Contrast blush is always a concern when seen on CT of the abdomen for trauma. It can represent one of two things, and both are bad:
Active extravasation of contrast
These two clinical issues can be distinguished by looking at the location of the contrast and its persistence. A pseudoaneurysm is located within the parenchyma, and the contrast will wash away, so it will not be visible on delayed images. Contrast that extends beyond the parenchyma or persists in delayed views represents active bleeding. In either case, the failure rate of nonoperative management exceeds 80% in adults without additional measures being taken.
Clinically, these patients usually act as if they are losing volume and require additional crystalloid and/or blood transfusion. The natural history in adults is for bleeding to continue or for the pseudoaneurysm to rupture, resulting in a quick trip to the operating room.
If vital signs can be maintained with fluids and blood, a trip to interventional radiology may solve the problem. Selective or nonselective embolization can be carried out and patients with only a few bleeding points can be spared operation. However, if multiple bleeding areas are seen, it is probably better to head to the OR for splenorrhaphy or splenectomy.
The image below shows likely areas of extravasation. They are a bit large to be pseudoaneurysms.
Children are different than adults. Extravasation from spleen injuries in prepubescent children frequently stops on its own. Angiography should only be used if the child is failing nonoperative management.
Spleen injury grading is not as complicated as people think! The grading system ranges from Grade I (very minor) to Grade V (shattered, devascularized).
There is one nuance that people frequently don’t appreciate: multiple injuries can increase the grade. Technically, multiple injuries advance the maximum grade by one point, up to a maximum of Grade 3. So Grade 1 + Grade 1 = Grade 2, but Grades 2+2 = 3! Weird arithmetic!
The vast majority of injuries are Grades 1 to 3, and they are actually the easiest to grade. I use this simple rule: 1 and 3, 10 and 50.
The first set of numbers indicates the depth of a laceration in centimeters.
Grade 1 – < 1 cm laceration depth
Grade 2 – 1-3 cm laceration depth
Grade 3 – >3 cm laceration depth
The second set of numbers refers to size of a subcapsular hematoma in percent of the total surface area of the spleen. Hint: most of these low grades are determined by laceration depth. Very few actually have sizable subcapsular hematomas. So memorize the 1-3 rule first!
Grade 1 – <10% subcapsular hematoma
Grade 2 – 10-50% subcapsular hematoma
Grade 3 – >50% subcapsular hematoma
Grades 4 and 5 use other criteria, but in general if it looks completely pulped it’s a 5, and if it’s a little less pulped, it’s a 4.
Grade 4 – hilar injury with >25% devascularization OR contrast blush (active bleeding)
Grade 5 – shattered spleen, or nearly complete devascularization
That’s it! Tomorrow I’ll talk about the real significance of the contrast blush.
This week I’ll be covering spleen injuries. The answer to the question “What is wrong with this spleen” is: 1. There is a spleen laceration (grade cannot be determined from this one slice) and 2. There is a contrast blush.
Today I’ll cover grading and tomorrow I’ll talk about the significance of blushes.
Smaller trauma hospitals, both designated and undesignated, are the front line for the initial care of the majority of trauma patients. Many patients can be evaluated and sent home or admitted to the initial hospital. More severely injured patients are commonly transferred to the nearest Level I or Level II trauma center for care of injuries requiring specialists.
Imaging studies such as conventional xray and CT scan are a necessary part of the initial trauma evaluation. But is it necessary to do a full radiographic evaluation, even when it is known that the patient will have to be transferred?
Researchers at Dartmouth Hitchcock Medical Center examined the issue of repeat imaging at their Level I center. They looked at 138 patients that were transferred to them from other rural hospitals. They found that 75% underwent CT scanning prior to transfer, and 58% underwent repeat scanning upon arriving at Dartmouth.
The authors discovered the following:
Head CTs were repeated 52% of the time, primarily due to clinical indications
Spine reconstructions were repeated 33-50% of the time due to inadequate reconstruction technique
Chest (31%) and abdomen (20%) were repeated due to inappropriate use of IV contrast
13% of image disks used incompatible software
7% of images were not sent with the patient
Here are my recommendations for imaging by hospitals that refer patients to Level I or II trauma center:
Obtain the essential plain films recommended by ATLS (chest, pelvis)
If an obvious injury requiring transfer is found on exam (e.g. open fracture) do no further studies
Obtain any imaging studies needed to decide if you can admit the patient to your own hospital (example: abdominal CT for abdominal pain and negative FAST. Keep if no injury, transfer if solid organ injury)
As soon as an injury is identified that mandates transfer, do no further studies
Always send image disks with the patient
Work with your referral trauma center to obtain a copy of their CT imaging protocols so if you do need to perform a study you can duplicate their technique
Reference: Gupta et al. Inefficiencies in a Rural Trauma System: The Burden of Repeat Imaging in Interfacility Transfers. J Trauma 69(2):253-255, 2010.
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