K
K. Trauma 

CLINICAL/DIAGNOSTIC

PROBLEM

INVESTIGATION

RECOMMENDATION

(GRADE) 

COMMENT

DOSE
Head injury
Any of the following clinical features indicates that the is a risk of a clinically significant brain injury requiring neurosurgical intervention:
  • GCS < 13 at any point since the injury
  • GCS 13 or 14 with failure to regain GCS 15 within 2 hours of injury
  • Suspected open or depressed skull fracture
  • Any sign of basal skull fracture (haemotympanum,'racoon eyes', CSF otorrhoea, Battle's sign)
  • More than one episode of vomiting
  • Age > 64 years
  • Post-traumatic seizure
  • Coagulopathy, including anticoagulant therapy
  • Focal neurological deficit

The following two features in the absence of any of the above indicates a risk of a clinically significant brain injury that does not require neurosurgical intervention:

  • Retrograde amnesia of greater than 30 minutes
  • Dangerous mechanism of injury: pedestrian struck by motor vehicle, occupant ejected from a motor vehicle, fall from a height > 3 feet or 5 stairs
 SXR Not indicated (B) When CT is not available SXR could be justified for triage. 

An important exception is in the case of suspected non-accidental injury in children, where SXR is routinely indicated as part of a skeletal survey. In children 0-2 years old, CT of the head is mandatory.

(For non-accidental injury in children see Section M)

I
CT Indicated (B) CT should be performed within 1 hour except in patients with only retrograde amnesia of > 30 minutes and/or dangerous mechanism of injury as risk factors. These patients are not at risk of a haematoma requiring neurosurgical intervention and CT may be delayed for upto 8 hours.

Deterioration in GCS by 1 point, particularly if on the motor score, may warrant an urgent CT.

If the patient with a normal initial CT fails to regain GCS 15 within 24 hours, a further CT or MRI may be appropriate.
 
Face and orbits
Nasal trauma SXR/XR facial bones/XR nasal bones Not indicated (B)

 

 XRs are unreliable in diagnosing nasal fractures and, even when positive, they do not usually influence patient management. They may be requested at ENT/maxillofacial follow-up depending on local policy. I/I/I
 
Blunt orbital trauma XR facial bones Indicated (B) Especially where a blowout injury is suspected. MRI or direct coronal CT may be required by specialists where there is persistent diplopia or XRs and clinical signs are equivocal. I
 
Orbital trauma: penetrating injury XR orbits Indicated (B) Indicated for suspected radio-opaque (metallic) intraorbital foreign body. I
CT Specialised investigation (B) Indicated for suspected poorly opaque (small or non-metallic) intraorbital foreign body. II
US Specialised investigation (B) Indicated for anterior intraocular foreign bodies 0
MRI Specialised investigation (B) Hazardous with metal intraorbital foreign bodies. Specialised investigation is needed in cases when there is a strong clinical suspicion but failure of localisation or identification of a foreign body on other imaging. 0
 
Middle third facial injury CT Specialised investigation (B) Patient cooperation is essential to obtain views of diagnostic quality. Consider delay if patient is unco-operative. II
XR facial bones Indicated (B) Discuss with maxillofacial surgeons, who may request low dose CT at an early stage in management of complex injuries. I
 
Mandibular trauma XR mandible Indicated (A) Panoramic XR is not appropriate in uncooperative or multiply injured patients. I
 
Cervical spine
Conscious patient with head and/or facial injury only XR cervical spine Indicated only in specific circumstances (A)

 

XR will not be necessary, provided that all five of the following criteria are met:

  • No midline tenderness

  • No focal neurological deficit

  • Normal alertness

  • No intoxication

  • No painful, distracting injury

 I
 
Unconscious patient with head injury XR cervical spine, CT Indicated (B) Good quality XRs should demonstrate the whole of the cervical spine down to T1/2. If cervico-thoracic junction is not clearly seen or there are any possible areas of fracture then CT is required. Where available, spiral CT may be used as an alternative to XR, and is essential if cervico-thoracic junction is not clearly seen on XR. Both techniques may be difficult in the severely traumatised patient, and manipulation must be avoided. I,II
 
Neck injury with pain XR cervical spine Indicated (B) Discuss with department of clinical radiology. I
CT/MRI Specialised investigation (B) May be valuable when XR is equivocal or lesion complex. II/0
 
Neck injury with neurological deficit XR cervical spine Indicated (B) For orthopaedic assessment. XR must be of good quality to allow accurate interpretation. I
MRI Indicated (B) MRI is the best and safest method of demonstrating intrinsic cord damage, cord compression, ligamentous injuries, and vertebral fractures at multiple levels. Some constraints with life support systems. 0
CT Specialised investigation (B) CT myelography may be considered if MRI is not practicable. II
 
Neck injury with pain but XR initially normal; suspected ligamentous injury XR cervical spine Specialised investigation (B) Views taken in flexion and extension (consider fluoroscopy) as achieved by the patient with no assistance and under medical supervision. I
MRI Specialised investigation (B) MRI demonstrates ligamentous injuries. 0
 
Thoracic and lumbar spine
Trauma without pain or neurological deficit XR Not indicated (A) Physical examination is reliable in this region. When the patient is alert and asymptomatic without neurological signs, the probability of a radiological finding that would alter management is low. I
 
Trauma with pain, no neurological deficit, or patient not able to be evaluated XR Indicated (B) Threshold to XR is low when there is pain/tenderness, a significant fall, a high-impact road accident, and the presence of other spinal fracture, or when it is not possible to clinically evaluate the patient. If XR suggests instability or posterior element fractures, CT or MRI is essential. I
 
Trauma with neurological deficit with or without pain XR Indicated (B) Initial investigation, but CT/MRI is essential. I
CT Indicated (B) Detailed analysis of bone injury is achieved with CT with or without reconstructions. II
MRI Indicated (B) Whole-spine MRI is indicated when there are multilevel or ligamentous injuries and cauda equina injuries. 0
 
Pelvis and sacrum
Fall with inability to weight-bear XR pelvis and Lateral XR hip Indicated (C) Physical examination may be unreliable. Check for femoral neck fractures, which may not show on initial XR, even with good lateral views. In selected cases, NM or MRI or CT can be useful when XR is normal or equivocal. I + I
 
Stress fracture XR Indicated (B) Although often unrewarding.      I
NM/MRI/CT Indicated (B) Provides a means of early detection as well as a visual account of the biomechanical properties of the bone. Some centres use US here. II/0/II
 
Imaging of a foreign body
Soft tissue injury: foreign body, e.g. metal, glass, painted wood XR Indicated (B) All glass is radio-opaque. Remove blood-stained or soiled dressings first where possible. I
US Indicated (B) US may be indicated for radiolucent foreign body or where XR is difficult. 0
 
Soft tissue injury: foreign body, e.g. plastic, wood XR Indicated only in specific circumstances (B) Plastic is not radio-opaque: wood is rarely radio-opaque. I
US Indicated only in specific circumstances (B) Soft tissue US may show non-opaque foreign body. 0
 
Swallowed foreign body suspected in the pharyngeal or upper oesophageal region.

 

 

 

 

(For children see section M)

 XR Indicated only in specific circumstances (B) After direct examination of the oropharynx (where most foreign bodies lodge), and if foreign body is likely to be opaque. Differentiation from calcified cartilage can be difficult. Most fish bones are invisible on XR. I
AXR Indicated only in specific circumstances (B) Maintain a low threshold for laryngoscopy or endoscopy, especially if pain persists after 24 hrs.

(NB For possible inhaled or swallowed foreign body in children see Section M)

 II
 
Swallowed foreign body: smooth and small, e.g. coin CXR Indicated (B) The minority of swallowed foreign bodies will be radio-opaque. In children a single, slightly overexposed, frontal CXR to include neck should suffice. In adults, a lateral CXR may be needed in addition if frontal CXR is negative. I
AXR Indicated only in specific circumstances (B) The majority of foreign bodies that impact do so at the cricopharyngeus muscle. If the foreign body has not passed within 6 days, AXR may be useful for localisation. I
 
Sharp or potentially poisonous swallowed foreign body, e.g. battery

 

 

 

(For children see Section M)

 AXR Indicated (B) Most swallowed foreign bodies that pass the oesophagus eventually pass through the remainder of the gastrointestinal tract without complication. However, the location of a battery is important, as leakage can be dangerous. I
  Indicated only in specific circumstances (B) Indicated only if AXR is negative

(For children see Section M)

 I
 
Chest
Chest trauma: minor CXR Indicated only in specific circumstances (B) The demonstration of a rib fracture does not alter management. I
 
Chest trauma: moderate CXR Indicated (B) Frontal CXR for pneumothorax, fluid, or lung contusion. I
CT Specialised investigation (C) May be required. III
 
Stab injury CXR Indicated (C) PA and/or other views to show pneumothorax, lung damage, or fluid. US is useful for pleural and pericardial fluid. I
 
Sternal fracture Lateral XR sternum Indicated (C) In addition to CXR, lateral XR of the sternum is required. Think of thoracic spinal and aortic injuries too. I
 
Abdomen (including kidney)
Blunt or stab injury AXR supine and CXR erect/US Indicated (B) Supine AXR and erect CXR are indicated. US valuable for detecting haematomas and possible injuries to some organs, e.g. spleen and liver. I/I/0
CT Specialised investigation (C) CT may be needed. III
 
Renal trauma IVU Indicated only in specific circumstances (B) Adults with blunt renal trauma , microscopic haematuria, and  no shock or major associated intra-abdominal injuries can safely be spared imaging. II
US Indicated only in specific circumstances (B) US can be useful in the initial assessment of patients with suspected renal injury, but a negative US does not exclude renal injury. 0
CT Indicated (B) CT is the imaging technique of choice in patients with major injury ± hypotension, ± macroscopic haematuria. Delayed (excretory phase) CT must be included to assess the collecting system III
 
Major trauma
Major trauma: general screen in the unconscious or confused patient XR cervical spine/CXR/XR pelvis/CT head Indicated (B) Patient’s condition must be stabilised as a priority. Only the minimum XRs necessary for initial assessment will be performed. XR cervical spine can wait as long as spine and cord are suitably protected. Pelvic fractures are often associated with major blood loss. I/I/I/III
 
Major trauma: abdomen/pelvis CXR, XR pelvis Indicated (B) Pneumothorax must be excluded. Pelvic fractures which increase pelvic volume are often associated with major blood loss. I + I
US/CT Indicated (B) Sensitive and specific, but time-consuming and may delay surgery. CT should precede peritoneal lavage. US widely used in the emergency room to show free fluid plus solid organ injury. US has replaced lavage in most circumstances, but has a low sensitivity for splenic injury. If doubt remains, CT should follow US. 0/III
 
Major trauma: chest CXR Indicated (B) Allows immediate management (e.g. pneumothorax). I
CT chest Indicated (B)

Especially useful to exclude mediastinal haemorrhage and aortic injury. Low threshold for proceeding to arteriography.

 III

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