Medical and surgical devices in the emergency and trauma patient: what the radiologist should know, and how they can add value

Abstract

A variety of different external and internal medical devices are used in the acute setting to maintain life support and manage severely injured and unstable trauma or emergency patients. These devices are inserted into the acutely ill patient with the specific purpose of improving outcome, but misplacement can cause additional morbidity and mortality. Consequently, meaningful interpretation of the position of devices can affect acute management. Some devices such as nasopharyngeal, nasogastric and endotracheal tubes and chest and surgical drains are well known to most clinicians, however, little formal training exists for radiologists in composing their report on the imaging of these devices. The novice radiologist often relies on tips and phrases handed down in an aural tradition or resorts to phrases such as: "position as shown". Furthermore, radiologists with limited experience in trauma might not be familiar with the radiological appearance of other more specific devices. This review will focus on the most common medical devices used in acute trauma patients, indications, radiological appearance and their correct and suboptimal positioning.

Figure 1.

(a) Patient intubated post-RTC. Coronal CT demonstrates the correct position of an ETT. The tip should be sited approximately 5 cm above the carina (arrow). Note also the lung contusion in the left hemithorax (arrowhead). (b) Sagittal CT demonstrates correct siting of the cuff (arrow), which lies at/just below level of the cricoid cartilage and below the level of the vocal cords which arise at the midpoint of the thyroid cartilage (arrowhead). (c) Patient who experienced difficult intubation resulting in ETT malposition. Sagittal CT demonstrates cuff inflated above the thyroid cartilage (arrow) and therefore malpositioned. Cuff is over inflated - a clue to the malposition. (d) Male with difficult intubation following blunt head trauma. Chest radiograph taken post-intubation demonstrates a calcified structure in the left main bronchus (arrow) causing partial left lower lobe collapse, in keeping with a broken and swallow tooth within the airway. ETT, Endotracheal tube; RTC, Road traffic collision.

Figure 2.

(a) Chest radiograph showing the normal position of the TT (arrow). (b) Sagittal CT image shows the tip of the TT projecting over the T3–T4 level (arrow). TT, Tracheostomy tube.

Figure 3.

Status: post-blunt head trauma. (a, b) Axial and sagittal CT images shows the normal appearance and position of bilateral nasopharyngeal tubes (arrows).

Figure 4.

Examples of malpositioned chest drains in different patients after blunt chest trauma. (a) Axial CT demonstrates a chest drain kinked (arrow) between rib fractures. (b) CXR demonstrates multiple right-sided rib fractures, pneumothorax and chest wall surgical emphysema, likely related to chest drain holes (arrow) outside the pleural space. (c) Axial CT shows a malpositioned chest drain in the anterior mediastinum. CXR, Chest X-ray.

Figure 5.

(a) Chest radiograph shows a needle projected in the right upper hemithorax, which was inserted to decompress a tension pneumothorax in the pre-hospital setting (arrowed). (b) RTC and blunt thoracic trauma. Axial CT demonstrates a pneumofix device (arrowed) sited within the anterior left chest wall draining a small left pneumothorax. RTC, Road traffic collision.

Figure 6.

(a, b) CT scout images of two different patients that sustained blunt trauma demonstrate a NGT coiled in the oesophagus (arrowed in a) and within the oropharynx (arrowed in b). (c) CXR demonstrates an NGT malpositioned in the right main bronchus (arrow). CXR, Chest X-ray; NGT, Nasogastric tubes.

Figure 7.

Male following RTC and blunt pelvic trauma. Sagittal CT in trauma patient with unstable pelvic fracture (note pelvic binder in situ (thick arrow) demonstrates contrast in the bladder (thin arrow), contrast extravasation around pubic bone from the urethral leak (arrowhead) and malposition of urinary catheter balloon inflated within the urethra (dotted arrow) rather than within the bladder. RTC, Road traffic collision.

Figure 8.

(a, b) Examples of standard gauze (top left), radiopaque marked gauze (top right) and CELOX haemostatic gauze (bottom) and their corresponding CT appearances of the different types of gauze. (c) 3D reconstruction demonstrates radiopaque gauze packing of an external wound (arrow). (d–f) Status post blunt liver trauma with grade V liver laceration. Post damage control surgery. Axial CT lung window, arterial and portal venous phase respectively demonstrate radiopaque packing (arrowhead), wet celox packing (thin arrow) and dry celox packing (thick arrow). 3D, Three-dimensional.

Figure 9.

(a) Example of head blocks with open circular areas at each side. (b) Elderly patient following fall. Head blocks noted on CT scout images. Note the circular areas projected over the temporal bone (arrows) representing the normal openings of the head blocks.

Figure 10.

Axial and peripheral devices. (a, b) Female following blunt pelvic trauma. Coronal MIP CT images demonstrates a pelvic binder (arrowed in a) correctly positioned at the level of greater trochanters. The axial image of the same patient shows the CT binder that is best appreciated in bone window (arrowed in b). (c) Status post blunt trauma with bilateral lower limb fractures and traumatic amputation of the left lower leg following RTC. CT scout image demonstrate the applied tourniquets in the proximal thighs (arrowheads). Note also the pelvic binder in situ (arrow). MIP, Maximum intensity projection; RTC, Road traffic collision.

Figure 11.

Axial and peripheral devices. (a) Male following RTC with left femoral shaft fracture. Note the Kendrich splint (arrowed) in the CT scout image. (b) Different patient following blunt force trauma to right ankle. CT scout image: External fixation of a bi-malleolar fracture of the right ankle. RTC, Road traffic collision.

Figure 12.

(a) Patient following RTC. Axial CT demonstrates an intraosseous needle (arrowed) sited within the right humerus (b) Female after blunt trauma. Axial CT image shows right arterial (arrow) and left venous (arrowhead) femoral lines in this trauma patient. (c) Male after RTC and severe haemorrhagic shock. A REBOA catheter was placed on the scene and the patient was transferred to the nearest trauma centre. Fluoroscopic image confirmed the position of the REBOA balloon (arrow) placed in zone 3. Courtesy of Dr Jonathan Morrison, Assistant Professor of Surgery, R Adams Cowley Shock Trauma Center, Baltimore, MD, USA. RTC, Road traffic collision.

Figure 13.

Patient involved in RTC and experiencing hypothermia. (a, b) Coronal scout image and axial CT image show the multiple heat pads projected over the patient’s pelvis (asterisks). The blanket containing the pads is usually placed over the torso of the patient and is usually removed before CT. In this case the blanket was likely displaced down onto the pelvis and inadvertently left on this location for the scan. (c) Picture show “Ready-Heat” 12 panel warming blanket used by some prehospital services. Courtesy of Dr Roger Bloomer, Consultant in Anaesthesia & Major Trauma, King’s College Hospital, London, UK. RTC, Road traffic collision.