Gary H. Danton

The initial role of radiological imaging–ranging from plain radiography to ultrasound, fluoroscopy, computed tomography with tri-dimensional reconstruction, magnetic resonance imaging, and angiography–are valuable extensions in the clinical evaluation of trauma patients. From diagnostics to interventional therapeutic procedures, imaging is a most useful adjunct to the provision of trauma care. This chapter covers in great detail the role of imaging in the care of trauma patients.

Blunt traumatic extracranial vascular injuries most often occur in the setting of motor vehicle accidents, and the majority of penetrating neck injuries involve guns and knives. Injury of the carotid and/or vertebral arteries of the neck in blunt and penetrating trauma can occur through a variety of mechanisms, from direct transection, to shearing of blood vessels from hyperextension of the cervical spine, to disruption by fractures, and is an important cause of morbidity and mortality in trauma patients. The purpose of this review is to present the evidence and the controversies surrounding the imaging workup of patients with suspected extracranial vascular injuries. Selection of subjects for imaging, suggested imaging protocols, and future research are reviewed.

The most salient dilemma in the post-surgical patient with abdominal distention and feeding intolerance is whether the bowel is obstructed. If the index of suspicion is high the questions of whether it is a functional or mechanical obstruction and where is the location of the obstruction needs to be addressed. If there is no bowel obstruction the diagnostic question turns towards the location and cause of the suspected ileus. The definitive cause of abdominal distention and feeding intolerance may be due to a variety of factors that include mechanical or functional small or large bowel obstruction, adynamic/paralytic ileus, or sepsis from a variety of causes including both intra- and extra-peritoneal etiologies. Radiographic studies play an important role in determining the etiology, evaluating for complications, and in monitoring resolution once the cause has been treated. The initial radiographic examination for evaluation and triage of patients with abdominal distention is the plain abdominal film. Computed tomography is the imaging modality of choice to confirm the diagnosis of small bowel obstruction and to identify its cause. If the initial radiograph or CT is inconclusive the differential diagnoses of low-grade, partial SBO or of an ileus should be considered and an imaging technique with increased sensitivity and specificity for distinguishing between the two has to be selected. Functional studies can reveal subclinically obstructed segments. This chapter will cover all these issues in detail.

The development of fever and leukocytosis in a post-surgical patient is a common clinical scenario that may arise due to a considerable number of various differential etiologies, including infection, inflammation, thromboembolic disease, as well as others. This often necessitates targeted diagnostic imaging to refine the suspected clinical diagnosis, which can aid in providing prompt specific therapy. Here, we discuss general related concerns of an intensivist, as well as specific imaging modalities such as Computerized Tomography, Radiography, Ultrasound, Nuclear Medicine, Interventional Radiology, and Magnetic Resonance Imaging. Specific etiologies and a proposed diagnostic imaging algorithm for the patient with fever and sepsis in the Intensive Care Unit are also discussed. Multiple figures as well as selected illustrative case examples are provided for added perspective.

Blunt trauma injuries are typically a result of motor vehicle crashes but can occur with any direct blow to the head or neck, strangulation, sports-related incidents, and manipulation of the spine. The majority of penetrating neck wounds are a result of guns and knives, with motor vehicle crashes and industrial and household accidents making up the remainder. Vascular injuries of the neck in blunt and penetrating trauma are an important determiner of morbidity and mortality and can occur through a variety of mechanisms, from direct transection, to shearing of blood vessels from hyperextension of the cervical spine, to disruption by fractures.

This chapter focuses on the measures to reduce structural damage and improve functional outcome of the brain, which depends on various factors. Various stroke risk factors, including hypertension, diabetes, obesity, smoking, and surgical procedures, are a few targeted factors discussed as preventive measures. In the area of traumatic brain injury (TBI), the use of automobile seat belts and airbags, and the use of motorcycle helmets, can help prevent or limit irreversible damage. However, after the primary insult has occurred, strategies, including intensive care procedures, to limit secondary insults and the use of protective strategies to inhibit secondary injury mechanisms may potentially limit damage and improve outcome. Although the location and severity of the primary insult are important factors to determine the impact of the individual injury process, excitotoxicity, calcium-mediated events, free radicals, mitochondrial damage, inflammation, and apoptosis are commonly discussed as possible targets for therapeutic interventions. Pharmacological treatments targeting specific injury cascades, and the use of therapeutic hypothermia, have provided compelling evidence for neuroprotection in preclinical studies. Nevertheless, few agents have been successfully moved to the clinic, and currently no pharmacological treatments have been proven to protect against the detrimental consequences of TBI.