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Hello and welcome to Noon Conference, hosted by MRI Online

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Noon Conference connects the global radiology community

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through free live educational webinars that are accessible

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for all and is an opportunity

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to learn alongside top radiologists from around the world.

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You can access a recording of today's conference

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and previous noon conferences

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by creating a free MRI in online account.

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Today we are honored to welcome Dr. Laura Avery

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for a lectured entitled abdominal trauma.

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Dr. Avery is an emergency radiologist,

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MGH radiology Vice Chair for education

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and director of the Harvard Medical School

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Radiology clerkship.

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She served on numerous committees

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and is a frequent invited speaker for A-U-R-A-S-E-R-R-S-N-A

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and a RRS Passionate about medical student education.

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She has received numerous teaching awards,

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including the RSS NA Honored Educator Award in 2016

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and the HMS Excellence

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and Residency Advising Award at the end of her lecture.

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Please join her in a q

1:00

and a session where she will address questions you may have

1:03

on today's topic.

1:04

Please remember to use the q

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and a feature to submit your questions so we can get to

1:08

as many as we can before our time is up.

1:11

With that, we are ready to begin today's lecture.

1:13

Dr. Avery, please take it from here.

1:17

Oh, thank you so much for inviting me. I am thrilled.

1:20

Uh, and I can take my own screen share. Right.

1:24

Okay, perfect. I think we're up and running.

1:27

Um, thank you so much for inviting me.

1:28

I'm thrilled and delighted to speak on one

1:30

of my favorite topics, abdominal trauma.

1:32

Um, here in Boston.

1:34

Uh, we have six trauma centers in the safest city in

1:37

America, so we're always a little concerned about

1:39

how much trauma we actually have,

1:41

but don't worry, we have plenty of poor, terrible drivers

1:44

and, um, all of those scooters

1:47

and mopeds have been bringing us lots of business.

1:50

So my lecture content will stay relevant, um,

1:53

for now anyway, so I have advance here.

1:58

There we go. I have no disclosures.

2:01

Our learning objectives will to be, uh, today are to be able

2:04

to apply techniques for multi detector CT evaluation

2:07

for injured patients.

2:08

Um, we want the learner to be able to recognize important

2:11

injuries resulting from blunt abdominal trauma.

2:14

This really will be a blunt abdominal trauma talk.

2:17

Um, again, I said safest city in America,

2:19

so I probably just wouldn't have the content for, um,

2:21

for the penetrating uh, injuries.

2:24

And we would like you to become, um,

2:26

better at looking at patterns of injuries

2:28

as they apply to the body.

2:29

Alright, so let's talk about our, um, imaging protocol.

2:33

We use contrast material in all of our, all of our CT scans.

2:37

Um, and we try to image patients in the abdomen at the 72nd

2:40

portal venous delay.

2:41

We also have other opportunities to enhance these studies

2:44

with further delayed images

2:46

or arterial images in an earlier phase and the like.

2:49

We'll go into various opportunities to, um, protocol,

2:53

protocol proper, uh, imaging technique here.

2:56

We do not use oral contrast at all in trauma.

2:59

Um, we're just moving too fast and that would be crazy.

3:02

We, at times we'll use, um, a split bolus technique

3:05

where we inject a patient, uh, at two different times

3:07

with one single acquisition, getting, um,

3:10

images in both the arterial phase of the aorta

3:12

and the parenchymal phase of the abdomen and pelvis.

3:15

This is a nice protocol in that it's very fast and easy.

3:19

I like to refer to it as our Costco protocol

3:21

because like at Costco where if you go

3:24

and buy a marinara sauce,

3:26

you're pretty assured it's a good sauce, right?

3:28

They had to buy 7 billion of that sauce.

3:30

Um, so, uh, they're pretty good at choosing the right thing.

3:33

So I do like a split bolus technique, full body pan scan

3:37

because it will answer most questions that you're looking

3:39

for for trauma and can also be used, um,

3:42

as just a good phishing, uh, expedition for patients

3:46

who need, um, imaging for other reasons.

3:49

Now, we may use our protocols

3:51

and then tailor them to very specific, uh, situations.

3:54

Um, let me see here. Sorry, this is all animating wrong.

3:57

Okay, there we go. Uh,

3:59

so we will use rectal contrast in patients who are stabbed.

4:03

Um, here in Boston. People do enjoy stabbing each other.

4:06

It seems to be our, um, way of showing, uh, dominance.

4:10

Um, and frequently the stabs.

4:11

A gentleman stab or, you know, a a, a friendly stab,

4:15

one might say, um, is to the flank of the patient.

4:18

Um, that's kind of how you do it, like west side story kind

4:20

of around the, around in the back, um, back and up.

4:23

So a lot of those flank stabs will be stopped

4:25

by the large musculature of the back

4:27

or the subcutaneous tissues,

4:29

and very few will actually penetrate into the,

4:30

into the retroperitoneum or peritoneum.

4:33

And in those cases, we would like

4:35

to exclude colonic injury in those patients

4:37

because then they can be discharged

4:40

with just a surface level stab.

4:42

So, um, we will actually use rectal contrast

4:44

for penetrating trauma to the flank in order

4:48

to exclude a colonic injury.

4:49

Here you'll see that the, um,

4:52

that the knife actually did penetrate the colon,

4:54

and now we have extravasation of rectal contrast and air.

4:57

Before this, um, we used to have to observe all patients

5:00

for 24 hours to make sure that they were not, uh,

5:03

did not have a colonic penetrating injury.

5:05

So we have have gone on to use that protocol quite,

5:08

quite avidly.

5:10

We'll also wanna increase, um, and,

5:12

and obtain a arterial phase of the pelvis in patients, um,

5:16

all the way down to the pelvis.

5:18

And patients who have volume increasing fractures

5:20

of the pelvis, meaning that their pelvic, um,

5:23

pelvis is increase in size by fractures.

5:26

Here we have an open book involving, uh,

5:28

and increasing the, the,

5:30

the pelvis increasing the opportunity for arterial

5:32

and venous bleeding into the retroperitoneum

5:35

or the vertical shear fracture here.

5:36

That also increases the volume of, of the pelvis.

5:39

So those are both, um, unstable pelvic fractures

5:43

where we will probably have interventional radiology come in

5:47

and, um, be embolizing vasculature in the retroperitoneum,

5:51

extra peritoneal spaces.

5:52

So we'd like to be able to, um, further, uh,

5:57

elucidate whether or not it's venous or arterial bleeding.

6:00

At times we're concerned about, uh, bladder injuries.

6:04

This is specifically when we see hematuria.

6:06

Almost all bladder injuries are, um, have hematuria.

6:10

So you will actually see red blood in

6:11

the Foley catheter bag.

6:13

We do a, um, dedicated cystogram, a retrograde cystogram

6:17

where we install thir 300 to four hundreds of c 400 ccs

6:21

of contrast through the Foley catheter in order

6:24

to maximally ex to extend the bladder, um, to look

6:27

for either these extra peritoneal bladder raptures,

6:30

which are the base of the bladder, those sheer injuries

6:32

to the base of the bladder, um, that frequently will have,

6:35

uh, pelvic fractures involved with them as well

6:37

and show, uh, contrast material into

6:39

that extra peritoneal space or the less frequent,

6:42

but always exciting intraperitoneal bladder rupture

6:45

where the bladder pops, um,

6:46

from compression on a full bladder

6:48

after somebody has um, been in an accident

6:51

after consuming large amounts of beverages.

6:53

So always empty your bladder before driving.

6:55

Um, and this is a surgical fix

6:57

and we'll see a contrast material going into the peritoneal

7:01

spaces such as the cul-de-sac here.

7:04

So that's another opportunity for fun.

7:06

Um, but in general we're really looking to, uh,

7:10

evaluate the abdomen in that portal venous phase

7:12

where we're going to see the best parenchymal enhancement.

7:15

Where you can see the spleen here has

7:17

multiple splenic lacerations.

7:19

Um, because when you do it too early in the arterial phase,

7:22

ah, this is Gigi, pardon me.

7:25

Um, you can have, uh, that very psychedelic appearance

7:28

of the spleen where it's so heterogeneous, kind of a,

7:31

a zebra look to it, that it's very hard to determine, um,

7:34

any abnormality within the spleen itself.

7:36

So you want that 72nd portal venous delay if possible.

7:40

At times we might even get more delayed studies.

7:43

Obviously the patient has to be safe

7:44

and, uh, stable enough on our table that we're willing to,

7:48

um, uh, have more delayed images.

7:51

But, uh, whenever we have a parenchymal injury,

7:54

we usually will try to get a three to five minute delay

7:56

to see how the contrast, um, and the blood, uh,

7:59

whenever we have extravasation of contrast, uh, during, uh,

8:02

parenchymal injury, we'll get a three to five minute delay

8:05

to see that contrast, um, accumulate.

8:08

You'll see cases of that in a moment.

8:09

And I always say when the ureters in play get delays,

8:12

we will get a five to seven minute delay

8:14

when the ureter is in play.

8:15

Um, whether it's an IR estrogenic, ure ureteral injury

8:18

because, you know, trauma just isn't on the streets,

8:21

that's in the hospital too.

8:23

Um, and

8:24

or if it's a shearing injury where we're concerned about,

8:27

uh, injury to the kidney

8:29

and injury to the renal collecting system.

8:32

So, um, we would see the extravasation of urine, uh,

8:36

on those delayed images.

8:38

Alright, so let's go in, let's start it. Let's do this.

8:41

So we're always gonna get the best images possible.

8:43

We're already optimizing that, that's a given.

8:46

Um, and now we're gonna figure out

8:47

how we're gonna look at these studies.

8:49

So we're always going to look at the abdomen

8:51

and look at where we see fluid, um, trying to find the, uh,

8:55

where the bleeding is from.

8:56

Okay, so you know,

8:58

we have water density fluid at times under 15 housefield

9:00

unit hemoperitoneum ranging from 30 to 70 housefield units,

9:04

depending on if it's the serous portions

9:06

of blood all the way down to those clotty portions of blood.

9:09

Um, with actual contrast being up to 300.

9:12

Mixed density fluid can occur when you have ruptures from

9:15

the glow, bladder, bowel and urinary bladder as well.

9:18

So here we can see an axial image with a large volume

9:21

of hemoperitoneum and even some, uh, active extravasation.

9:24

But when you're going through, you always just wanna check

9:26

for blood in those places where blood will accumulate.

9:28

Similar to if you were doing a fast exam

9:31

or point of care ultrasound, you wanna look anterior

9:35

to the liver here, posterior to the spleen in this location.

9:38

You can see from our splenic laceration there.

9:41

Coming down to Morrison's pouch

9:43

or the hepato renal recess is a really important area.

9:46

Always something you would look

9:47

for on your fast exam coming down the

9:50

paracolic gutters as well.

9:51

And then looking deep within the pelvis in that, um,

9:54

uh, cul-de-sac location.

9:56

For, for blood products, we like

9:59

to talk about the sentinel clot sign

10:00

and this is, um, a sign that we see where the blood

10:04

that is coming from the site

10:06

of bleeding will be denser than the

10:07

remaining blood in the abdomen.

10:09

So on this axial image, um, lean on in, uh, you're gonna see

10:13

that there's blood around the spleen

10:15

and that blood is a little dense.

10:17

It's similar in attenuation, maybe to the lip, to the,

10:20

to the muscle next to it, as opposed

10:22

to the blood here along the liver,

10:24

which is much more similar to the attenuation

10:27

of the gallbladder

10:28

and lower an attenuation when compared to the liver.

10:31

So we would suspect the site

10:32

of bleeding is in the left upper

10:34

quadrant near that dense blood.

10:35

And of course, as we come down, no prizes for this,

10:38

you actually see those lacerations of the spleen.

10:41

So blood in the abdomen acts like it doesn't attest tube

10:45

where the clotty portions of blood that are gonna try

10:47

to stop the bleeding are gonna be denser

10:49

and, you know, attenuate your photons more.

10:52

So they're gonna be higher in attenuation near the site

10:54

of bleeding as opposed to the more serious portions of blood

10:57

or the water, air portions of blood,

10:59

which will spread out more.

11:03

Sometimes we can actually see, um,

11:06

hemoperitoneum again in this case we see that,

11:08

that those measurements

11:10

of 55, 51 hounds field units near the side of bleeding

11:13

as opposed to the more serious portions elsewhere.

11:15

And in this case, we actually had water density, um, uh,

11:18

fluid, which ended up being from a bladder rupture.

11:20

So we're always measuring the fluid, trying to look

11:23

for active extravasation.

11:24

Here's a stab wound to the liver with active extravasation.

11:27

This was actually a pediatric patient who came back

11:29

to our CT scanner, um,

11:31

and people thought he had a surface, you know,

11:33

little surface stab.

11:34

Um, and you can see that it was much deeper and that's

11:36

because pediatric patients can really look very stable

11:39

until they're not.

11:40

So, um, I always have co caution with the pediatric world

11:43

that they can have a larger scale

11:45

injuries than anyone suspects.

11:47

Uh, clinically here is active extravasation from

11:50

the splenic injury.

11:51

So on portal venous phase,

11:53

once we see active extravasation from a contrast from a

11:56

parenchymal injury, we're lucky in our trauma center,

11:59

we're usually at the table with our trauma surgeons.

12:01

I don't know if that's lucky or not,

12:02

'cause they're usually like breathing over your back

12:04

and, um, trying to push you outta the way

12:05

or push you into the CT console.

12:07

Um, either way I feel like it's a, it's,

12:09

it's a little bit much, but it's, you know, part

12:11

of the fun, part of the fun.

12:12

Um, so we're there.

12:13

So we're able to say, okay, let's get a three

12:16

to five minute delay and look at that contrast, accumulate,

12:19

see how that contrast works.

12:21

Why, why might you say?

12:23

And that's because we're always trying

12:24

to exclude the formation of a pseudo aneurysm

12:27

or a, uh, a VF.

12:29

So, um, pseudo aneurysms,

12:31

you're gonna have like a little pool of blood here in the

12:35

spleen and that pool of blood will be similar in attenuation

12:38

to the blood pool of the aorta and wash out on delays

12:41

and may even be present the next day.

12:43

And that's an indication that you have a pseudo aneurysm

12:45

and that that pseudo aneurysm is at risk of delayed rupture.

12:49

You know what, we're gonna see this again

12:51

because the make it stick ideology is that you go back

12:53

and forth to the same thing.

12:54

So looking for pseudo aneurysms is your job.

12:57

That is the biggest part of your job

12:59

because these are the patients who are going to be stable,

13:01

they're gonna look like they're doing fine

13:03

and that's gonna rupture in a delayed fashion

13:05

and cause them, um, to possibly a ate here.

13:08

This one was caught at, at the time of an of, um, imaging

13:12

and the patient went on for, uh, embolization of

13:15

that pseudo aneurysm, which was wonderful.

13:18

Go ir, um, never sleep anyway.

13:21

So, uh, I wanna talk about some other things we

13:23

see in trauma.

13:25

Here is a typical appearance of a patient

13:27

who has periportal edema

13:29

and a patient who's been over fluid resuscitated.

13:31

We do see this not as much as we used to.

13:34

I think that the trauma teams are much more careful about

13:37

using just, um, saline

13:38

and now they use many, many more blood products to, um,

13:41

with a theory that, uh, just, you know,

13:44

saline in your blood wasn't helping you stop the bleeding.

13:46

It was basically making you break your clot.

13:48

So, um, we don't see this as much,

13:50

but we definitely see it sometimes when the patients come in

13:52

from far away, um,

13:54

or that they were in the helicopter

13:56

for longer than expected.

13:57

When we see this, you can tell

13:59

that there's these little halos all

14:01

around the portal venous triads.

14:03

Um, and that's just fluid in that third space.

14:05

So this is third stage fluid.

14:07

Notice how thickened the gallbladder wall is as well.

14:10

That's a sign of third space fluid.

14:12

Um, and this periportal edema, it's pretty dramatic

14:15

as opposed to a patient who has, um, dilated bile ducts,

14:19

which would be on one side of the portal vein as opposed

14:22

to in this potential space around the portal vein

14:25

where we find lymphatics

14:27

and other, um, so other connective tissues.

14:30

So the halos are an indication that you have, uh,

14:33

over fluid resuscitated

14:35

and sometimes you can have a kind of a dramatic amount

14:37

of fluid into the retroperitoneal, especially kind of around

14:40

that periportal region down into the duwan mill region.

14:42

So just be cognizant of, um, that opportunity for fun.

14:48

Alright, so, uh, shock bowel.

14:51

This is something we see our patients are hypotensive.

14:54

They can be hypotensive at the scene.

14:56

They can be on a myriad of pressors

14:57

that are basically inducing chemical shock.

15:00

So we see shock bowel quite frequently.

15:02

Here's a patient who has very, very bright kidneys.

15:04

Do they burn your eyes? Their light bulb

15:06

bright, someone might say.

15:07

So that's an indication that whatever blood is going,

15:11

whatever blood is in their body, is just your contrast.

15:14

Um, so, uh, like 30% of your blood flow goes to your kidney.

15:17

So a large volume of blood is going to those kidneys.

15:20

Um, and they're very, very bright.

15:22

You also have, uh, increased attenuation of the mucosa

15:25

of the bowel and stomach here.

15:27

Very dramatic. It looks like they have oral

15:29

contrast, but they do not.

15:31

Um, and that's because the blood is being

15:33

shunted to the mucosal layers.

15:35

And the mucosal layers, uh,

15:36

are a little bit more purative is a, is a,

15:38

is an ischemic a severe ischemia, right?

15:41

You can also hear, see here

15:42

that the IVC is just nearly collapsed.

15:45

So that's a hypovolemic appearance.

15:47

When I, um, make this even larger, you can see

15:49

that there's some edema around the pancreas.

15:51

That's a typical appearance for shock pancreas, which, um,

15:55

you can actually have increased serologies

15:57

as well in those cases.

15:58

Look at how tiny this aorta is.

16:00

It's doing the best it can to clamp down

16:03

and stop that bleeding.

16:04

As I come down this patient, you'll see that very bright.

16:07

This is windowed a little bit more for your comfort.

16:09

Um, you'll see that very, very bright mucosa there

16:13

of the stomach coming down.

16:15

You even see quite a bit

16:16

of avid enhancement of the gallbladder.

16:18

I always look for that if possible

16:20

'cause I have had a few cases of gallbladder of BULs in

16:23

where the gallbladder has basically just come right off.

16:27

So, um, if I, you know, if I have no enhancement

16:30

of the gallbladder, I always have to question

16:31

that as a possibility.

16:32

Coming down, we have that edema around the pancreas.

16:36

Again, that shock pancreas, those bright kidneys, the, the,

16:39

um, window to bit the tiny, tiny aorta.

16:42

And that collapsed IVC coming down into the pelvis.

16:45

We'll see that this patient has a large amount

16:47

of retroperitoneal bleeding related

16:49

to displaced pelvic fractures

16:51

and a large acetabular fracture there.

16:55

So, um, you just wanna be aware of that appearance of shock,

16:58

bowel shock, uh, shock, body shock, everything.

17:02

Um, you can actually use it to your advantage.

17:03

You know, you might as well figure out whether

17:05

or not you think the bowel iss enhancing,

17:07

and we'll see some cases later of that.

17:09

But let's go into the big players, big players.

17:11

We have the liver and the spleen.

17:14

Our surgeons like to say, the liver's your friend

17:17

and the spleens your enemy.

17:18

And I think after I show you all of these cases,

17:20

you will see why that's a possibility.

17:23

So, um, right upper quadrant injuries, uh,

17:26

it's very preferable to be non, uh,

17:29

surgical if at all possible.

17:30

Um, and the CT scans are really helpful

17:32

because we can identify, uh, the degree

17:35

of which the laceration extends to the capsule,

17:37

how much bleeding there is and the like.

17:39

And we can see if there's any significant deep injuries, um,

17:43

that were really hard surgically back in the day for them

17:46

to evaluate because, uh, those deep injuries going

17:49

to the juxta, hepatic venous system,

17:51

no one wanted to explore that.

17:53

It wasn't fun. So, um, I think we really rely, even in cases

17:58

where they're going straight to the OR packing,

18:00

they come back and we get CT scans to look at the, um,

18:04

at the liver for any deeper injuries.

18:06

So the liver, at least, you know,

18:10

it's a pretty dense organ.

18:12

It's, it's got some solid components to it.

18:14

It's wrapped in a pretty, you know, tight sheet there.

18:17

It's pretty well adhesed to the body.

18:20

It's not, you know, it's, it's, it's solid.

18:22

It's in the right upper quadrant, I'll tell you the

18:25

spleen poorly designed.

18:26

Um, so the liver has, uh, some benefits to it.

18:30

So when we look at the grading system,

18:31

I think this is somewhat reflected in the grading system.

18:34

I always say, Hmm, grading systems, who cares, right?

18:38

I mean, you can Google this and that's really important.

18:42

Do not commit this to memory.

18:43

You don't have the brain cells.

18:45

You're gonna have something else that you like

18:47

to know come out.

18:48

So don't keep this on your iceberg of a brain.

18:51

Like there's only so much space and it's always shrinking.

18:53

But, um, I think it's just good to understand the principles

18:56

and why we grade things.

18:58

So why do we grade?

19:01

Um, you know, communication definitely between surgeons,

19:05

uh, is a huge part of it.

19:07

This is a surgical grading system

19:08

that only recently in 2018 was updated to even include, uh,

19:12

active extravasation and imaging components

19:15

and is still designed by surgeons.

19:17

So it's a bit cockamamie. That's to be expected.

19:20

They're surgeons. Um,

19:22

but it is an important grading system in that it's, it,

19:25

its principles are, um, are helpful again for communication.

19:30

They're also, uh, it's, you have to grade,

19:33

if you're a level one trauma center in America, you have

19:36

to grade your parental entries.

19:37

It's part of the A A ST accreditation system.

19:41

So when they come through

19:42

and they do their audits on your hospital, you actually have

19:45

to have the grades in your reports.

19:47

No, I have ways to hack that as I would,

19:49

but, um, in general, you wanna just Google it, bring it up,

19:52

put those grades in just

19:54

so you don't have to make addendums.

19:55

So let's look at this, um, grading system.

19:58

Uh, grade one is less than a centimeter in size.

20:02

That's quite small. The, um, grade two,

20:06

uh, injury.

20:07

The key here is that it can be a parenchymal depth

20:10

of 10 centimeters, which is a big laceration as long

20:14

as it doesn't go to the capsule.

20:15

Um, and capsular tears, one to three centimeters.

20:18

So that's pretty impressive.

20:19

That's a pretty big intraparenchymal, um, injury

20:22

that still is agreed to.

20:24

So I always wanna highlight that as the fact

20:27

that you can have a big intraparenchymal shearing, stellate

20:32

laceration of your liver, and actually you're gonna do

20:34

pretty good, which pretty good.

20:36

Um, now once you have vascular injury, uh,

20:39

with active bleeding contained in the liver, parma,

20:41

that you're gonna go onto a grade three.

20:43

And once it's into the peritoneum,

20:44

which is quite frequent, then you have four.

20:47

So no grade four is active bleeding into the

20:49

preco, into the peritoneum.

20:50

Now let's go through the various grades. Um, just a moment.

20:53

I do wanna show you the original, the, uh, the, um, images.

20:57

If you end up just googling it

20:59

to the A A ST, this is what you're gonna see.

21:01

And be aware that a grade one injury,

21:05

if you have more than one, you upscale it to a two.

21:07

If you have two, you know, two lacerations, you upscale it

21:10

to a two, two goes to a three,

21:11

and then you stop the upscale.

21:12

But this is a little known thing down here.

21:15

So that actually upgrades our injuries all the time.

21:18

I mean, how many subcapsular, hematomas are less than 10%

21:22

of the surface area or less than a centimeter?

21:24

I can measure everything at a centimeter.

21:25

So I like to call this, um, you know,

21:27

you're not gonna really see it.

21:29

Uh, I don't even start at two.

21:31

I figure why not bring up the drama a little bit.

21:32

I like to bring up the drama, um,

21:34

volume on all of these things.

21:36

So I really kind of start at, uh, at at at two.

21:39

Um, because even in that case, if it's under a centimeter,

21:41

which it's never gonna be, uh,

21:43

once you have multiplicity, you'd be up to it too.

21:45

So let's just start at grade two.

21:47

Um, 'cause we have to know how to

21:48

hack a system more than anything.

21:49

And you can see here that there's a very large

21:51

intraparenchymal tear, uh, or laceration of this liver.

21:55

This is still grade two. There's no active bleeding or cool.

21:58

Now, once you start, again, this is an intraparenchymal, um,

22:01

laceration, less than 10 centimeters.

22:03

No capsular involvement, no hemoperitoneum grade two.

22:07

This is gonna be fine. This could be all good.

22:09

They're gonna do well. Now we're starting

22:11

to get a capsular tear.

22:12

Okay, so here we have a grade three with hemorrhage.

22:16

Um, and we do have a, a big capsular tear here,

22:18

greater than three centimeters.

22:20

So we're, we're moving up in the world.

22:22

Um, and this one has bleeding.

22:24

So there's, there's, there's much more that needs

22:26

to be done here, including blood products for sure.

22:29

I mean, all of 'em need to have blood product stabilization,

22:31

but this is gonna require more blood products

22:33

and possibly even embolization.

22:35

Um, here we have a grade four

22:37

based on parenchymal disruption, which is another asset

22:41

of this grading system.

22:42

So I would say that this, this liver here has, um,

22:46

extensive parenchymal, uh, disruption, probably 25 to 50,

22:50

75% given that it's in the right lobe.

22:53

And, you know, I oftentimes describe these as stellate.

22:56

That's another one. Sometimes you'll see what we see here,

22:58

which is blood going along the periportal regions.

23:01

That's a pretty frequent finding

23:02

and lacerations, um, of the liver as well.

23:06

So this is a lot of parenchymal disruption

23:09

and active bleeding into the peritoneum.

23:10

So at least a grade four there.

23:12

Now, I will say in my collection,

23:15

here's a grade four with active bleeding.

23:17

Yay. Which went on to, again, I like to push

23:20

that IR gets involved.

23:21

I mean, our IR folks are such

23:23

dulls that they're willing to be there.

23:24

Uh oh, which just happened. Oh no, did I just do that?

23:28

I was just trying to close down. Okay, fine. We're back.

23:31

Um, uh, that they come in all night, all times at night

23:36

to help our trauma team out, which is great.

23:39

Um, because I think that being a referring clinician

23:42

where you can do a lot of, um, intervention, that's key.

23:45

Okay? So grade five, grade five is actually

23:47

really hard to find in my collection.

23:48

These are deep, deep lacerations going to the deep vessels

23:53

of the IBC or portal vein.

23:55

I was talking to one of our trauma surgeon, he was like,

23:57

oh yeah, it has to be actively

23:58

bleeding to be considered a five.

23:59

And I was like, well, that seems a little dramatic,

24:00

but, um, I do bring you here, uh,

24:03

active bleeding from a main portal vein,

24:06

that would definitely be a grade five.

24:08

I think it's hard to know how

24:10

to apply this grading system when it comes

24:12

to reading the definition by the, um, by the, uh,

24:16

surgery A A ST

24:17

because it says anything that goes jux to hepatic

24:20

but doesn't necessarily have to be bleeding.

24:22

Our trauma surgeons want it to be bleeding.

24:24

Um, but I would say that's a very minority of cases

24:26

that would make it to our CT scanner if they

24:29

were bleeding from the IVC.

24:30

I don't wanna see you, you're not safe on my CT scanner,

24:33

please bypass me straight to the or.

24:35

Um, so some of those higher level injuries,

24:37

we just don't see a lot.

24:38

Let's talk about some special considerations.

24:41

Now, the liver's in the right upper quadrant,

24:43

and, um, this is very interesting when we have

24:46

that segment seven high posterior lacerations going

24:50

posteriorly here to where the IVC is in the caudate lobe.

24:53

This can be very interesting

24:54

because these may just bleed into the retroperitoneum

24:58

and you can of oftentimes also have, um,

25:01

an adrenal hematoma.

25:03

Uh, why is that? That's

25:04

because, um, well the, the forces are posterior like that,

25:07

and the liver actually can, can choose the, uh,

25:10

adrenal gland or hit the IVC causing increased blood volume

25:13

to the adrenal gland, which is already pretty vascular.

25:15

And that can bleed like crazy.

25:18

But also because that segment seven of the liver is

25:22

that bear area of the liver

25:23

that you may remember from your day of anatomy, um,

25:26

or days of anatomy, pardon me, uh, is, uh,

25:30

is actually con continuous with the retroperitoneum.

25:33

So if you have a laceration to the bear area,

25:36

you'll actually bre bleed into the retroperitoneum

25:39

as opposed to, um, into the peritoneum.

25:42

So be aware of that as an option. All right.

25:46

Should we go on to our friend the spleen?

25:49

All right, the spleen not well designed, right? What is it?

25:53

It's like red and red

25:54

and white pulp kind of wrapped in a thin layer of,

25:59

uh, cellophane here.

26:01

Um, it's on a pedicle.

26:02

It's not well adhesed,

26:03

it doesn't have those peritoneal reflections

26:05

to the retroperitoneum.

26:07

Instead, it's just absolutely mobile is all day.

26:09

So, you know, I was tell my residents, like I say,

26:12

it's trauma, you say spleen, trauma, spleen, trauma, spleen.

26:15

So the spleen is really damaged a lot just

26:18

because it's poorly designed

26:19

and there's not much we can do about that, unfortunately.

26:22

So we're gonna look at the trauma, um, grading system here,

26:25

uh, like we did the other one.

26:27

But note that the parenchymal laceration

26:29

for a grade two is up to three centimeters

26:31

and up to over three centimeters already

26:33

upscales you to a three.

26:34

So much smaller lacerations upscale you

26:38

to a much higher grade.

26:39

And that's because the risk of bleeding, um,

26:41

is much higher again, um,

26:44

because that capsule isn't as strong

26:46

and the capsule will, uh, perforate much easier,

26:49

these large subcapsular hematomas as well.

26:51

We'll see, um, can be a problem.

26:53

And I'll show you cases of that

26:55

and know that, um, the active, uh, bleeding is a grade five.

26:58

So once you're actively bleeding into the peritoneum

27:01

of the spleen, grade five, it was a grade four in liver.

27:05

So, um, it's a, you're bleeding a lot more.

27:08

Again, we have that upgrading for multiplicity

27:12

and we're just gonna start at two.

27:14

'cause I just don't believe in

27:15

anything under one centimeter.

27:16

I'm just not that good. Maybe I should wear glasses.

27:18

Um, but either way, you're going to see here that we have,

27:21

uh, a nice splenic laceration.

27:24

Sorry, I went through that suit so fast, uh,

27:27

that it was hard to see it with, um, hemoperitoneum, uh,

27:31

but no active extravasation of contrast.

27:33

Typical appearance of, um, a grade two, one

27:38

to three centimeter laceration with hemoperitoneum.

27:42

Here we have a grade three laceration.

27:44

These are bigger, this is greater than three

27:46

centimeters for sure.

27:47

No, no active extravasation either.

27:50

We have fairly large lacerations here in this patient.

27:54

Woo, a big subcapsular hematoma.

27:56

Notice I'm gonna call this a subcapsular hematoma,

27:59

not per splenic bleeding

28:00

because of the deformity of the underlying splenic tissue.

28:04

Okay? So if it looked like a normal spleen with just blood

28:07

around it, that's per splenic.

28:09

Once it starts deforming the spleen, then

28:12

that's a subcapsular hematoma.

28:14

That is a ticking time outta my friend

28:16

that is like under pressure.

28:18

I wanna sing the queen song under pressure,

28:20

like it's under the pressure and it can just blow up.

28:23

So these are, um, very dangerous.

28:26

We wanna really like, think of those sub sub hapa, those,

28:29

um, uh, the subcapsular hematomas as a,

28:33

as a real, as a really high end injury.

28:36

Here's a patient who has some bleeding

28:38

just confined to the spleen.

28:39

It took me forever to find this

28:41

because I actually don't think this is that common.

28:43

Um, but you know, I tell you, our surgeons

28:46

who make upgrading systems, they they get creative,

28:48

they get creative, um, unicorns and rainbows.

28:53

Um, here's a more common, once you get to grade five,

28:55

you get, once you get to inter parenchymal

28:57

bleeding, that's the fun.

28:59

Um, that is when you have a grade five

29:01

and you just look at your surgeon, you say grade five,

29:04

you drop the mic, you walk out the door

29:05

and you let them take the patient

29:06

off the table and get out, right?

29:07

Because, you know, that's bad. Um, we like to say that.

29:12

And mo many of those will either go for embolization

29:14

or for, uh, splenectomy.

29:17

This is a grade five

29:18

because, um, there's active extravasation.

29:21

And I would like to say potentially if I stop this, um,

29:25

you would call this shattered, uh,

29:28

that is a non-medical term

29:30

that I've talked to our, our trauma surgeon.

29:32

They're like, what do you mean by shattered?

29:33

They're like, I don't know, when you pick it

29:34

up, it falls through all your fingers.

29:35

And I'm like, oh, well, you know, I'm not doing that.

29:37

Um, so a shattered spleen,

29:39

but it's kind of fun to say shattered in your,

29:41

in your reports just to make it more dramatic.

29:43

Um, so, you know, can we, what can we do?

29:45

Uh, if the patient is stable,

29:46

they will embolize these at times.

29:48

Um, and you'll see, uh, they're able to salvage the spleen,

29:52

which is ideal for the patient.

29:54

Um, but when they're unstable,

29:55

those patients are usually going

29:57

for splenectomy, unfortunately.

29:58

So this is an interesting case here.

30:00

We have a patient who let me get this movie going,

30:04

has some lacerations to the spleen

30:06

and notice that they're all at the splenic hilum, um, loss

30:08

of lacerations and irregularity in the splenic hilum.

30:12

So this is pretty high grade injury.

30:14

Um, and when we look here, you can see

30:15

that there is a little focus of contrast that's irregular.

30:19

It doesn't look like a vessel. It's pretty far this in,

30:21

in the hilum

30:23

where there should just be nice delicate vessels.

30:25

Um, and that little pool of contrast is the same attenuation

30:29

as the aorta here.

30:31

And again, similar to that case I showed you a while ago,

30:34

you can see that it, um,

30:35

it actually has blood revolving in it, in

30:39

that the blood here in this space is the same attenuation

30:43

as blood pool in the aorta.

30:45

And this is a splenic pseudo aneurysm.

30:48

Um, it was, the patient was imaged 24 hours later,

30:50

unfortunately, at the time of interpretation,

30:53

no one really noticed this.

30:54

And they just said multiple splenic lacerations.

30:57

Um, and this patient was discharged, uh, to, um,

31:01

a rehab center where their spleen had delayed rupture.

31:04

And that was a big problem. So this is one

31:07

of those situations where this is our job,

31:09

you know, do your job right.

31:11

Our job is to look for the things that would make a patient

31:16

unstable, which make a patient look stable to a surgeon,

31:20

but we know puts them at future risk of rupture.

31:23

So definitely always look for these pseudo aneurysms.

31:26

And sometimes you don't know when they're gonna happen.

31:27

Here's somebody who just had a pretty high end, a young, uh,

31:30

a young, uh, football player with a high end splenic injury,

31:33

didn't have any extra, extra active extravasation,

31:35

but when they came back a couple of weeks later, um,

31:39

they were imaged with ultrasound

31:40

'cause they were, uh, they were a teenager.

31:43

And you can just see that on this ultrasound clip,

31:46

which is causing me trouble.

31:47

Um, there's just this fluid space.

31:49

Well, our technologists are brilliant

31:51

and they, um, did a beautiful color sweep here

31:54

where you can see that region of koic,

31:59

irregular koic fluid is indeed blood.

32:02

And this is that ying yang appearance,

32:05

that pseudo aneurysm within the splenic parenchyma

32:09

where the blood is going towards the probe and is red

32:12

and the blood going away from the probe, um,

32:14

because it's blood going into this potential space

32:17

and swirling here.

32:19

Um, and this is definitely at risk of rupture.

32:22

We, uh, then repeated it a CT scan where you can see

32:25

that area with the arterial phase and delayed.

32:28

And the patient went on to, um, uh,

32:33

embolization of the pseudo aneurysm

32:35

and they were able to keep their spleen, which was lovely.

32:38

So we're always looking for the splenic aneurysm, right?

32:41

We're always looking for the intraparenchymal pseudo

32:44

aneurysm because that was, is what can rupture.

32:47

Well, let's talk again. All right.

32:49

So, you know, I show you the troubles. Let's do that.

32:51

So here's another patient who had, um,

32:55

who was a sports sports player as they are

32:58

and got a hockey stick.

32:59

'cause we like our hockey here in Boston, um,

33:02

to the left upper quadrant.

33:03

I can tell you as a mom, I'm always

33:05

so glad my kids didn't play hockey too early in the morning.

33:08

Um, if you're, if you played

33:09

hockey, you should love your mom.

33:10

Anyway. Um, you can see here

33:12

that there are some splenic lacerations, small ones.

33:15

I'm gonna make this bigger

33:18

and I think I can convince you that this per splenic blood

33:24

is not per splenic blood.

33:25

It's actually subcapsular blood.

33:27

Notice that the capsule is in continuity

33:30

here with that hematoma.

33:31

So that's different. These small little lacerations would've

33:35

been fairly low grade injury.

33:36

But once you have a big per splenic hematoma,

33:38

you're at least a grade three.

33:40

This patient unfortunately was discharged.

33:42

They were like, oh, they're okay.

33:46

Small, um, splenic lacerations.

33:48

Uh, but because people don't listen to doctors, um,

33:52

this patient decided to go and play hockey the next day.

33:55

And we were lucky that they were close to the hospital

33:57

because this is what happened

33:59

after their conservative management.

34:02

Um, they came back with just a huge ruptured spleen,

34:05

active extravasation of contrast, large volume

34:07

of hemoperitoneum.

34:08

Look at how small the aorta is.

34:10

We have all of the findings of shock in this patient,

34:14

including that collapsed aorta, a large volume of site,

34:17

large volume hemoperitoneum and the like.

34:20

And this patient unfortunately did go on

34:22

for a splenectomy as a result of this.

34:24

So it just breaks up the, brings up the point

34:26

that we in medicine have really moved towards a conservative

34:29

management approach to a lot of, um, entities.

34:33

But that's not a no management approach,

34:37

like conservative management.

34:38

The patient is supposed to be laying flat,

34:40

maybe not playing hockey, um,

34:43

and have serial hematocrits drawn and serial exams.

34:47

Um, and then you can safely manage them for, for a period

34:49

of time until you believe that they have stabilized.

34:51

Also, I think if this had been graded properly based on the

34:55

hematoma, um, they would've been less likely

34:57

to be discharged here.

34:59

So, um, we really have

35:01

to bring up those per splenic hematomas.

35:03

Have I told you this enough?

35:04

You're looking for pseudo aneurysms

35:05

and per splenic hematomas.

35:07

Yes, yes, yes. Those are the ones that cause us trouble.

35:11

This is just fun. This is a patient who came in

35:13

after having had a splenic injury

35:16

and you can just see all of these little dots

35:19

of bright spleen throughout the whole abdomen into the

35:23

paracolic gutters.

35:25

Impressive, right?

35:26

This is stenosis and a patient whose spleen was shattered

35:29

and then just traveled everywhere it wanted to in the body,

35:32

which makes you realize how.

35:34

And they also have appendicitis. That's just an aside.

35:36

Um, how, uh, how, you know,

35:39

the spleen can be like a parasite.

35:41

It's pretty impressive. All the way down into the pelvis

35:43

as well, into the cul-de-sac.

35:45

Um, and can grow wherever it wants to.

35:47

So don't mess with the spleen.

35:48

Here's a little bit of, um, spleen that decided

35:51

to grow in the abdominal wall

35:52

after a s splenectomy that was done

35:53

for a stab wound, I believe.

35:55

So the fun is, um, at times when you see, uh,

35:59

these crazy abdominal cases

36:02

where you think, oh, what could that be?

36:03

Always think, could I be dealing with osis?

36:06

Could I be dealing with endometriosis?

36:08

Those are the two things. Oh, end tuberculosis.

36:10

I'm telling you those three things cause you more trouble

36:13

as a, as a radiologist in life.

36:15

I mean, what do I like to tell my re my medical students?

36:19

Tuberculosis causes everything but pregnancy.

36:21

So, um, you know,

36:23

whenever you're thinking of some weird stuff,

36:25

do you have sp osis endometriosis or tuberculosis?

36:28

But I digress. Let's go on.

36:30

Okay, so now let's talk about some pancreatic trauma.

36:34

Um, this is not as common. This is a rare bird.

36:37

Uh, it's, uh, pretty uncommon to have pancreatic trauma.

36:41

You have to have a pretty deep abdominal blow.

36:44

Um, sometimes from bike riding.

36:46

Bike handle, I think would be your USME question.

36:49

Um, and it's, it's, it's tough to get.

36:52

Uh, also, we like to say about the pancreas.

36:55

Eat when you can sleep with, you can,

36:56

but don't mess with the pancreas.

36:57

So you do not want pancreatic trauma. It is bad.

37:01

Usually takes a deep abdominal blow

37:04

where the pancreas cont chooses against the spine

37:06

and can be quite devastating.

37:08

The mortality is very high from nine to 34%.

37:12

I hate when mortality are like a large variation like that.

37:14

Um, and you know, there can be direct signs of,

37:17

of pancreatic trauma here.

37:19

You can have lacerations, transections, focal enlargement,

37:22

but you can also have indirect signs of pancreatic trauma

37:24

where you just have fluid collections, hematomas, um, and,

37:28

and the likes and stranding.

37:29

So we always wanna take a good close look at the,

37:32

at the pancreas because it is so evil and out to get you.

37:36

Um, I mean any organ that can digest you from inside of you.

37:40

Mm, not the best. Uh, so you wanna be really careful here.

37:45

When we talk about evaluating, we're always gonna evaluate

37:48

for contusions and lacerations.

37:50

The lacerations should be a bit more linear and,

37:52

and in, um, appearance.

37:55

Now pancreatic trauma has a really weird grading system,

37:59

but we're gonna go with it 'cause we can't choose again.

38:01

It's, it's, um, determined by the, uh, the trauma surgeons,

38:05

and I'm gonna go into it, but a lot

38:07

of it is based on the location in the pancreas,

38:10

whether it's in the proximal pancreas, which is defined

38:13

as proximal to the smv, uh, to the portal vein here,

38:16

SMV portal vein axis, that would be the proximal pancreas

38:19

as opposed to the distal pancreas.

38:21

Here, remember that the pancreas lies in the,

38:26

um, anterior pararenal space.

38:29

If we remember our tricompartmental theory of the re of the,

38:32

um, retroperitoneum, which I teach,

38:34

I think in my abdominal imaging course, um,

38:37

I do know that it's in there.

38:38

Uh, so anyway, it's always, you know, you're gonna look

38:41

for fluid in this space that kind

38:42

of just interdigitates posterior to the, um, to the, to the,

38:46

uh, colon here and look in that space.

38:49

This is just a patient with pancreatitis showing you

38:51

that fluid kind of deep in those little,

38:54

that little anterior pararenal space deep

38:57

to the paracolic gutters.

39:00

Okay? So the pancreatic grading system is really based on

39:03

whether or not you can determine if the pancreatic, um,

39:07

injury involves the duct.

39:08

This can be nearly impossible, but we're gonna try.

39:11

Alright, so, um, the, the various, uh,

39:15

locations are really important.

39:16

So we're gonna talk about the low grade injuries

39:19

where they probably don't involve the duct versus the high

39:22

grade injuries where the duct is involved.

39:25

So, um, we're gonna grade them based on location, proximal,

39:29

distal and duct or no duct in involvement.

39:32

And you know what? You're just gonna do the best you can.

39:35

You, the pancreas is hard.

39:36

The pancreas is mean to all of us.

39:38

It's mean to the surgeons, it's mean to the patients.

39:40

It's mean to us as well. So at times you'll just see like a

39:43

grade one where you just have a small peri peri

39:45

pancreatic hematoma.

39:47

Um, and you just have some indistinct ness

39:48

of the pancreatic head as we have here.

39:51

Other times you may see a pancreatic laceration hard

39:54

to determine if it's really to the level of the duct or not.

39:57

Um, I usually try to make, uh, three, uh, curved reformats

40:01

to the actual pancreas to make these images

40:04

or try to determine that.

40:05

I mean, they're pretty everyone. And then I like put my

40:07

name on them to get credit.

40:09

Um, everyone thinks they're really fun

40:10

and exciting during a pancreatic,

40:12

during a trauma conference.

40:13

So that one, maybe it's less than 50%, you'd have to try

40:16

to grade that as is, um, some contusions, which are just,

40:20

uh, focal defects of the pancreatic, um, parenchyma

40:24

and, um, low attenuation regions.

40:27

But, um, you know, this is somebody

40:29

who is a, who is a biker.

40:31

We like to bike in Boston, not the safest place

40:33

to bike, but we do it anyway.

40:34

And they had this contusion so at least we can grade that.

40:37

The patient has a contusion of the pancreas.

40:39

And the important thing about that is,

40:40

although we may not be able to really tell if it's a higher

40:43

low grade, um, injury at that time,

40:46

we will always suggest a 24 hour follow up of all

40:50

of the pancreatic injuries if they're non-operative at the

40:52

time of injury.

40:54

Um, because then here we can see that there's a lot

40:56

of fluid developing over time.

40:57

So probably it does involve the duct in this case

40:59

or has gone on to eat itself into the duct.

41:03

Um, so we will, uh, want pretty early, um,

41:06

intervention there, which is important.

41:09

Uh, here's a, um, again,

41:11

increased fluid at that 24 hour spot.

41:13

This same patient goes on for, um, an endoscopy

41:18

where they can, where you can actually see extravasation

41:20

of contrast from the injured duct, um, outlining the aser,

41:24

uh, formation of the remainder of the tail of the pancreas.

41:27

And they put in a nice duct stent in order to have that, um,

41:31

uh, in that ductal injury heal conservatively.

41:36

So that's an option here, which is, which is quite nice.

41:38

But we usually, if we see any injury,

41:40

you're gonna get a 24 hour follow up if there's increased

41:43

fluid or duct injuries.

41:44

Um, the decision will have to be between going surgically in

41:47

or going in endoscopically and adding a stent.

41:51

Here's one, you know, once you get to to um, grade three,

41:54

you have a duct injury, it's usually a distal injury.

41:56

This is a distal transection

41:58

or deep parenchymal injury as well.

42:00

Here's a patient who, oh, that's our patient who had the one

42:04

that we thought was a grade duke

42:05

but was a grade three with duct injury.

42:07

Now here's a patient who had a snowmobile accident.

42:10

Um, you can tell that it was a pretty dramatic an accident

42:12

from the 3D reformations of the femur

42:14

with bilateral femoral injuries.

42:16

Um, and uh, significant impaction there.

42:19

We have a bunch of small lacerations within the left lobe

42:23

of the liver where the patient, um, again,

42:25

that handlebar injury of a snowmobile might occur.

42:30

And as we come down we're going to, I was gonna show it.

42:35

You're gonna just barely see a pancreatic injury.

42:39

They're subtle, right?

42:41

Um, just a little tiny laceration there.

42:43

But because you know, the patient had these large, um,

42:46

midline, uh, liver lacerations, you're gonna look like

42:50

millimeter by millimeter at the pancreas.

42:52

So that's a beautiful pancreatic injury.

42:54

Grade three distal to the, um, pardon me, distal

42:58

to the SMV access in pretty large grade.

43:02

This is the patient after they were transferred

43:04

that same patient with um,

43:06

a large volume pancreatic ascites.

43:08

Uh, unfortunately, um, let's go on

43:11

to a more interesting one.

43:14

Here's a large transection of the distal pancreas as well

43:17

that also had a kidney injury.

43:19

So that would be kind of a left sided package

43:20

where the patient has significant injury to

43:22

that left upper quadrant causing a, uh, a, um,

43:25

endothelial injury to the vessel as well.

43:29

Okay, so here's your 21-year-old in a bar fight.

43:32

Woke up with some abdominal pain coming down.

43:35

We are in our axial view.

43:37

Again, you're gonna see the pancreas here.

43:38

Pancreatic body, a bit of fluid, not good, not good.

43:41

And then you'll see a large defect

43:43

of the pancreas in the midline here.

43:45

Again, that's the pancreatic body distal to the,

43:47

to the level of the S-M-V-S-M-A with a bunch of blood

43:51

and fluid around that.

43:53

Um, mesenteric root.

43:54

And this is a large, fairly classic pancreatic injury

43:59

where you actually see the defect.

44:00

It's in that location right anterior to the spine from

44:04

just a deep abdominal blow her lower.

44:08

This is how Houdini died.

44:09

He had um, a trick he used to do where he would let people,

44:14

uh, punch him in the stomach

44:15

but he would flex the muscles of his abdominal wall

44:17

and he was able to survive it and someone sucker punched him

44:20

and punched him really hard in the stomach

44:21

and it caused him to have pancreatic laceration,

44:25

um, as a result of that.

44:26

So, um, this is a typical like large scale pancreatic

44:30

injury, which is very, very bad.

44:33

And um, accounts

44:34

for about this pancreatic body location right in front

44:36

of the spine accounts for two thirds of the injuries.

44:39

If you're lucky it can be repaired,

44:40

but it takes quite a bit for the surgeons

44:42

to get this repaired and that they frequently have

44:44

to do a jho, uh, pancreatic aje ostomy here.

44:47

And so off the, um, the other end. So it's pretty dramatic.

44:51

Here's a patient trying to find a grade four.

44:53

It was pretty hard. Um, proximal injury, you know,

44:56

I don't think a lot of these actually come to us,

44:57

but here you can see one where you just have zero

44:59

distinctness of the pancreatic head.

45:01

The patient has a big contusion in that location.

45:03

So we call this a grade four.

45:05

Um, it's not that common and they can be pretty devastating

45:09

'cause you're, you can uh, ul some

45:11

of the more delicate architecture of the um,

45:14

common bile duct and the like, you know, uh,

45:17

grade five haven't seen it.

45:19

Probably you're not hitting me in the,

45:21

you're probably not coming to me if you've got a shattered

45:23

pancreas to be honest, you probably have a

45:24

shattered brain in that case.

45:26

Um, so I like to call it spontaneous human

45:28

combustion 'cause I think it really is.

45:29

Um, once you are combusting your pancreas to that level,

45:34

you are probably combusting.

45:37

Let's move on to some more

45:38

of the deep abdominal injuries here.

45:40

Here's a 19-year-old who got knee by a bouncer.

45:43

We are college tenol.

45:44

Um, so as you come down you're going to see

45:48

this big mixed uh, attenuation lesion here, kind of um,

45:52

uh, fluid and soft tissue.

45:54

This patient did get oral contrast

45:56

'cause it was kind of when we were still

45:57

using a lot of oral contrast.

45:58

And honestly he came in a couple days

46:00

after this injury when he was just, and he was vomiting.

46:04

So, um, I think the thought was

46:06

that he had something else going on.

46:08

But you see this very big, uh,

46:10

large duodenal hematoma right in front of the spine like

46:13

that causing gastric outlet obstruction.

46:15

So this is a big, um, did I say echogenic?

46:18

I didn't mean to say that. Uh, mixed attenuation region

46:21

of this third portion of the duodenum, typical

46:24

for a duodenal hematoma.

46:26

Frequently they will come in with signs

46:28

of gastric outlet obstruction

46:31

and they can even have active bleeding within them.

46:33

Um, they're usually treated conservatively

46:35

'cause if you can just not touch these, you're better off.

46:37

Uh, and they will, um, make the patient NPO uh,

46:41

for a long period of time.

46:42

Sometimes we'll put in a judge ostomy tube, um,

46:44

percutaneous ju ostomy tube, uh, if they have to

46:47

or they'll put you on TPN.

46:48

So it's a pretty dramatic injury.

46:50

Um, kind of classic to that location.

46:52

Here's this, uh, 46-year-old who decided

46:54

to ride his motorcycle through fan hall,

46:55

which is a big tourist destination where we are

46:58

and unfortunately hit the metal chain in his abdomen.

47:01

So let's come on down.

47:02

Um, and that's a deep abdominal blow if I've ever heard one.

47:05

And we have a lot of edema

47:06

and blood around the root

47:08

of the mesentery there coming down.

47:11

Sorry, we're gonna see even more blood in that location.

47:15

And you're actually going to start to see distinctness

47:19

of the second portion of the duodenum, more blood

47:22

and fluid into the retroperitoneum

47:24

and actually a dot of error as well.

47:26

So this is an appearance of, um, the blowout of the second

47:30

to third portion of the duodenum.

47:31

You can see that below here. I'm gonna make it bigger.

47:34

You can see the second portion of the duodenum coming

47:36

over to the third portion.

47:37

And we actually have blown

47:38

through the wall inferiorly at surgery.

47:41

They can see a large laceration.

47:42

Here is the liver, here is the gallbladder

47:44

and that large duodenal blow.

47:46

This is a pretty typical location.

47:48

Let me see if I can bring up the, um, image here.

47:51

So back from Grey's Anatomy, when you have impaction of

47:56

the pylori here

47:59

and this third portion of the duodenum against the, um,

48:02

spine hard for that blow,

48:05

actually the weakest portion according

48:06

to the plus's law would be this

48:08

under surface of the second portion.

48:10

So it just blows out. So it's actually just

48:12

that sudden pressure in the c portion of the duodenum

48:15

that causes this, uh, injury.

48:18

Now what we didn't make on this, on this study,

48:20

and let tell you this surgeon let me know as they do,

48:23

is the fact that there is also an

48:26

avulsion at the ligament of trites.

48:27

And I haven't made that, that, um, mistake again

48:30

because I find it so frequently now.

48:32

Um, and that's basically

48:33

where the duodenum goes from the retroperitoneal more fixed

48:38

location up to the ligament of trites of the jun.

48:40

And that's a relative location of fixation versus mobility.

48:43

And during those are the locations that cause problems

48:46

during, um, during a sudden stop for during your sudden, uh,

48:50

uh, blunt trauma.

48:52

That's the location of sheer injury,

48:54

whether it's your aorta be between, uh, the ESUs

48:57

of your aorta, that's a similar location

48:59

between mobile ascending and relatively fixed descending.

49:03

So the ligament of traits avulsions are to be looked for,

49:06

follow the duodenum all the way into the genome

49:10

'cause you'll just find that they will be discontinuous

49:12

as we see in this surgical situation.

49:14

Here's a 17-year-old, um, definitely injured.

49:18

We have a renal injury there.

49:19

Uh, with uh, devascularization we have a lot of fluid

49:24

in the left upper quadrant.

49:26

I mean the question is do we have a pancreatic injury

49:28

or duodenal injury?

49:29

It can be really hard, but I would say the pancreas looks

49:31

fairly homogeneous and attenuation.

49:34

And as you come down you can actually see defects within

49:36

the jejunum here.

49:38

So if you see fluid interloop fluid in a trauma patient

49:42

in the left upper quadrant, you have a small bowel injury,

49:46

they're not that uncommon.

49:47

Um, other things you wanna look for though,

49:49

when you have these deep abdominal blows,

49:51

these singular deep abdominal blows are injuries

49:54

to the aorta.

49:55

Here's a minimal aortic injury,

49:56

just a tiny endothelial injury that's gonna need to be cared

50:00

for maybe with anticoagulation.

50:01

And here's just a extremely dramatic pseudo aneurysm

50:04

with a focal rupture.

50:06

So something to be aware of.

50:07

Now moving on to instead

50:09

of those high deep abdominal blows from the, um, snowmobile

50:13

or the bike, let's talk more about the motor vehicle

50:17

accident where you have seatbelt injuries.

50:19

Seatbelt injuries tend to be a little lower down.

50:20

You're gonna get that, um, that seatbelt, uh, you know,

50:25

hematoma along the lower abdomen if placed correctly.

50:28

Let's go to this one, lemme play it again

50:31

and you're gonna see that there's hemoperitoneum here.

50:33

Um, but coming down you'll also see that there's a lot

50:36

of blood in the, in the right lower quadrant

50:38

with little tiny, um, regions

50:40

of active extravasation as well.

50:42

And that's from these deep abdominal blows lower down

50:45

where you can have, uh, injuries to the mesentary.

50:49

Um, these mesentary injuries usually have fluid,

50:53

accumulate fluid and fluid

50:55

and blood accumulate in, um, the interloop areas

50:58

of the bowel causing these kind of classic triangles

51:02

of blood in the mesentery.

51:03

So as soon as you see trials of blood, you want to say

51:07

that there's a mesenteric injury

51:08

and a potential bowel injury.

51:10

So let's go on. Um, here again we have mesenteric fluid

51:14

and then we have another finding that we see in the setting

51:16

of these deep abdominal lower abdominal blows,

51:19

which is a traumatic lumbar hernia.

51:21

When you have that just sudden impact on your,

51:24

on your lower abdomen, you can actually blow out

51:27

of the abdominal wall causing a traumatic injury.

51:30

Here, of course it's named as all of the hernias are.

51:34

Um, you know, if only I could get my name on a hernia,

51:37

I'd be so sad, so excited.

51:38

But we just call them traumatic lumbar hernias

51:40

or petit hernias

51:41

and those have a very, very, very high likelihood

51:44

of bowel injuries regardless.

51:46

So you always wanna look for those.

51:47

And in this case it's kind of nice,

51:49

you can use your hyper enhancing bowel from your patient

51:52

who has a bit of shock bowel to tell them

51:54

that there's no enhancement of the ileum here.

51:56

And indeed they went in for surgery

51:57

and it was just completely uls.

51:59

Um, 'cause what happens is during these situations

52:01

that there's a lot of traction

52:03

and, um, traction on the mesentery to the small bowel

52:06

and it can just rip off such as this, it's called a handle,

52:10

uh, bucket handle tear of the mesentery

52:12

and it just devascularize, uh, loops of small bowel

52:15

and they can shear as well.

52:16

You may even see very dramatic cases

52:18

where the entire abdominal wall has um, blown out

52:22

and you have, uh, the bowel contents just kind

52:24

of laying in the subcutaneous tissues as such.

52:27

Small bowel is, you know,

52:28

small bowel injuries can be very difficult.

52:30

Like frequently. We really don't get these small bowel

52:33

injuries where you have extra luminal error.

52:34

Like, that'd be nice. But most

52:36

of the time it's just an indication

52:37

that you have a small bowel injury

52:39

because of the mesenteric fluid that, um,

52:44

that, uh, lumbar hernia or some other secondary signs.

52:48

Now clinically, small bowel uh, injuries

52:52

and colonic injuries usually don't

52:53

present for about 24 hours.

52:55

So those patients will become Perone attic, um,

52:58

regardless in 24 hours.

53:00

But we, we try to make the diagnosis as soon as possible

53:02

so they can be remedied

53:04

before, you know, peritonitis signs in, which is good.

53:07

Um, here's another case that I found very interesting here.

53:09

We had a patient who came in, um, with

53:12

that seatbelt sign clinically

53:14

with the contusions on the flanks.

53:16

Um, we had, uh,

53:17

hematoma in the right lower quadrant in those interloop

53:20

regions and we had that hernia as well.

53:23

So this is an indication

53:24

that the patient had a bowel injury.

53:26

Um, then the patient got a follow up

53:29

for some other reason a week later

53:31

and you could see some very thickened bowel there, which is,

53:34

which is an indication of a problem.

53:35

Now, I met the patient at three month follow up where um,

53:40

they were coming into the ER with,

53:42

with abdominal pain in inability

53:44

to eat and feeling really bad.

53:46

And we saw this, uh, loop of small bowel

53:48

with hyper enhancing mucosa

53:51

and uh, really hypertrophied blood vessels

53:54

to that small bowel loop.

53:55

And, um, everyone seemed to think that the person had, uh,

53:58

Crohn's disease just

53:59

'cause that's a similar appearance of Crohn's disease,

54:02

though it's not in the terminal ileum.

54:04

And it makes you realize that probably Crohn's disease

54:05

really is a microvascular ischemic, uh, process.

54:10

Um, but this indeed,

54:11

because we had the old ones, we were able to say, no, no,

54:13

no, no, no, don't,

54:14

well they didn't believe us and they did it anyway.

54:16

Um, we were like, no, no, no, it's an ischemic, uh,

54:19

stricture related to this bowel injury.

54:21

Probably that bucket handle tear of the mesentery.

54:24

So, um, but they were like, no, we think he has Crohn's,

54:26

his brother has Crohn's

54:27

and they gave him steroid for a couple months.

54:29

And I tell you, I followed this case.

54:31

I followed it, followed it, followed it

54:33

until finally they took him for surgery.

54:35

Um, and uh, it was indeed a chronic ischemic,

54:39

uh, enteritis.

54:41

So, you know, sometimes you have

54:42

to let the surgeons know back that they miss things too.

54:45

Um, and uh,

54:46

but bowel injuries are something that you just have

54:48

to have a really pretty good awareness

54:50

of knowing if they have an upper abdominal in um, injury.

54:53

You really wanna look for those ligament of traits,

54:56

injuries, uh, those are pretty subtle.

54:58

And then the lower injuries,

54:59

you'll have those bucket handle tears

55:01

of the small bowel and colon.

55:03

Um, really highlight that

55:04

as a possibility if you have the hernia

55:07

or the um, triangles of blood.

55:11

Alright, thank you very much. I hope that that was helpful.

55:15

Um, if there are any questions, I'm happy to answer them,

55:18

but I also wanna highlight, uh, the abdominal pro call prep,

55:23

um, course that was put together in the fall

55:25

and finally released now.

55:27

Um, you know, I spent a lot of time on that.

55:29

There was some all-nighters in my fifties, so, um, uh,

55:32

please give feedback on that

55:33

and have a chance to look at that.

55:35

It's not traumatic, um,

55:36

but it has a lot of really good er content as well.

55:39

And thank you so much for inviting me

55:40

and I hope that this was a foray through some

55:43

of the more fun aspects of trauma.

55:46

Thank you so much, Dr. Avery. That was excellent.

55:49

Excellent, excellent. We've got a couple questions

55:51

and then we'll get you outta here.

55:53

Um, how do you differ

55:55

between a pseudo aneurysm para hemal from a heman heman?

56:00

Well, I can't say the word. Uh,

56:01

Heman, Yes, thank you so much.

56:04

Interesting. Um, you know,

56:06

honestly a pseudo aneurysm is just blood.

56:08

The hemangiomas, at least, you know, in the liver

56:10

and like in the spleen too, have

56:12

that peripheral nodular enhancement that comes in slowly.

56:15

So I would say that on your arterial phase you're gonna have

56:18

just a pool of blood that,

56:19

that then just goes straight with blood pool.

56:22

It's not gonna have this centripetal enhancement pattern.

56:25

It'll just be a blood pool arterial and then portal venous.

56:29

Got it. All right. This is a double question.

56:32

If you have a single porter Ven portal venous stays

56:35

of the abdomen and you see contrast extra visitation,

56:38

how are you able to differentiate if the contrast is from an

56:41

arterial source versus a venous source?

56:44

So it's, the attenuation of the contrast will be higher.

56:47

If it's arterial it should be like 300.

56:48

If it's venous it should be a little lower,

56:50

like 120 or something.

56:52

So usually you can determine, um, if you have high,

56:55

high attenuation contrast

56:57

because that's what's gonna be the pre blood pool

56:59

arterial phase contrast.

57:01

So, um, that's usually how we do it.

57:03

Some people don't like the one pass we're,

57:06

we've kind of abandoned it.

57:07

Um, I still like it.

57:09

Uh, I think it has some major advantages for our trauma

57:13

system here.

57:14

Um, but uh, you know,

57:16

different institutions go back and forth on it.

57:19

I would say it gets trendy for a while

57:20

and then it goes away and comes back.

57:23

Alright. Um, one more, in the case

57:26

before aorta injury, I saw attenuation

57:29

of the left kidney parenchyma.

57:32

Is it related to vascular injuries?

57:34

Yeah, so that was a case of, um,

57:36

a left upper quadrant injury in total.

57:38

I didn't get into too much detail on the, um,

57:41

parenchymal injury of the kidney.

57:43

Um, but it was probably the case with uh,

57:46

a tail pancreatic lesion.

57:48

Um, so a deep abdominal blow causing tail pancreas

57:51

and a vascular injury to the, um, left renal artery.

57:55

Awesome. We

57:57

Do actually try to go in now and salvage those.

57:59

They will take those for interventional, um, uh,

58:02

to our interventional suite and try to stent them.

58:04

That wasn't the case like 10 to 15 years ago,

58:06

but they've had a pretty good rate of, um, salvageability

58:10

so now we're, they're trying for sure.

58:13

Um, okay, I lied one more.

58:15

When you have a, um, metric hematoma and interloop fluid

58:19

but no definite bowel injury, what do you say

58:22

and recommend in terms of occult bowel bowel injury?

58:26

I would highlight that there's a high, so I would,

58:28

you know, I would obviously look for anything.

58:30

I would highlight the fact that there's a high likelihood

58:32

of the col bowel injury.

58:34

Our surgeons would choose to observe that with an indication

58:39

that they're gonna have, you know, pretty close serial exams

58:41

and that the patient should present in 24

58:44

to 48 hours at 24 usually if there is indeed a laceration.

58:48

Um, but also in the case

58:50

where it was just an ischemic stricture like

58:52

that can be a problem in the long run.

58:53

So I think just knowing that there's a high likelihood

58:56

of injury, um, is enough for certain indications for them

59:01

to explore, if not to try conservative management.

59:04

But a lot of patients fail it

59:05

'cause they actually have an underlying bowel injury.

59:07

Bowel injuries are hard to see,

59:09

they're just really hard to see.

59:11

So it's the secondary signs that we have to go with.

59:15

Thank you so much Dr. Avery.

59:16

We will let you get outta here. Appreciate this

59:19

so much and thank you.

59:20

Thank you. Yeah, thank you so much.

59:22

And folks, if you want more from Dr. Avery yes,

59:24

please check out her course.

59:26

Go ahead, Dr. Avery. Did you Yes.

59:28

See the course. It's fun. It's fun, I swear.

59:30

And it, what was it, 90 videos, it took us some time.

59:33

It yeah, yeah. It's worth it though, I promise.

59:37

Um, you can access a recording of today's conference

59:40

and all our previous noom conferences

59:42

by creating a free MRI online account.

59:44

We will also email out a link to this replay later

59:48

and that will also contain the link to Dr.

59:50

Avery's full course. Be sure

59:52

to join us next week on Thursday,

59:54

August 1st at 12:00 PM Eastern,

59:55

where Dr. David Ssim will deliver a lectured entitled How

59:59

to Avoid Getting Sued.

60:01

You can register for that@mrionline.com.

60:03

Follow us on social media

60:05

for updates on future noon conferences.

60:08

Thanks again for learning with us and have a great day.