Radiographers are aware that image quality is often compromised when examining a patient who has suffered acute trauma as their mobility and ability to cooperate is often reduced greatly.it is ironic that these patients,who require the highest-quality diagnostic images to detect the serious injuries associated with trauma,often will have a set of images that are of reduced quality as a result of their inability to cooperate.
Plain radiography of trauma,whether undertaken in the emergency room or within the imaging department,should therefore be considered as an imaging speciality in its own right.radiographers undertaking these examinations need to have specialist knowledge that will help them to be aware of all the factors that reduce image quality and how to minimize their effects.it is beyond the scope of this section to give a detailed account of all the relevant imaging factors relevant to trauma radiography.however,it is possible to provide a series of points that all radiographers should be mindful of when undertaking any radiography of the acutely injured patient.C:\Users\Nazattul Fatihah\Desktop\asaimen pakya image\trauma.jpgC:\Users\Nazattul Fatihah\Downloads\download
ASSESSMENT OF THE PATIENT'S CONDITION
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A vital first step in the examination is to scrutinize the imaging request and assess the patient's condition.an assessment of the mechanism of injury and a discussion with the patient (if possible) relating to their condition and capabilities will enable the radiographer to properly plan the examination for the maximum diagnostic outcomes.
PLANNING THE EXAMINATION
When the radiographer is presented with a patient requiring multiple examinations,it is important to spend some time planning the whole examination so that it can be conducted efficiently,using the most appropriate equipment for the task.
Consider a patient who requires examination of the whole spine,chest and pelvis.it would be more efficient if all the lateral radiographs were performed before all the antero-posterior radiographs.this avoids wasting time in moving the tube back and forth between exposures.
When examining patients on stretchers,it is also worth considering the side of any lateral examinations as the trolley enters the x-ray room.by doing this,the appropriate side of the body can be positioned against the vertical Bucky at this stage,rather than disrupting the examination halfway through by moving the trolley around.
Good communication with the accident and emergency (A&E) department staff is also of vital importance at the planning stage of any procedure.this will provide the radiographer with valuable information about the patient's condition and ability to cooperate.in addition,if the procedure is being undertaken as a mobile examinatiom,then good communication is vital ensure that the radiographer takes the correct equipment to the emergency room and correctly times their arrival in the department.
ADAPTATION OF TECHNIQUE
Much of the skill of a trauma radiographer stems from an ability to be able to produce radiographs of diagnostic quality when the patient is unable to cooperate to such an extent that the standard positioning cannot be undertaken.
It is beyond the scope of this section to give a full account of all the common adaptations that are used in trauma radiography.what has been provided is a series of general points and principles that radiographer should consider when presented with a difficult trauma case.
HORIZONTAL BEAM LATERALS
This is an extremely useful adaptation that is used when the patient cannot move into the standarad lateral position with a vertical central ray.in the example shown opposite,the use of a horizontal beam is actually advantageous to diagnosis.a lipohaemarthrosis,which is a soft tissue indicator of injury within the knee joint,would not be visible if a standard lateral projection was performed.
STANDING UP OR SITTING
Patient may find it difficult to attain the standard positioning when the radiographs are undertaken in the usual seated or supine position.in such cases,asking the patient to stand up (if the condition will allow) may be beneficial.one good example of a situation where this is useful is in the case of a suspected supracondylar fracture of the elbow.the patient may not be able to extend the elbow to attain a good antero-posterior position whilst seated,but they may be able to do this if imaged erect.
CONSIDER THE PATHOLOGY
Always on Time
Marked to Standard
The radiographer will constantly strive to produce standard projections that meet strict positioning criteria,but it is easy to forget to consider the pathology in question.this could lead to an important diagnosis being overlooked.an example of where this might happen is in a long bone when a joint examination is requested.the radiographer may not include an area of pathology in a long bone near to a joint if the radiation field is restricted to the joint region.
Radiographers should not become accustomed to doing this in a particular manner,otherwise they will become inflexible and unable to deal with unusual situations.consider the cassette size used for lateral cervical spine radiography.in most cases,an 18x24-cm cassette would be used,but it is often difficult to support this cassette in a vertical position,especially in the resuscitation room.in such a situation,a 30x40-cm cassette resting on the trolley cassette tray may prove to be a useful alternative.
It is important to closely supervise trauma patients at all times,as their condition can easily deteriorate.patients who initially appear quite cooperative may suddenly become unstable and be in danger unless an appropriate intervention is made.
As discussed above,the patient's ability to cooperate will have a strong bearing on the quality of the final images.for the most part,there is nothing that can be done when a patient cannot cooperate,other than to adapt the imaging technique accordingly.there are some situations,however,when the radiographer may have some control over the patient's ability to cooperate.some of these are outlined below:
The intoxicated patient: in the absence of serious trauma,if possible delay the examination untill the patient is sober enough to cooperate fully.this is particularly important for regions of the body where injuries can be difficult to diagnose.the quality of facial-bone radiographs obtained using a skull unit are far superior to those taken with the patient supine on a trolley.it would be unwise or even dangeraous to attempt a facial-bone examination using a skull unit on a patient who is heavily intoxicated.
Delaying the examination may also be considered when the patient's ability to cooperate is restricted severely by immobilization devices or clothing.once other injuries have been excluded,these devices may be removed and the patient may be more able to cooperate.
EQUIPMENTS AND IMAGING CONSIDERATIONS
Several x-ray equipments manufactures offer a range of dedicated systems for trauma radiography.these are certainly useful in terms of time-saving and image quality when undertaking multiple procedures.it is possible,however, to obtain images that are equally as good as those taken using dedicated systems tube,a vertical Bucky,a floating-top table with Bucky,and appropriate emergency equipment.a skull unit,although not essential,will increase the quality of skull and facial-bone images.one of the most desirable fetures of a room used for trauma radiography is space.if a radiographer has a generous space allocation,then this will give them greater flexibility when adaptations in technique are required.
Other more specific considerations are considered individually.
Any room used for trauma radiography should have a generous supply of radio-lucent foam pads and sandbags for supporting patients or cassettes.specialist devices,such as the leg support used for lateral hip radiography,are often invaluable.
Adaptations in technique will often result in the use of stationary grids for trauma radiography.these should be used only as a last resort due to the poor efficiency of such grids in terms of scatter attenuation compared with that of a Bucky with a moving grid mechanism.the grid lattice pattern from the stationary grid,and the relatively low grid ratio,contribute to a lower image quality when stationary grids are used.the type of grid is also important.if a focused grid is employed,then the radiographer must ensure that the correct focus-to-film-distance (FFD) for the type of grid is used,otherwise a 'cut-off' artefact will result.
OBJECT - TO - FILM DISTANCE
In many cases,an increase in object-to-film distance (OFD) will results from the modifications in technique required in trauma radiography.a good example is the horizontal beam lateral radiograph of the thoracic or lumbar spine.if the patient is lying in the middle of the trolley,then spine will often be positioned at some distance from the cassette.this results in an increase in magnification and geometric unsharpness.the problem is easily remedied by increasing the focus-to-object distance (FOD) (within the focus of the grid) to compensate.remember that if this strategy is employed,and no automatic exposure device is used,then the radiographer must increase the exposure factors.
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Many trauma radiographic examinations are prone to high levels of scattered radiation that degrade overall image quality.a good example of such an examination would be the horizontal beam lateral lumbar spine,as described above.the extra tissue from the abdominal viscera lying other side of the spine increases the amount of tissue irradiated compared with a standard lateral,and there is corresponding increase in scatter production.in such cases,close attention to collimation is important,as this will serve to vastly decrease the scatter produced and will significantly improve image quality.
TYPE OF TROLLEY
There are many different type of trolley available for use in A&E work,some of which are far more suitable for plain film imaging than others.it is strongly recommended that radiographers maintain close links with A&E staff so they can involve themselves with the purchase of new trolleysa period of evaluation when any potential new trolley is tested in practice is essential as part of the procurement process.
The rolley must have either a movable tray underneath the patient to accomodate cessettes and grids or a wide platform that runs the length and width of the trolley.the latter may offer greater flexibility if the patient is not central to the trolley.alternatively,separate cassette holders are available or can be made to suit a particular purpose.
ACCESS TO CASSETTE
Whichever method is used to support the cassette underneath the trolley,it is important that the radiographer can easily gain access and view the cassette wherever it is positioned relative to the patient.this is vital for accurate alignment of the cassette to the beam before exposure.
OBJECT - TO - FILM DISTANCE
The distance between the trolley top and the cassette holder underneath should be as small possible but still allowing reasonable access for the positioning of cassettes.if this distance increases,then geometric unsharpness will also increases,thus reducing image quality.
UNIFORM TROLLEY TOP
The trolly top should be completely radio-lucent (no metal bars or hinges) and designed in such a way that there is a minimum of joints in the material that the trolley top is constructed of.these may cause artifacts on any images taken using the cassette holder underneath the patient.
VERTICAL CASSETTE HOLDER
Some trolleys come equipped with vertical cassette holders,which are useful,but not vital,for performing horizontal beam lateral examinations.
Artefacts from clothing or immobilization devices applied by ambulance staff are an ongoing difficulty for radiographers to deal with..necklaces or earrings under rigid neck collars cause many problems,as the radiographer may not be aware of their presence until an image is obtained.again,the establishment and maintance of good communication links between professional groups will allow communication of such problems and raise awareness of the difficulties that arise as a consequence.
When imaging trauma patients,the efficiency and effectiveness of a radiology department will spring from good teamwork.this applies between professional groups as well as within the radiology department.close links between radiology and the A&E department will help each other group to understand their respective difficulties and will help to overcome problems and maximize efficieny.when imaging a patient who has suffered multiple trauma,a tem of two-one radiographer positioning the patient and the other processing the images-will serve to maximize efficiency.
Trauma radiography often requires adaptations in exposure factors due to the non- standard imaging conditions encountered.some considerations that the radiographer should be aware of are listed below:
REDUCING EXPOSURE TIME
If movement unsharpness is likely,then the exposure time can be reduced in a variety of ways:
Increase the kVp and reduce the mAs.
If possible,increase the tube mA and reduce the exposure time.
Increase the tube loading to 100%.most generators are routinely operated at a loading of less than this.
Consider using a faster imaging system and thus reducing exposure time.
Use of a broad focal spot will allow a shorter exposure time.
Consider altering the kVp to manipulate the image contrast.a low kVP will be useful for demonstaring foreign bodies such as glass or for highlighting a subtle fracture.a high kVp may be useful for reducing large differences in subject contrast-differing regions within spine being a good example.
Systems that offer wide exposure latitude are particularly useful,as they are more able to cope with the variations in conditions encountered in the trauma setting.the digital systems are particularly useful in this respect.
AUTOMATIC EXPOSURE DEVICE
These are advantegeous for trauma imaging,particularly those located in the erect Bucky,which are used for horizontal beam spinal imaging.care should always be taken to ensure that the tube is centred correctly to the Bucky at all times,otherwise the device will not give the correct exposure.it is easy to decentre the tube from the Bucky whilst making fine alterations to the final centring point.
CORRECT LABLELLING OF IMAGES
Given the many modifications in technique often employed in trauma radiography,it is important that the final image is labelled correctly (e.g. supine,erect,horizontal beam,etc) so an accurate diagnosis can be made.
ADVANCED TRAUMA AND LIFE SUPPORT (ATLS)
This is comprehensive protocol introduced by the American College of Surgeon to ensure that any patient suffering major trauma is given adequate emergency care,even remote from a major trauma centre,thus allowing patients to arrive at a centre of excellence in the best possible condition.the ATLS workbook specifies minimum standards of care to all body systems from a variety of viewpoints,including specifications for radiographic examination.it is also being widely adopted outside USA.
According to protocol,the initial radiographic assessment of the severely injured patient includes:lateral cervical spine,chest x-ray (CXR) and pelvis.N.B skull x-ray is not included.
These are performed immediately as part of the initial assessment and before full clinical examination.following full clinical evaluation,further projections or projections of other areas may be requested.at same point (determined by the clinical priorities),full projections of the cervical spine should be obtained.
The definitions of 'full projections' will be determined by local protocols,but is usually three projections (antero-posterior,lateral,peg), with the addition of trauma oblique projections in some centres.if adequate basic projections are not obtained,then the use of computed tomography (CT) may become necessary,again as determined by local guidelines.CT is not a quick examination in the unconscious,ventilated patient,and it can be a high-dose examination.it should not be viewed as an easy alternative to good plain-film radiography.
ATLS also calls for flexion projections of the cervical spine under supervision of an experienced doctor,prior to full 'clearance' of the spine in patients who are alert and neurologically normal but suffering neck pain.flexion of the spine in an injured patient should be undertaken only under medical supervision.
As 70% of patients with cervical spine fracture have an associated fracture of thoracic or lumbar spine,projections of these areas may also be indicated.
Significant injury to the thoracic and lumbar spine can occur without local tenderness or pain,especially in the presence of a painful lesions elsewhere.it may therefore be appropriate to perform full spine projections in patients with major trauma and other painful lesions,as well as those with depressed level of conciousness and those with cervical spine injury.