Advanced

Trauma

Life

Support

ABCDE

from

a

radiological

point

of

view

Accidents

are

the

primary

cause

of

death

in

patients

aged

years

or

younger

In

many

countries

Advanced

Trauma

Life

Support

-LRB-

ATLS

-RRB-

is

the

foundation

on

which

trauma

care

is

based

We

will

summarize

the

principles

and

the

radiological

aspects

of

the

ATLS

and

we

will

discuss

discrepancies

with

day

to

day

practice

and

the

radiological

literature

Because

the

ATLS

is

neither

thorough

nor

up-to-date

concerning

several

parts

of

radiology

in

trauma

it

should

not

be

adopted

without

serious

attention

to

defining

the

indications

and

limitations

pertaining

to

diagnostic

imaging

Introduction

In

many

countries

trauma

care

is

based

on

Advanced

Trauma

Life

Support

-LRB-

ATLS

-RRB-

-LSB-

-RSB-

Although

the

ATLS

manual

and

course

are

neither

evidence

based

nor

up-to-date

concerning

several

parts

of

radiology

in

trauma

surgeons

use

the

ATLS

recommendations

if

present

routinely

to

support

indications

for

diagnostic

imaging

In

addition

surgeons

refer

to

the

ATLS

unjustly

with

indications

for

imaging

that

are

not

supported

by

the

ATLS

at

all

Radiologists

must

be

aware

of

this

to

intervene

appropriately

when

sub-optimal

imaging

indications

are

presented

In

this

respect

knowing

the

content

and

the

language

of

the

ATLS

can

be

helpful

The

objective

of

this

review

is

to

familiarize

radiologist

with

the

ATLS

For

this

purpose

the

rationale

and

indications

of

diagnostic

imaging

is

assessed

where

it

pertains

to

the

ATLS

protocol

Instances

of

disagreement

with

the

evidence

in

the

literature

and

daily

practice

are

highlighted

-LSB-

-RSB-

Purpose

of

ATLS

Accidents

are

the

primary

cause

of

death

in

patients

aged

years

or

younger

In

The

Netherlands

out

of

people

die

each

year

because

of

accidental

injury

For

every

one

patient

who

dies

there

are

three

survivors

with

serious

disabilities

-LSB-

-RSB-

The

purpose

of

adequate

trauma

care

is

to

decrease

this

morbidity

and

mortality

which

is

expected

to

be

achieved

by

fast

systematic

and

effective

assessment

and

treatment

of

the

injured

patient

Contrary

to

the

ATLS

guidelines

we

think

that

imaging

should

play

a

prominent

role

in

this

process

History

of

ATLS

In

an

airplane

with

an

orthopedic

surgeon

his

wife

and

children

crashed

in

a

corn

field

in

Nebraska

The

wife

died

The

surgeon

and

three

of

his

four

children

were

seriously

injured

Although

they

survived

he

considered

the

standard

of

care

in

the

local

hospital

insufficient

and

decided

to

develop

a

system

to

improve

the

care

for

trauma

victims

and

thus

ATLS

was

born

Since

the

first

ATLS

course

in

the

concept

has

matured

has

been

disseminated

around

the

world

and

has

become

the

standard

of

emergency

care

in

trauma

patients

in

countries

-LSB-

-RSB-

The

ATLS

concept

is

also

used

in

the

pre-hospital

phase

of

trauma

patient

care

and

has

been

adopted

for

non-trauma

medical

emergencies

and

implemented

in

resuscitation

protocols

around

the

world

Originally

ATLS

was

designed

for

emergency

situations

where

only

one

doctor

and

one

nurse

are

present

Nowadays

ATLS

is

also

accepted

as

the

standard

of

care

for

the

first

-LRB-

golden

-RRB-

hour

in

trauma

centers

The

priorities

of

emergency

trauma

care

according

to

the

ATLS

principles

are

independent

of

the

number

of

people

caring

for

the

patient

ATLS

course

The

ATLS

course

is

organized

under

license

of

the

American

College

of

Surgeons

Before

the

course

the

students

peruse

the

course

manual

During

a

course

students

mostly

residents

in

surgery

and

anesthesiology

are

trained

by

eight

instructors

These

instructors

now

number

more

than

in

the

Dutch

ATLS

section

mostly

surgeons

and

anesthesiologists

but

also

two

radiologists

During

the

course

all

emergency

measures

are

taught

and

reviewed

By

means

of

observing

practicing

and

repeating

the

ATLS

concepts

the

object

of

the

course

is

that

the

students

are

capable

to

perform

the

necessary

measures

independently

with

the

correct

priorities

The

course

concludes

with

a

written

and

practical

examination

which

has

a

pass

rate

of

During

the

course

attention

is

also

given

to

the

multidisciplinary

character

of

trauma

care

and

the

organization

and

logistics

of

trauma

care

in

hospitals

and

surrounding

area

Radiology

has

a

minor

part

in

the

course

There

are

only

min

to

teach

the

systematic

evaluation

of

chest

radiographs

and

another

min

to

teach

in

cervical

spine

radiographs

with

the

objective

for

the

student

to

be

able

to

identify

life-threatening

and

potentially

life-threatening

injuries

on

chest

radiographs

and

identify

fractures

on

the

radiographs

of

the

spine

There

is

no

lecture

or

skill

set

concerning

computed

tomography

-LRB-

CT

-RRB-

Essentials

of

ATLS

ATLS

is

a

method

to

establish

priorities

in

emergency

trauma

care

There

are

three

underlying

premises

-LRB-

-RRB-

Treat

the

greatest

threat

to

life

first

-LRB-

-RRB-

Indicated

treatment

must

be

applied

even

when

a

definitive

diagnosis

is

not

yet

established

-LRB-

-RRB-

A

detailed

history

is

not

necessary

to

begin

evaluation

and

treatment

Therefore

the

assessment

of

a

trauma

patient

is

divided

in

a

primary

and

a

secondary

survey

In

the

primary

survey

life-threatening

injuries

are

diagnosed

and

treated

simultaneously

All

other

injuries

are

evaluated

in

the

secondary

survey

Primary

survey

In

the

primary

survey

the

mnemonic

ABCDE

is

used

to

remember

the

order

of

assessment

with

the

purpose

to

treat

first

that

kills

first

-LRB-

Table

-RRB-

Airway

obstruction

kills

quicker

than

difficulty

of

breathing

caused

by

a

pneumothorax

and

a

patient

dies

faster

from

bleeding

from

a

splenic

laceration

then

from

a

subdural

hematoma

Table

the

primary

survey

the

mnemonic

ABCDE

is

used

to

remember

the

order

of

assessment

with

the

purpose

to

treat

first

that

kills

firstThe

ABCDEAAirway

and

C-spine

stabilizationBBreathingCCirculationDDisabilityEEnvironment

and

Exposure

Injuries

are

diagnosed

and

treated

according

to

the

ABCDE

sequence

Only

when

abnormalities

belonging

to

a

letter

are

evaluated

and

treated

as

efficacious

as

possible

can

one

continue

with

the

next

letter

In

case

of

deterioration

of

a

patient

's

condition

during

assessment

one

should

return

to

A.

Imaging

should

not

intervene

with

or

postpone

treatment

A

Airway

The

airway

is

the

first

priority

in

trauma

care

All

patients

get

oxygen

through

a

non-rebreathing

mask

The

airway

is

not

compromised

when

the

patient

talks

normally

A

hoarse

voice

or

audible

breathing

is

suspicious

facial

fractures

and

soft

tissue

injury

of

the

neck

can

compromise

the

airway

while

patients

in

a

coma

are

not

capable

of

keeping

their

airway

patent

Endotracheal

intubation

is

the

most

definite

way

to

secure

the

airway

In

A

the

cervical

spine

needs

to

be

immobilized

As

long

as

the

cervical

spine

is

not

cleared

by

physical

examination

with

or

without

diagnostic

imaging

the

spine

should

remain

stabilized

For

the

evaluation

of

A

no

diagnostic

imaging

is

necessary

Imaging

of

the

cervical

spine

is

just

an

adjunct

to

the

primary

survey

and

not

part

of

the

A

specifically

because

as

long

as

the

spine

is

immobilized

possible

spinal

injury

is

stabilized

and

diagnostic

imaging

can

be

postponed

When

A

is

secure

one

can

continue

with

B.

B

Breathing

Breathing

is

the

second

item

to

be

evaluated

in

trauma

care

Tension

pneumothorax

massive

hemothorax

flail

thorax

accompanied

by

pulmonary

contusion

and

an

open

pneumothorax

compromise

breathing

acutely

and

can

be

diagnosed

with

physical

examination

alone

and

should

be

treated

immediately

Most

clinical

problems

in

B

can

be

treated

with

relatively

simple

measures

as

endotracheal

intubation

mechanical

ventilation

needle

thoracocentesis

or

tube

thoracostomy

The

lack

of

a

definitive

diagnosis

should

never

delay

an

indicated

treatment

To

evaluate

the

efficiency

of

breathing

a

pulse

oximeter

can

be

applied

Injuries

like

a

simple

pneumothorax

or

hemothorax

rib

fractures

and

pulmonary

contusion

are

often

more

difficult

to

appreciate

with

physical

examination

Because

these

conditions

have

less

effect

on

the

clinical

condition

of

the

patient

they

can

be

identified

in

the

secondary

survey

A

chest

radiograph

is

an

adjunct

to

the

primary

survey

and

can

be

helpful

in

evaluating

breathing

difficulties

and

is

necessary

to

evaluate

the

position

of

tubes

and

lines

When

B

is

stabilized

one

can

continue

with

C.

C

Circulation

Circulation

is

the

third

priority

in

the

primary

survey

Circulatory

problems

in

trauma

patients

are

usually

caused

by

hemorrhage

The

first

action

should

be

to

stop

the

bleeding

Hemorrhage

can

be

external

from

extremity

and

facial

injury

or

not

visible

from

bleeding

in

chest

abdomen

and

pelvis

Instable

pelvic

fractures

can

be

temporarily

stabilized

with

a

pelvic

band

to

decrease

blood

loss

Blood

pressure

and

heart

rate

are

measured

two

intravenous

lines

are

started

and

blood

is

obtained

for

laboratory

investigation

In

the

search

for

internal

blood

loss

imaging

can

be

very

helpful

Radiological

investigations

such

as

a

chest

radiograph

when

not

already

performed

ultrasound

of

the

abdomen

-LRB-

focussed

abdominal

sonography

in

trauma

FAST

-RRB-

and

a

pelvic

X-ray

can

suggest

the

localization

of

the

bleeding

A

tension

pneumothorax

can

be

the

cause

of

circulatory

distress

but

is

usually

diagnosed

and

treated

in

B.

When

a

patient

's

condition

deteriorates

this

diagnosis

must

be

reconsidered

Hemodynamic

instability

can

infrequently

be

caused

by

pericardial

tamponade

Therefore

ultrasonography

of

the

pericardial

sac

is

part

of

a

FAST

examination

Other

less

frequently

occurring

causes

of

circulatory

problems

in

trauma

patients

are

myocardial

contusion

and

loss

of

sympathetic

tone

caused

by

cervical

and

upper

thoracic

spinal

cord

injuries

When

it

is

not

possible

to

stabilize

the

patient

in

the

trauma

suite

other

intervention

like

operation

or

embolization

should

be

performed

The

remainder

of

the

primary

survey

will

be

finished

thereafter

When

C

is

stabilized

one

can

continue

with

D.

D

Disability

Disability

should

be

assessed

as

the

fourth

priority

in

the

primary

survey

and

this

includes

assessment

of

the

neurological

status

The

Glasgow

coma

score

-LRB-

GCS

-RRB-

is

used

to

evaluate

the

severity

of

head

injury

This

score

is

arrived

at

by

scoring

eye

opening

best

motor

response

and

best

verbal

response

Patients

who

open

their

eyes

spontaneously

obey

commands

and

are

normally

oriented

score

a

total

of

points

The

worst

score

is

points

A

decreased

GCS

can

be

caused

by

a

focal

brain

injury

such

as

an

epidural

hematoma

a

subdural

hematoma

or

a

cerebral

contusion

and

by

diffuse

brain

injuries

ranging

from

a

mild

contusion

to

diffuse

axonal

injury

To

prevent

secondary

injury

to

the

brain

optimal

oxygenation

and

circulation

are

important

Also

impaired

consciousness

can

be

caused

or

aggravated

by

hypoxia

or

hypotension

for

which

ABC

stabilization

is

essential

If

a

cranial

CT

is

indicated

it

should

be

done

in

the

secondary

survey

E

Environment

and

exposure

Environment

and

exposure

represent

hypothermia

burns

and

possible

exposure

to

chemical

and

radioactive

substances

and

should

be

evaluated

and

treated

as

the

fifth

priority

in

the

primary

survey

At

the

end

of

the

primary

survey

before

continuing

with

the

secondary

survey

the

ABCDEs

should

be

re-evaluated

and

confirmed

Secondary

survey

During

the

secondary

survey

the

patient

is

examined

from

head

to

toe

and

appropriate

additional

radiographs

of

the

thoracic

and

lumbar

spine

and

the

extremities

are

performed

when

indicated

CT

scans

when

indicated

are

also

done

in

the

secondary

survey

If

during

the

secondary

survey

the

patient

's

condition

deteriorates

the

primary

survey

should

be

repeated

beginning

with

A.

The

rigid

spine

board

should

be

removed

as

early

as

possible

because

it

is

a

serious

risk

for

decubitus

ulcer

formation

Removing

the

hard

backboard

should

not

be

delayed

for

the

lone

purpose

of

obtaining

definitive

spine

radiographs

Diagnostic

imaging

Radiographs

of

the

chest

pelvis

C-spine

and

FAST

are

adjuncts

to

the

primary

survey

Imaging

is

considered

helpful

but

should

be

used

judiciously

and

should

not

interrupt

or

delay

the

resuscitation

process

When

appropriate

radiography

may

be

postponed

until

the

secondary

survey

CT

contrast

studies

and

radiographs

of

the

thoracic

spine

lumbar

spine

and

extremities

are

also

adjuncts

to

the

secondary

survey

Imaging

is

most

useful

and

efficient

if

consulting

with

a

radiologist

becomes

routine

-LSB-

-RSB-

We

extrapolate

this

advice

to

the

trauma

setting

and

endorse

consultation

with

clinicians

strongly

however

consulting

a

radiologist

is

not

mentioned

once

in

the

ATLS

manual

Contrary

to

-LRB-

ever-increasing

-RRB-

daily

practice

CT

plays

a

minor

role

in

the

ATLS

With

the

increasing

use

of

CT

in

the

evaluation

of

trauma

patients

radiation

exposure

should

be

a

major

issue

in

the

field

of

emergency

radiology

CT

scanners

using

an

automatic

exposure

control

technique

can

help

to

reduce

radiation

dose

-LSB-

-RSB-

Blunt

trauma

Thorax

A

chest

radiograph

must

be

obtained

to

document

the

position

of

tubes

and

lines

and

to

evaluate

for

pneumothorax

or

hemothorax

and

mediastinal

abnormalities

When

not

obtained

in

the

primary

survey

it

should

be

done

in

the

secondary

survey

From

the

ATLS

manual

it

is

not

clear

if

a

chest

radiograph

should

be

performed

in

every

patient

-LSB-

-RSB-

However

this

is

in

accordance

with

the

literature

At

present

no

clinical

decision

rule

is

available

concerning

the

indication

for

chest

radiography

in

trauma

patients

A

CT

of

the

chest

is

considered

an

accurate

screening

method

for

traumatic

aortic

injury

If

a

contrast

enhanced

helical

CT

is

negative

for

mediastinal

hemorrhage

and

aortic

injury

no

additional

diagnostic

imaging

is

necessary

-LSB-

-RSB-

If

a

CT

is

positive

the

ATLS

manual

states

that

the

trauma

surgeon

is

in

the

best

position

to

determine

which

if

any

other

diagnostic

imaging

is

warranted

The

possibility

to

construct

multiplanar

reconstructions

-LRB-

MPRs

-RRB-

maximum

intensity

projections

-LRB-

MIPs

-RRB-

volumetric

and

virtual

angioscopic

three-dimensional

views

from

MDCT

data

making

diagnostic

angiography

superfluous

is

not

stated

-LSB-

-RSB-

The

same

post-processing

tools

can

be

used

to

differentiate

between

traumatic

aortic

injury

and

normal

variants

-LSB-

-RSB-

Neither

consulting

with

a

radiologist

nor

endovascular

treatment

of

traumatic

aortic

injury

are

mentioned

in

the

ATLS

manual

Although

it

is

recognized

that

the

severity

of

pulmonary

contusions

does

not

correlate

very

well

with

the

chest

radiograph

a

CT

for

the

evaluation

of

pulmonary

contusion

is

not

mentioned

The

superiority

of

CT

in

the

detection

of

pneumothoraces

and

evaluation

of

the

position

of

chest

tubes

is

not

stated

-LSB-

-RSB-

Abdomen

FAST

is

used

in

hemodynamic

abnormal

patients

as

a

rapid

non-invasive

bedside

repeatable

method

to

document

fluid

in

the

pericardial

sac

hepato-renal

fossa

spleno-renal

fossa

and

pelvis

or

pouch

of

Douglas

When

FAST

is

available

it

replaces

diagnostic

peritoneal

lavage

-LRB-

DPL

-RRB-

-LSB-

-RSB-

FAST

is

a

good

performing

screening

tool

in

evaluating

hypotensive

trauma

patients

to

differentiate

those

patients

who

do

need

urgent

laparotomy

from

those

who

do

not

-LSB-

-RSB-

An

abdominal

CT

is

the

most

sensitive

and

specific

investigation

for

the

diagnosis

of

visceral

and

vascular

injury

however

according

to

the

ATLS

an

abdominal

CT

can

only

be

performed

in

hemodynamically

normal

patients

because

a

CT

is

considered

time

consuming

This

is

no

longer

true

with

the

helical

CT

available

today

The

rate-limiting

step

has

become

the

movement

of

the

patient

to

the

CT

suite

and

on

and

off

the

CT

table

-LSB-

-RSB-

According

to

the

ATLS

manual

an

upper

GI

contrast

study

is

the

imaging

method

of

choice

in

suspected

diaphragm

rupture

CT

is

not

mentioned

as

an

option

On

the

contrary

it

is

stated

that

CT

misses

diaphragmatic

injuries

Although

CT

is

not

sensitive

neither

are

GI

contrast

studies

A

comparative

study

is

not

available

MDCT

has

the

advantage

that

it

is

much

easier

and

quicker

to

perform

in

trauma

patients

-LSB-

-RSB-

Although

no

consensus

of

opinion

exists

coronal

and

sagittal

multiplanar

reconstructions

-LRB-

MPRs

-RRB-

might

improve

the

accuracy

of

MDCT

for

the

diagnosis

of

blunt

traumatic

diaphragm

rupture

-LSB-

-RSB-

A

final

omission

and

contrary

to

daily

practice

in

many

hospitals

is

that

interventional

radiology

is

not

mentioned

as

an

adjunct

to

non-operative

management

in

patients

with

abdominal

visceral

injury

-LSB-

-RSB-

Pelvis

It

is

recommended

that

a

pelvic

radiograph

should

be

performed

when

the

mechanism

of

injury

or

the

physical

examination

indicates

the

possibility

of

a

pelvic

fracture

Evaluation

of

the

pelvis

on

an

abdominal

CT

is

not

mentioned

-LSB-

-RSB-

Compared

to

conventional

radiography

CT

has

a

higher

sensitivity

and

specificity

for

the

diagnosis

of

pelvic

fractures

and

MPRs

can

be

used

to

delineate

the

full

extend

of

the

fracture

-LSB-

-RSB-

In

a

hemodynamically

abnormal

patient

with

a

pelvic

fracture

and

no

indication

for

intra-abdominal

hemorrhage

on

FAST

or

DPL

angiography

with

embolization

is

advised

preceding

surgical

pelvic

fixation

In

patients

with

an

unstable

pelvic

fracture

inability

to

void

blood

at

the

meatus

a

scrotal

hematoma

perineal

ecchymoses

or

a

high-riding

prostate

there

is

a

suspicion

of

a

urethral

tear

and

in

these

patients

a

retrograde

urethrogram

should

be

performed

before

inserting

a

urinary

catheter

-LSB-

-RSB-

To

exclude

an

intraperitoneal

or

extraperitoneal

bladder

rupture

in

patients

with

hematuria

a

conventional

or

a

CT

cystogram

can

be

performed

-LSB-

-RSB-

Cervical

spine

Cervical

spine

radiographs

are

not

indicated

in

patients

who

are

awake

alert

sober

neurologically

normal

have

no

neck

pain

or

midline

tenderness

can

voluntary

move

their

neck

from

side

to

side

and

flex

and

extend

without

pain

In

all

other

patients

a

lateral

AP

and

open-mouth

odontoid

view

should

be

obtained

Although

it

is

not

mentioned

in

the

ATLS

manual

this

seems

to

be

a

combination

of

the

Canadian

C-spine

rules

and

the

Nexus

criteria

but

the

criterion

painful

distracted

injury

has

disappeared

between

the

sixth

and

the

seventh

edition

of

the

ATLS

manual

-LSB-

-RSB-

Possibly

this

was

done

because

the

definition

of

painful

distracting

injury

is

difficult

but

if

omitted

this

reduces

the

sensitivity

of

the

clinical

decision

rule

-LSB-

-RSB-

On

the

lateral

view

of

the

cervical

spine

film

the

base

of

the

skull

to

the

first

thoracic

vertebra

must

be

assessed

If

not

all

seven

cervical

vertebrae

are

visualized

a

swimmers

view

must

be

obtained

and

is

considered

sufficient

and

safe

-LSB-

-RSB-

Supine

oblique

views

and

contrary

to

available

literature

performing

a

CT

scan

of

this

area

is

not

mentioned

-LSB-

-RSB-

Further

of

all

suspicious

areas

and

all

not

adequately

visualized

areas

an

axial

CT

with

intervals

should

be

obtained

In

the

cervical

spine

section

multidetector

CT

assessment

with

coronal

and

sagittal

MPRs

is

not

mentioned

at

all

-LSB-

-RSB-

Performing

a

CT

of

the

cervical

spine

without

a

preceding

conventional

radiograph

as

the

screening

method

of

choice

is

not

mentioned

The

recent

ACR

appropriateness

criteria

suggest

otherwise

-LSB-

-RSB-

To

detect

occult

instability

in

patients

without

an

altered

level

of

consciousness

or

those

who

complain

of

neck

pain

flexion-extension

radiographs

of

the

C-spine

may

be

obtained

-LSB-

-RSB-

As

flexion-extension

radiographs

are

often

non-diagnostic

and

necessitate

movement

of

the

spine

that

is

potentially

dangerous

at

least

performing

a

CT

first

to

exclude

osseous

injury

or

a

magnetic

resonance

imaging

-LRB-

MRI

-RRB-

for

the

detection

of

ligamentous

injury

should

be

recommended

today

-LSB-

-RSB-

MRI

is

recommended

in

patients

with

neurological

deficits

to

detect

an

epidural

hematoma

or

a

traumatic

herniated

disc

Contrary

to

the

ACR

appropriateness

criteria

the

ATLS

states

that

when

a

MRI

is

not

available

CT

myelography

may

be

used

-LSB-

-RSB-

Angiography

or

CT

angiography

for

the

evaluation

of

injury

to

the

carotid

or

vertebral

artery

is

not

mentioned

-LSB-

-RSB-

Head

Again

according

to

the

protocol

a

cranial

CT

should

be

considered

in

all

head-injured

patients

with

a

focal

neurologic

deficit

of

which

the

cause

can

be

localized

in

the

brain

a

Glasgow

coma

scale

less

than

amnesia

loss

of

consciousness

of

more

than

min

or

severe

headaches

This

is

insufficient

to

detect

all

clinical

relevant

brain

injury

There

is

no

reference

to

evidence-based

clinical

decision

rules

such

as

the

Canadian

head

CT

rule

the

New

Orleans

head

CT

rule

or

the

CHIP

prediction

rule

-LSB-

-RSB-

Thoracic

and

lumbar

spine

The

indications

for

diagnostic

imaging

are

the

same

as

for

the

cervical

spine

AP

and

lateral

radiographs

should

be

performed

with

additional

CT

of

suspicious

areas

-LSB-

-RSB-

It

is

not

mentioned

that

the

thoracic

and

lumbar

spine

can

be

reliably

evaluated

on

a

CT

of

thorax

and

abdomen

When

a

CT

of

thorax

and

abdomen

has

already

or

will

be

performed

conventional

radiography

does

not

have

any

additional

value

especially

when

MPRs

of

the

spine

are

obtained

-LSB-

-RSB-

Penetrating

trauma

Chest

Pneumothorax

and

hemothorax

can

be

diagnosed

with

a

chest

radiograph

Even

in

patients

with

a

normal

chest

radiograph

a

CT

is

advocated

for

the

evaluation

of

heart

pericardium

and

great

vessels

in

patients

with

a

suspicion

of

mediastinum

transversing

injury

For

the

heart

and

pericardial

sac

a

CT

can

be

replaced

by

ultrasound

and

for

the

major

vessels

an

angiography

can

be

performed

For

the

evaluation

of

oesophageal

injury

esophagography

using

a

water-soluble

contrast

agent

and

complementary

esophagoscopy

should

be

performed

The

trachea

and

bronchial

tree

can

be

evaluated

by

bronchoscopy

Patients

with

penetrating

injury

of

the

lower

chest

below

the

transnipple

line

anterior

and

the

inferior

tip

of

the

scapula

posterior

are

considered

to

have

abdominal

trauma

as

well

until

proven

otherwise

-LSB-

-RSB-

Abdomen

A

hemodynamically

abnormal

patient

with

a

penetrating

abdominal

wound

does

not

need

diagnostic

imaging

but

should

undergo

laparotomy

immediately

In

a

hemodynamically

normal

patient

an

upright

chest

radiograph

can

document

intraperitoneal

air

and

is

useful

to

exclude

hemothorax

or

pneumothorax

An

abdominal

radiograph

-LRB-

supine

upright

or

lateral

decubitus

-RRB-

may

be

useful

in

hemodynamically

normal

patients

to

detect

extra-luminal

air

in

the

retroperitoneum

or

free

air

under

the

diaphragm

In

all

patients

with

penetrating

abdominal

injury

an

emergency

laparotomy

is

a

reasonable

option

especially

in

patients

with

gunshot

wounds

In

initially

asymptomatic

patients

with

a

lower

chest

wound

or

injuries

to

the

back

or

flank

the

ATLS

considers

double

or

triple

contrast

CT

DPL

and

serial

physical

examination

less

invasive

diagnostic

options

equivalent

to

each

other

-LSB-

-RSB-

For

asymptomatic

patients

with

anterior

abdominal

stab

wounds

DPL

laparoscopy

and

serial

physical

examination

are

mentioned

as

diagnostic

options

However

although

there

is

a

significant

body

of

evidence

that

this

may

not

be

optimal

CT

is

not

mentioned

as

a

diagnostic

option

in

these

patients

-LSB-

-RSB-

Conclusion

ATLS

is

a

well-tried

systematic

approach

for

the

assessment

of

trauma

patients

In

multidisciplinary

trauma

care

it

is

beneficial

and

maybe

even

mandatory

for

effective

communication

that

all

members

of

the

trauma

team

including

the

radiologist

speak

the

same

ATLS

language

Although

imaging

should

not

intervene

with

or

postpone

treatment

a

chest

radiograph

pelvic

radiograph

and

FAST

can

direct

treatment

decisions

and

should

be

performed

in

the

primary

survey

when

indicated

Imaging

of

the

cervical

spine

is

also

an

adjunct

to

the

primary

survey

but

can

be

postponed

as

long

as

the

spine

is

immobilized

All

other

imaging

should

be

done

in

the

secondary

survey

Unfortunately

according

to

the

ATLS

CT

plays

a

minor

role

in

the

evaluation

of

trauma

victims

In

the

ATLS

chest

CT

is

only

mentioned

for

the

diagnosis

of

traumatic

aortic

injury

but

in

our

experience

chest

CT

is

valuable

for

the

evaluation

of

pulmonary

contusions

and

hemothorax

and

pneumothorax

Nowadays

abdominal

CT

is

less

time

consuming

than

the

ATLS

states

and

can

be

used

to

evaluate

the

extent

of

the

abdominal

injury

in

patients

in

whom

no

immediate

laparotomy

is

indicated

to

evaluate

the

possibilities

for

non-operative

management

with

or

without

endovascular

embolization

The

indications

for

head

CT

according

to

the

ATLS

are

insufficient

to

diagnose

all

patients

with

significant

head

injury

CT

of

the

cervical

spine

can

be

used

as

a

primary

investigating

tool

and

not

only

as

an

adjunct

to

conventional

radiography

When

a

CT

of

the

chest

and

abdomen

is

indicated

the

thoracic

and

lumbar

spine

as

well

as

the

pelvis

can

be

evaluated

on

the

axial

CT

images

combined

with

coronal

and

sagittal

multiplanar

reconstructions

and

in

these

cases

conventional

radiography

of

the

spine

and

pelvis

do

not

have

any

additional

diagnostic

value

Because

the

ATLS

is

neither

thorough

nor

up-to-date

concerning

several

parts

of

radiology

in

trauma

it

should

not

be

adopted

without

questions

to

define

indications

for

diagnostic

imaging

Consultation

between

clinicians

and

radiologists

can

improve

the

efficiency

and

quality

of

diagnostic

imaging

in

trauma

patients

O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O B O O O O O O O O O O O O O O O O O B I O O O O O O B O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O B O O O O O O O O O O O O O O O O B I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O B O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O B O O O O O O O O O O B I O O B O O O O O O O O O O O O O B I O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O B I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O B I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O B B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O B I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O B I O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O B O B O O O O O B O B O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O B O O O O O O O O O O O O B I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O B O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O B O B O O O O O O O O O O O O B I O O O O O O O O O O O O O B I O B O O

trauma
diagnostic imaging
radiology
thorax
abdomen
spine