Clinical Radiology (1983) 34, 441-445 0009-9260/83/00810441502.00 © 1983 Royal College of Radiologists

Immediate Radiological Management of Disasters J. O. M. MILLS

Department of Radiology, Royal Victoria Hospital, Belfast

During the past 13 years, 93 civil disasters have been dealt with by the Accident and Emergency (A/E) depart- ment of the Royal Victorial Hospital, Belfast. The average number of patients requiring hospital treatment was 30 per incident. Most of these needed some form of radiographic examination. The radiological work-load in one major disaster is described. The need for senior radiological, radiographic and clerical staff at such times is emphasised. The rapid and efficient management of patients is essential to avoid life-threatening delays. Radio- logical priorities in the immediate phase of trauma are discussed. Chest, spinal and pelvic X-rays usually take precedence. A review of 100 patients with significant intra-abdominal trauma showed a poor correlation with the plain-film appearances. Early resort to more accurate diagnostic methods, such as angiography and com- puted tomography, is suggested. The need for more active participation by radiologists in the A/E department is stressed.

Trauma constitutes a major epidemic in Western societies. In the United Kingdom it is the chief cause of death in people under the age of 40. The total cost in the UK of road-traffic and industrial accidents alone is £2250 million per year (Crockard, 1981).

This paper deals with the problems of management and care related to a particular form of trauma; the civil disaster. An Accident and Emergency (A/E) department which is able to cope with such a disaster can confidently deal with all other forms of trauma, whatever their presentation. A disaster may be defined as an emergency of such magnitude as to require extraordinary mobilisation of emergency services (Rutherford, 1972).

As a result of civil unrest in Belfast, the Royal Victorial Hospital (RVH) has been required to activate its disaster plan on no fewer than 93 occasions over the last 13 years. The number of dead and injured in these separate incidents ranged from 15 to 127. The average number of patients per incident admitted to the A/E department was 30.

Table 1 - Types of radiographic examination requested in one major disaster

No. of patients %

Extremities 68 47.5 Skull 24 16.7 Chest

supine 17 11.9 portable 5 3.5

Abdomen 17 11.9 Spine & pelvis 10 7.0 IVU 2 1.4 Total 143 100

30

The types of injury were wide ranging and resulted from street rioting, bomb explosions and gun shots. Although the number of patients injured in disasters comprised a small proportion of the total A/E admissions (6%), they presented a particular problem in that a large number of injured patients arrived at the A/E department almost simultaneously.

Most departments can cope adequately with a small number of injured patients. Disasters are rare and this, in itself, may lead to problems due to lack of experience. No A/E department or Casualty X-ray department is now exempt from the possibility of a sudden influx of seriously injured patients. Radiology may be involved at all stages of surgical triage (Yates, 1979) and, often, this leads to delays in the X-ray department (Rutherford, 1975).

In 1972 a bomb exploded without warning in a crowded city cafe, injuring 83 people. They were all admitted to the Royal Victoria Hospital, Belfast. Two died, 56 were subsequently discharged and 25 required hospital admission. Table 1 shows an analysis of the radiographic examinations carried out in the A/E X-ray department. The time taken to process these patients through the X-ray department was 5 h. A total number of 287 radiographs was required. If one includes 'retakes', approximately one exposure per minute was made during the 5 h period. As is usually the case, the majority of examinations were of the extremities. Skull and chest X-ray examinations, both supine and portable, in almost equal numbers were the next largest groups. This work-load made a singular demand on the radiographic and radiological staff at all levels. The lessons we learned from this and other disasters handled in our department are described.

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PROCEDURE

Senior radiographers and radiologists are mobilised; they should be available at all tknes. Experienced clerical and darkroom staff are also brought in. Close radiological-clinical liaison is immediately estab- lished. This is vitally important and should be an integral part of the hospital disaster plan. Failure to do this will result in considerable confusion.

After consultation with clinical colleagues the radiographic priorities should be decided for each patient. The examinations are listed in descending order of priority, as follows:

1. Chest and major vessels; spine and pelvis. 2. Skull. 3. Abdomen; IVU. 4. Peripheral skeleton.

DISCUSSION

It is essential that close radiological-clinical liaison is established, not only at the time of a disaster but also prior to such an event. Regular meetings between senior members of the medical staff help to define and anticipate problems. We have found that regular radiological tuition of each new group of A/E junior clinical staff is very beneficial, as they are often the first doctors to attend the injured. It is preferable to have a small number of well trained staff present than large numbers of enthusiastic amateurs milling around.

When senior clerical and darkroom staff are present, the risk of serious mistakes in patient identi- fication is reduced. Swift and accurate documentation is essential. Ideally, two radiologists should be present in the A/E department, one in the resuscitation area and the other in the X-ray department. The former can consult with his surgical colleagues; the latter can give instant reports and monitor the examinations. Either can decide when more views need to be taken or that the examination, while not technically perfect, gives the required information. By acting in this way as a manager the radiologist will greatly speed up the management of large numbers of injured patients. Confusion, unnecessary delays and unnecessary radiography will, thus, be minimised.

The A/E X-ray department should have at least one room large enough to accommodate life-support equipment, monitoring devices and their operating personnel. This room should be as close to the resuscitation area as possible. All X-ray rooms should have suction and oxygen.

We believe it is important that a system of priorities be employed for radiographic examination. The practice of accepting without question every request for a radiographic examination may put at risk patients with deteriorating or unrecognised conditions.

Priority 1

Trauma to the following regions may be life- threatening.

Chest. Establishment of the airway and adequate ventilation is always the first priority. A chest X-ray is necessary to determine the presence or absence of such injuries as pulmonary contusion, pneumothorax, haemothorax, great-vessel rupture or flail chest, as these conditions are not always clinically apparent. Furthermore, a chest X-ray is mandatory in patients with multiple injuries because of the frequent associa- tion of chest injuries in such cases. Often, only an AP projection can be carried out safely. When possible, an erect or decubitus examination should be attempted. As our radiology rooms are close to the resuscitation area, we try to avoid portable X-ray examinations. The best possible quality of radiograph must be obtained.

When allowance is made for the projection, any suspicion of mediastinal widening warrants immediate aortic angiography (Fisher et al., 1981). If aortography is contemplated an anaesthetist, cardiothoracic surgeon and adequate resuscitative measures must be at hand. It is pointless and, possibly, dangerous to perform this examination if proper surgical expertise is not available.

Spine and pelvis. The need to suspect and immobilise spinal trauma is imperative from the out- set. The diagnosis may be clinically obvious but, often, is not. Junior medical staff and radiographers must be continuously reminded of this fact.

A tomographic facility should be available to delineate problem areas such as the cervical-dorsal junction. Spinal trauma should be suspected in all deeply unconscious patients but this may be forgotten in the heat of the moment.

Cervical X-rays are mandatory in all unconscious head injuries. The high incidence (24%) of cervical spinal injuries reported in a large series of road traffic fatalities emphasises this fact (Bucholz, 1979).

A pelvic radiographic examination is required in the immediate phase as fractures of the pelvis may pass clinically undetected and be the source of massive, life-threatening blood loss (Rothenberger et al., 1978).

I M M E D I A T E R A D I O L O G I C A L M A N A G E M E N T O F D I S A S T E R S 443

Priority 2

Skull. The timing and precise indications for skull X-rays are much debated questions. After blunt trauma the fracture area usually conforms fairly accurately to the site o f injury. If the patient is being admitted to hospital, in many instances, skull X-rays can be delayed. It has been stated that it is rare for the course of treatment of a closed head injury to be influenced by the presence or absence o f a fracture o f the skull and that the radiographic examination should be deferred until more vital matters are under control and the patient is more cooperative (American College of Surgeons, 1976). We would agree with this policy. A British study has also suggested that the findings o f skull radiography are unlikely to contribute to the avoidance of death or secondary brain damage more than once in every 1460 patients radiographed (Royal College of Radiologists, 1980). However, is one prepared to tell the young doctor not to X-ray patients after blunt skull trauma?

When penetrating trauma occurs, a different situa- tion arises. The surgeon needs to know the site of the fractured bone, which may extend far beyond the area underlying the external wound. Radiological assessment is carried out so that cranioplasty can be planned and bone fragments and foreign bodies be removed from necrotic brain tissue (Gordon, 1980). Skull radiography may, therefore, be carried out at any time, before the patient goes to theatre.

Priority 3

Abdomen. We carried out a retrospective study of 100 patients who had sustained significant abdominal trauma, requiring surgery within the first 6 h. They had incurred both blunt and penetrating injuries. Forty-one had gun-shot/missile wounds, 36 had been

Table 2 - Distribution of abdominal blunt and penetrating injuries in 100 patients, all requiring surgery within 6 h

Penetrating Blunt Total

Stomach 11 5 16 Duodenum 0 7 7 Small bowel 25 2 27 Large bowel 12 0 12 Rectum 5 0 5 Pancreas 4 0 4 Liver 25 18 43 Spleen 4 46 50 Right kidney 4 14 18 Left kidney 3 12 15 Diaphragm 13 9 22 Vascular 10 4 14 Spinal 5 0 5

involved in road traffic accidents and 23 were the result of other forms of blunt trauma. There was an 11.5:1 male:female ratio. The average age was 27 years. Table 2 illustrates that the spine, kidneys, liver and diaphragm were most frequently affected by blunt trauma. The distribution of penetrating trauma was much more random, with frequent involvement of the hollow viscera. The high incidence of liver trauma in this latter group is probably due to the size of the organ.

Review of the f'mdings on the plain abdominal X-rays taken soon after trauma showed abnormalities in 45% of patients with missile wounds, 26.3% of those involved in road traffic accidents and 45% of patients suffering from other forms of blunt trauma. Most of the abnormalities were non-specific and included such findings as retained missile fragments and indeterminate soft-tissue masses. Only l 1% of those with proven gut perforations showed free gas on the decubitis or erect studies. A possible explanation for this finding is that many of the admissions were within minutes o f injury occurring, and the surgeons frequently reported that at operation perforations

v

v

. . . . i Fig. 1 - (J.M.H.) Multiple gun-shot wounds to lumbar region.

444 C L I N I C A L R A D I O L O G Y

had been sealed off by tissue swelling and herniated mucosa, caused by the sucking effect of a high-velocity missile.

The correlation is particularly poor in patients with high-velocity missile wounds. After such injuries the traumatised area correlates poorly with the trajectory of the missile. The abdominal film is useful for localising the position of foreign bodies but time should not be wasted in marking exit and entrance wounds. Our surgical colleagues confirm this and advise immediate surgery, often without recourse to radiology (Kennedy et al., 1981). Therefore, it is our experience that the plain abdominal film is of little value in assessing the extent and site of injury in the severely traumatised patient (Figs 1, 2; Table 3).

One notable exception is the use of emergency intravenous urography in the assessment of renal tract damage. It should be accompanied by tomography of the renal areas, if possible. We have found very good correlation in this particular type of injury. Urography

Table 3 - Operative findings in patient J.M.H. (age 30 years) i l lustrated in Figs 1 and 2 (died 12 h later)

1. Perforat ion o f s tomach 2. Three perforat ions o f small bowel 3. Four perforat ions o f transverse colon 4. Torn superior mesenter ic artery 5. Torn superior mesenteric vein 6. Perforat ion o f vena cava 7. Perforation o f aorta 8. Spinal injury with paraplegia

also provides a safeguard by ruling out the possibility of a non-functioning or severely diseased kidney on the non-injured side.

Priority 4

Extremit ies . With the obvious exception of major peripheral vascular trauma, injury to the extremities rarely threatens life. However, suspected fractured limbs should be assessed as early as possible to enable provisional splinting and to avoid repeat trips to the X-ray department.

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v~ v z

Fig. 2 - (J.M.H.) The only abnormal i ty is shattering of L3 and soft-t issue metallic f ragments extending across the mid- line. Residual contrast med ium in bladder f rom emergency IVU.

Computed Tomography An EMI 5005 whole body scanner has been in

operation at the RVH for 5 years. Due to long scanning times and its remote position from the A/E depart- ment, it has not been used for immediate trauma assessment. It has been useful as a 'second phase' investigation, particularly of the head. The advantages of computed tomography (CT) scanning in head and body trauma have been well documented (Peyster and Hoover, 1982; Federle et al., 1982; Toombs et al., 1981). It has not, however, yet been established as an essential tool in the evaluation of the traumatised patient. Indeed, very few A/E departments in the UK have immediate access to a scanner. If one accepts the limitations of current diagnostic methods, and the fact that trauma is often eminently treatable, the availability of the newer imaging techniques and, in particular, CT scanning, which greatly improve our diagnostic capability, demand immediate considera- tion. Is it not better to diagnose a retroperitoneal haematoma rather than a retroperitoneal sarcoma? Can the case, therefore, be made for the future installation of dedicated fast scanners in major trauma centres, enabling more accurate assessment of the injured patient immediately on arrival at hospital? If the answer is 'yes', the radiologist will have to alter his present role and be prepared to meet the patients on admission, along with the A/E surgeon.

IMMEDIATE RADIOLOGICAL MANAGEMENT OF DISASTERS 445

coNCLUSIONS

The Belfast experience has drawn at tention to the necessity of establishing an A/E radiological service capable of providing a planned and coordinated system of radiographic examinations when a large number of patients are admitted following a disaster. If radiology is to fulfil its proper role in the expanding field of trauma, radiologists and clinicians must work more closely together. Radiological priorities must be established and followed during the immediate, critical stage after injury. If these principles are applied, a significant reduction in morbidity and mortality may be expected.

Acknowledgements. I wish to thank Mrs S. Smyth for her patience and diligence in preparing this manuscript.

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Early care of the injured patient, 2nd edn. W. B. Saunders, London.

Bucholz, R. W. (1979). Occult cervical spine injuries in fatal traffic accidents. Journal of Trauma, 19, 768-771.

Crockard, A. (1981). Trauma Care, pp. 3-18. Academic Press, London.

Federle, M. P., Crass, R. A., Jeffrey, R. B. & Trunkey, D. D. (1982). Computed tomography in blunt abdominal trauma. Archives of Surgery, 117,645-650.

Fisher, R. G., Hadlock, F. & Ben-Menachem, Y. (1981). Laceration of the thoracic aorta and brachiocephalic arteries by blunt trauma: report of 54 cases and review of the radiologic literature. Radiologic Clinics of North America, 19, 91-110.

Gordon, D. (1980). Personal communication. Kennedy, T. L., Johnston, G. W. & Odling-Smee, W. (1981).

Trauma Care, pp. 527-547. Academic Press, London. Peyster, R. G. & Hoover, E. D. (1982). Computed tomo-

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Major vascular injuries secondary to pelvic fractures: an unsolved clinical problem. American Journal of Surgery, 136,660.

Royal College of Radiologists (1980). A study of the utiliza- tion of skull radiography in 9 accident and emergency units in the United Kingdom. Lancet, 6 December, 1234-1236.

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