May Case-based Learning – IV Contrast for Trauma

66 y.o. otherwise healthy female presented to the emergency room in full spinal precautions after being involved in a high speed MVA. Patient was a restrained driver with a prolonged extrication. On arrival to the ED, patient was anxious, but conscious and complained of right-side chest pain, right lower extremity, and left wrist pain.

Key findings on EXAM: GCS: 14/15, VS: 102/54, 110, 18, 96% on non-rebreather.

HEENT: Negative except dried blood right forehead with small abrasion and surrounding 5 cm hematoma. PERRL EOMI. Neck: in collar, no tracheal deviation, no crepitus, neck tender along right paraspinal region.

HEART: RRR No murmurs, rubs, gallops, no carotid bruits, no JVD; radial, dorsal pedal, post tibialis pulses 1+ bilaterally.

Lung: Shallow rapid breath, no wheezes, no crackles

Chest: Bruising over right upper chest. No crepitus. No deformity.

ABD: bruising over lower abd consistent with a seat beat sign. Diffusely tender. Non distended.

Back: No step offs, no focal tenderness T/L spine. No bruising

Pelvis: stable, no pubic or iliac spine tenderness.

UE: obvious closed left wrist fracture.

LE: Bruised swollen right anterior lateral thigh; tender to palpation midshaft
Neuro: GCS: 14/15 secondary to confusion, sensation intact both distal UE/LE

Psych: confused anxious

Skin: pale, no rashes, cap refill at 2 seconds.

ORDERS: Non contrast CT: Head, c-spine, and abdomen/pelvis; left wrist XR, right femur XR, Chest XR, CBC, CMP, PT, PTT, Urinalysis, ETOH, UTOX, Lactic Acid. Cardiac Monitor, two large bore peripheral IVs and lactated ringers.

Initial findings: Right Femoral shaft fracture, Left Colles fracture, Scalp hematoma right frontal bone, right anterior rib fractures (6 & 7th), HCT 31, Lactic Acid 3.2, UA 10 RBC HPF. CT abd/pelvis did not identify a cause for patients’ abdominal pain and provider called the transfer center to discuss the case with the surgeon on call.

OUTCOME: This patient initially arrived with “ok VS” and seemed stable to the ED provider who first evaluated the patient and ordered the above studies. Unfortunately, the patient acutely deteriorated approximately 50 to 60 minutes after arrival while waiting for the transfer center to reach the trauma surgeon to discuss her case.

Provider was called back into patient’s room to re-evaluate. The ED team activated medivac and began an aggressive resuscitation. She ultimately was flown to a trauma center and ended up with a prolonged ICU stay secondary ARDS. Unfortunately, there was initial delay in identifying patient’s internal injuries, which could have been avoided. The original CT was limited to the abdomen and pelvis and was a non-contrast CT, which can miss visceral lacerations.

Role of Contrast in Trauma:

Intravenous (IV) contrast is vital in CT trauma body imaging to diagnose solid organ injuries, vascular injuries, and vascular extravasation. Missed injuries can be life-threatening.

IV contrast must be given on all trauma patients unless contraindicated, such as a previously documented severe allergic reaction to iodinated contrast media.

 

CT scanning in trauma:

CT head and CT cervical spine without IV contrast.

CT chest, abdomen, pelvis with IV contrast (not CTA – this can miss parenchymal injuries).

 

Misconceptions:

Renal function:

ER Patients: Creatinine levels can be waived in severe trauma. New data shows risk of renal injury due to IV contrast is not as significant as previously thought.

Age: ACR no longer considers age as an independent risk factor for chronic kidney disease and doesn’t recommend using age as requirement for screening eGFR prior to IV contrast.

Contrast allergies:

Contrast allergies are rare with new IV contrast formulations, accounting for 0.6% of cases with only 0.04% considered aggressive. Prior minor contrast allergy is not a contraindication.

Concern is only for osseous injuries:

If decision is made to do a CT scan to assess for osseous injuries, then enough mechanism is present for internal injury concern. Give IV contrast to avoid missing injuries and rescanning.

Giving contrast takes too much time.

Giving IV contrast does not take significantly more time. Managing delayed or missed injuries takes more time than giving IV contrast.f

Pediatrics:

Injuries in children can be difficult to diagnose clinically and IV contrast is vital in these patients.

Link to CT imaging protocol for pediatric patients: https://helpdesk.inlandimaging.com/kb

Radiation.

Giving IV contrast does not increase the radiation dose.

Orders.

CT technologists are instructed to question CT chest-abdomen-pelvis non-contrast orders in trauma to reduce missed injuries. They will discuss with ordering provider and recommend contrast and may discuss with radiologist.

 

Resources: ACR Manual on Contrast Media 2023. https://www.acr.org/Clinical-Resources/Contrast-Manual/Inland Imaging Professional Services.