Interventional radiology (IR) can be a very helpful adjunct to the evaluation and management of trauma patients. I’m going to talk specifically about using it for blunt trauma today because the use in penetrating trauma can be a little more nuanced.
For blunt trauma, IR is used primarily to stop bleeding. In a smaller subset of patients, this tool is used to evaluate pulse deficits. There are two basic principles that apply in either case, and I’ve wrapped them up into a single concept: the 30:60 rule for interventional radiology.
Of course, the second law of trauma still applies: hypotensive patients cannot leave the ED to go anywhere but the OR. Once you make sure you are not violating that one, you can start the process of going to IR.
The two portions of the rule are times: the time for the IR team to arrive to start the evaluation, and the maximum time allowed for them to succeed, hence the 30:60 numbers.
The maximum acceptable time for the patient to wait until the IR team is ready for them is typically 30 minutes. US trauma center verification requires a reasonable arrival time frame, and the vast majority of hospitals have a 30 minute expectation if the team is not already in place. This response time needs to be monitored by the trauma performance improvement program (PI) and addressed if it ever exceeds the limit.
The second number is the maximum time the radiologist is given to be successful. Like other physicians, radiologists like to do a good job and finish the work they start. If they find a particularly tortuous splenic artery to navigate, they will persist at trying to get through it in order to do a selective embolization and kill the smallest piece of spleen possible. Unfortunately, this takes time and radiation (lots). And a bleeding patient is running out of time.
The good thing is that there are surgical alternatives to most of the tasks the radiologist is working on. True, some are much more difficult surgically, like managing a shattered liver or dealing with a bleeding pelvis. In those cases, I may let the interventionalist work a little longer while I keep up with blood transfusions and monitor patient status.
- Expect a 30 minute response time from the IR team
- Let the radiologist know they have about 60 minutes to succeed. If it looks like they can’t make that, have them go to plan B (e.g. main splenic artery embolization instead of selective)
- Make sure an experienced trauma physician is watching the patient for decompensation and is managing fluids and blood products (no pressors!)
- If the patient decompensates at any point, they are done in IR and must proceed to OR