................................... 3 1. Overview ................................................................................................ 4 Part 1: General Issues ........................................................................... 4 Part 2: Contrast Considerations .............................................................. 8 Part 3: Sedation .................................................................................10 2. Brain Imaging .........................................................................................15 3. Cervical Spine Imaging .............................................................................21 4. Imaging for Blunt Cerebrovascular Injury .....................................................32 5. Chest Imaging ........................................................................................36 6. Abdominal Imaging ................................................................................ 40 7. Genitourinary Imaging .............................................................................45 8. Thoracic and Lumbar Spine Imaging .......................................................... 48 9. Whole-Body CT Imaging ...........................................................................51 10. Imaging in Orthopaedic Trauma ...............................................................56 11. Imaging for Extremity Vascular Injury ........................................................ 60 12. Interventional Radiology for Traumatic Injuries ........................................... 64 13. Imaging in Penetrating Neck Injury ............................................................72 14. Imaging in Penetrating Transthoracic Trauma ..............................................76 15. Imaging in Penetrating Abdominal Trauma ................................................ 80 16. Imaging in the Trauma Patient Who Is Morbidly Obese ................................. 84 17. Imaging in the Trauma Patient Who Is Pregnant .......................................... 88 18. Imaging in Geriatric Patients with Low Energy Mechanism Injuries ..................92 19. Imaging for Intentional Injury in Children ................................................... 96 20. Imaging at Rural Trauma Centers ............................................................ 101 21. Dealing with Incidental Findings ............................................................. 105 22. Performance Improvement and Implementation ....................................... 109 Acronyms ................................................................................................111 Appendix ............................................................................................... 112 Expert Panel ............................................................................................ 113 2 and provides concise, evidence-based INTRODUCTION expert panel recommendations for practices to improve trauma patient Radiologic imaging remains a critical imaging. Additionally, appropriate tool of emergency and trauma providers performance indicators are identified for the initial assessment of patients to guide the evaluation of imaging presenting with injury. With the services in your trauma center. See the introduction of the Advanced Trauma Life appendix for definitions of terminology Support® (ATLS®) course by the American used in this Best Practices Guideline. College of Surgeons (ACS) Committee on Trauma (COT) in the early 1980s, chest Important Note and pelvic radiographs became a primary The intent of the ACS Trauma Quality adjunct to rapidly diagnose immediate Improvement Program (TQIP) Best life-threatening injuries. Computed Practices Guidelines is to provide health tomography (CT) and magnetic care professionals with evidence- resonance imaging (MRI) later became based recommendations regarding additional imaging modalities important care of the trauma patient. The Best for injury diagnosis and management. Practices Guidelines do not include By the early 90s, bedside abdominal all potential options for prevention, examination with Focused Assessment diagnosis, and treatment and are with Sonography in Trauma (FAST) not intended as a substitute for the largely replaced diagnostic peritoneal provider’s clinical judgment and lavage as the primary imaging modality experience. The responsible provider for rapid assessment of intra-abdominal must make all treatment decisions hemorrhage in unstable trauma patients. based upon his or her independent This guideline is intended to assist judgment and the patient’s individual trauma centers and their referring clinical presentation. The ACS and any facilities to determine best practices to entities endorsing the Guidelines shall capture optimal imaging to diagnose not be liable for any direct, indirect, injuries, while managing radiation special, incidental, or consequential exposure and avoiding potential damages related to the use of the adverse events associated with information contained herein. The ACS imaging. This document consolidates may modify the TQIP Best Practices recommendations from existing Guidelines at any time without notice. guidelines of national organizations 3 physician to expeditiously assess for, and 1. OVERVIEW immediately intervene in, life-threatening conditions such as cardiac tamponade, pneumothorax, or hemothorax. Perform a chest radiograph in all trauma patients Part 1: General Issues with potential for thoracic injury and for Key Points evaluation of any tubes and lines placed during resuscitation. In the experienced z Chest and pelvic radiographs provider’s hands, FAST may have continue to be a primary adjunct sensitivities higher than a conventional to diagnose immediate threats chest radiograph for pneumothorax and to life related to breathing and hemothorax.1 Extremity radiographs hemorrhage in the chest and/ remain an important secondary adjunct or extraperitoneal pelvis. for diagnosis of extremity orthopaedic injury. A best practice is interpretation z A best practice is concurrent trauma evaluation and radiograph of all radiographs concurrent with interpretation to facilitate timely the trauma evaluation to facilitate treatment interventions for timely treatment interventions. patients with severe injuries. Computed Tomography Imaging z Definitive imaging of complex Multi-detector computed tomographic vascular injuries ideally requires (MDCT) imaging is now well established at least a 64-channel scanner to as the imaging modality of choice perform high quality vascular in hemodynamically stable patients CT arteriography with three- following the secondary survey dimensional (3D) reconstruction. exam. Oral contrast is not necessary in abdominopelvic MDCT for blunt z Provide injury descriptors in radiologic reports to enable trauma; however, IV contrast is American Association for the Surgery required for visceral and vascular of Trauma (AAST) organ injury scale enhancement to identify visceral (OIS) grading and trauma injury injury and vascular hemorrhage. severity score determination. Oral contrast may be beneficial in penetrating thoracoabdominal Radiographic Imaging trauma to distend the esophagus and stomach if this is of clinical concern. Conventional torso radiographic imaging is a primary adjunct to rapidly facilitate Each center needs MDCT trauma the diagnosis of immediate threats to life protocols for each body region. Optimal related to breathing and hemorrhage diagnostic abdominopelvic MDCT for in the chest (chest radiograph) and/or trauma includes IV contrast. Delayed extraperitoneal pelvis (pelvis radiograph). scans are performed selectively These radiographs allow the treating when the initial scan is positive or inconclusive for the purpose of: 4 z Evaluating collecting system rupture z Make MDCT imaging available in the setting of renal trauma, or 24/7/365 with trauma patient priority access to the scanner before patients z Evaluating for active bleeding with non life-threatening conditions; and formation of hematomas. z Prioritize and expedite radiologic Delayed scans are focused on the area interpretation with immediate of interest and are performed with communication of life-threatening a lower dose than the initial scan. and emergent findings in a closed MDCT must be readily available loop fashion to facilitate immediate 24/7/365 in trauma centers. Technology treatment decision-making. advances have reduced acquisition The critical importance and ultimate times and improved image quality. impact of a real-time collaborative Consequently, MDCT has replaced availability of the interpreting conventional diagnostic angiography, radiologist in severely injured eliminating delays associated with patients cannot be overstated. mobilizing personnel for these Include injury descriptors needed to procedures.2,3 Utilization of whole-body appropriately determine AAST organ MDCT imaging of the head, neck, and injury scale (OIS) grading and trauma torso facilitates rapid and comprehensive injury severity score determination injury identification in the patient with for radiologic reporting.4 For rib multiple injuries, allowing optimal fractures, the radiologist needs to sequencing of treatment for patients with report the number of rib fractures, competing priorities. Providers must pay location of rib
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