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Blunt abdominal trauma is one of the major causes of morbidity in children and requires accurate assessment with imaging at presentation. B-mode ultrasound (US) and focused assessment with sonography for trauma (FAST) have been widely used in children, especially in cases of low-grade mechanism of injury or low level of suspicion, to overcome the numerous disadvantages of contrast-enhanced computed tomography (CE-CT), especially the risks related to ionizing radiation exposure to such vulnerable patients. In the scenario of low-energy trauma, both B-mode US and FAST imaging have poor sensitivity for the detection of solid organ injuries, resulting in an unnecessary CE-CT. With the advent of contrast-enhanced ultrasound (CEUS), many of the limitations of US could be overcome: CEUS can readily detect solid organ injuries, with sensitivity similar to CE-CT. In recent years, the role of CEUS in trauma has expanded in the paediatric population and recognized as useful in reducing CE-CT imaging.

BACKGROUND: Extended focused abdominal sonography for trauma (e-FAST) is part of the primary survey in patients with high-energy trauma. However, it does not identify patients with retroperitoneal haemorrhage associated with significant pelvic trauma. A traumatic diastasis of pubic symphysis, as well as an ‘open book’ (OB) pelvic injury, is a diagnostic clue to recognize unstable pelvis with higher risk of bleeding. FAST–PLUS (FAST–PL pleural –US ultrasound of symphysis) protocol is an addendum to the e-FAST, which takes into account the study of the pubic symphysis in a single transverse scan after the traditional focused evaluation of the abdomen and thorax. OBJECTIVES: The aim of this study is to determine the value of FAST–PLUS protocol in the evaluation of pubic symphysis injuries and the identification of ‘open book’ (OB) unstable pelvic fractures. METHODS: Between January 2018 and December 2019, we retrospectively reviewed 67 polytraumatised patients with clinical suspicion of pelvic instability and with known anteroposterior pelvis compression injuries who underwent e-FAST with an additional transverse scan of the pubic symphysis, named the FAST–PLUS protocol and computed tomography (CT) exam in order to assess the correlation between them in defining the presence or absence of pubic symphyseal widening (SW). A cutoff value of 2.5 cm in transverse diameter was used to diagnose OB unstable pelvic injury. The results were analysed using Cohen's test, which uses the Kappa value as the reference index. RESULTS: The analysis carried out to assess the degree of agreement between FAST–PLUS and CT showed 5/67 patients (7.5%) with a critical pubic SW (> 2.5 cm transverse diameter) suggestive of unstable OB pelvic injury and 62/67 (92,5%) without any signs of SW at FAST–PLUS. At CT, findings of unstable OB pelvic fracture were confirmed in all patients with positive results at FAST–PLUS. Similarly, all patients with negative results for critical pubic SW (

De Garengeot’s hernia is a rare condition defined by the herniation of the vermiform appendix within a femoral hernia sac. We report a case of an 80-year-old woman admitted to our emergency department complaining of pain in the right groin. This symptomatology, present for 2 days, increased in the following 12 h. Ultrasonography (US) and contrast-enhanced computed tomography (CECT) were performed, which showed the herniation of the vermiform appendix in the femoral hernia sac. Doppler ultrasonography (DUS) and CECT were the fundamental imaging investigations for this diagnosis. The management of De Garengeot’s hernia is surgical through herniorrhaphy, which makes it possible to repair the femoral hernia and perform an appendicectomy in case of appendicitis.

BACKGROUND AND OBJECTIVE: Pneumothorax (PNX) detection is of the utmost clinical relevance because it may quickly progress to cause hemodynamic instability as a consequence of invasive ventilation. Radiography is characterized by a low sensitivity to detect this disease; in recent years, chest ultrasound (US) has gained increased visibility in the diagnosis of acute respiratory emergencies including PNX. The aim of this retrospective study was to evaluate the clinical impact of extended focused assessment with sonography in trauma (E-FAST) during the past 6 years of experience with this technique in our Level I trauma center. METHODS: Between January 2013 and December 2018, we performed a retrospective case-series study including 3320 consecutive patients admitted to the emergency department of our hospital because of major trauma. Extended-US was always performed and reported immediately after FAST during primary survey and before multidetector computed tomography (MDCT) scans. The presence of PNX was determined using the well-known accepted US criteria. US findings were compared with computed tomography (CT) findings, the reference standard for PNX detection. RESULTS: Of the 6640 lungs observed with E-FAST, there were 1244 PNX cases, while 1328 PNX cases were detected either on the basis of MDCT or on the basis of the presence of air flush during the thoracic decompression in the emergency room. Among the 84 false negatives, 12 patients had subcutaneous emphysema, 38 had a body mass index higher than 27, 6 had a thoracic wall hematoma, and 4 had chest penetrating trauma. There were 10 false positives in the diagnosis of PNX at US examination, with mild extension and not clinically significant. The overall sensitivity of E-FAST for PNX detection was 93.6% (1244/1328), the specificity of E-FAST was 99.8% (5312/5322), the negative predictive value (NPV) was 98.4% (5312/5396), and the positive predictive value (PPV) was 99.2% (1328/1338). CONCLUSION: Our results demonstrate that bedside thoracic US is characterized by a very good accuracy in the diagnostic work-up of major trauma patients, even in difficult conditions, allowing rapid diagnosis of PNX. ADVANCES IN KNOWLEDGE: The novelty of this research lies in the possibility of diagnosing potential life-threatening conditions in a very short time by means of US, thus proposing a revision of the Advanced Trauma Life Support (ATLS) guidelines in order to incorporate it in the work-up of high-energy injured patients.

The acute abdomen and pelvis is a serious clinical condition which may require urgent surgery. The potential causes of the acute abdomen and pelvis in pediatric patients are numerous, as in adults, and diagnosis is often delayed due to misleading signs and symptoms. Clinical signs and symptoms are often nonspecific; abdominal and pelvic pain and abdominal distention are common in a wide variety of disorders. Other signs and symptoms can include bilious vomiting, other signs of intestinal obstruction, urinary tract signs, fever, and weakness. Although in adult patients with an acute abdomen/pelvis, computed tomography (CT) is the mainstay of diagnosis and for discriminating conditions requiring surgery from those which can be treated conservatively, the use of CT in pediatric patients in recent years has decreased due to the potential risks of radiation exposure. The role of ultrasound (US) has become increasingly important. US does not use ionizing radiation, is usually readily available in emergency departments, is inexpensive, is portable, and does not require patient sedation. Furthermore, US allows assessment of intestinal peristalsis, and allows compression of the bowel. Magnetic resonance imaging (MRI) also does not use ionizing radiation, and can be used to diagnose a wide variety of pediatric acute abdominal and pelvic conditions, but MRI is more expansive, is not always available in emergency departments, and often requires sedation of pediatric patients to obtain good-quality images. Despite this, in line with radioprotection criteria, MRI should be considered as an alternative to CT, for its excellent ability to depict the causes of acute abdominal and pelvic disease, to provide valuable assistance in differential diagnosis, and for evaluation of any complications.

Over the last decades, as well as diagnostic radiology, interventional radiology techniques have been improved thanks to technological evolution, mostly related to the production of new devices enabling the interventional radiologist to reach anatomical districts not accessible before. As a result of this technological improvement, it was observed an increase of procedures around the world in both vascular and extravascular interventions in terms of numbers and variability, and this was associated with a change in treatment strategies for traumatic patients with the willing of surgeons to prefer, when possible, a Non-Operative Management (NOM).

Thoracic trauma account for about 25% of all trauma deaths and may produce injuries to endothoracic organs that play a vital role in normal physiology and homeostasis; some injuries to the chest and its contents, if unrecognized or untreated, may produce death within minutes. In the diagnostic algorithm of thoracic trauma, clinical data are of extreme importance and must be well recognized by the emergency physician. But, because of the low specificity of most of them consisting mainly in dyspnea, cough, hemoptysis, chest pain and, in very critical cases, in severe hypoxia or shock, imaging plays an essential role in the diagnostic work-up of these events permitting in most cases a fast and definite diagnosis and, therefore, a prompt adequate treatment. In an emergency context, three imaging modalities are helpful in the diagnosis of a thoracic trauma: chest X-ray, ultrasound (US) examination, and multidetector computed tomography (MDCT). Chest plain film and US examination play an important role in the initial emergency work-up of post-traumatic thoracic injuries as they are cheap and bedside available. Actually, MDCT has established itself as the preferred imaging method for the evaluation of polytrauma patients. This chapter will consider the main pleural and lung lesions and the injuries caused by open trauma.

For a long time, complication of pelvic fractures has been described as associated injuries, emphasizing on fracture classification. Indeed, the enormous amount of energy that determines a pelvic ring fracture is also often the cause of severe and life-threatening visceral and multiorgan injuries, which must be promptly recognized before any detailed fracture evaluation and classification. Though over the years treatment of vascular and visceral injuries has been greatly improved, bleeding remains a dreadful complication and other acute lesions, such urological and neurological injuries or bowel entrapment, have still devastating consequences. In this chapter, we offer the radiologist a diagnostic management guide to identify the most significant visceral injuries associated with pelvic trauma but at the same time we want you to increase your awareness of these complications that, if ignored, lead to poor outcomes.

Blunt thoracic trauma commonly causes lung contusions, pneumothorax, and pleural effusions, requiring an intensive treatment, often including mechanical ventilation.

The adrenal gland injuries after major blunt (81.4%) or penetrating (18.6%) trauma are rarely reported especially as isolated lesions and their involvement is more frequent in patient with severe trauma, in association with other lesions. They have been associated with overall increased patient’s morbidity and mortality. In the Injury Severity Score (ISS) stratified analysis, the frequency of adrenal hematoma is increased with higher ISS categories.

Neck injuries are often a challenge for emergency room radiologists. This chapter describes the anatomy, pathology, radiological techniques, protocols, and main radiological signs needed to recognize and to correctly describe epi-aortic vessel pathology in trauma patients.

Trauma is one of the main leading causes of death, and it requires an efficient and well-organized network, including extra and in-hospital care, to significantly reduce the injury-related mortality.

Nowadays, the growing tendency to treat patients with organ injury with nonoperative management, as well as attention to problems concerning limiting X-ray exposure for the patients, have led to the search for alternative methods for the follow-up of sick patients. Transportation of the critically bedridden patient to another department with nonnegligible risk of displacement of medical devices is another important concern in the management of polytrauma patients.

Bowel and mesenteric injuries from blunt abdominal trauma are uncommon and difficult to diagnose. The clinical signs and symptoms of these injuries are subtle and not specific, and they may be delayed in presentation. Due to major advancements in technology, multidetector computed tomography (MDCT) has become the diagnostic modality of choice in the evaluation of blunt abdominal trauma in hemodynamically stable patents. MDCT easily identifies injuries to solid organs and in the recent past years has been considered a sensitive tool in the detection of bowel and mesenteric lesions.

Pelvic ring fractures are a common consequence of high-energy blunt trauma, as may result from motor vehicle collisions and work-related falls from great height or crushing, and occur in younger adults. A constantly rising number of pelvic fractures have also been observed. The seriousness of pelvic fractures lies in the high rates of morbidity and mortality due to accompanying injuries associated with other organ systems, particularly vascular and visceral structures. Improvements in outcome depend on management of patients with pelvic ring fractures: the appropriate treatment depends upon a thorough knowledge of pelvic anatomy and biomechanics and understanding of the various types of lesions. Use of a classification system of pelvic fractures based on force vectors provides a logical approach to the multidisciplinary management of pelvic ring disruption (PRD) and allows early and aggressive treatment. Advantages of a “restitutio ad integrum” of normal pelvic anatomy, in a young population, offer a fast operative recovery that avoids probable complication due to a long period in bed. Diagnostic imaging should be considered the key to understand the mechanism of injury. Computed tomography (CT) is the technique of choice in the management of polytraumatized patients. Multi-planar reconstruction (MPR) and volume-rendering (VR) three-dimensional (3D) reconstruction views, reproducing radiological standard representations and oblique projections, are powerful modalities in classifying the various types of fractures and the mechanism and severity of injury. The pelvic bone is an anatomically complex tridimensional, ringlike structure, and for this reason, the integration of the information amongst axial, bi-, and three-dimensional images appears to be fundamental and eliminates any interpretive problems to understand the anatomy of the pelvis in all its aspects, and exactly detect the fracture sites, especially in complex cases. Three-dimensional reconstruction views are a kind of ideal conjunction between the traditional information gained from the radiographic images and axial CT scans.

Adrenal hemorrhage in newborn may have no clinical signs, while in other cases it may present itself as an abdominal mass; in case of adrenal capsule breaking, clinical symptoms of hemorrhage can be evident, often associated with ipsilateral scrotal hematoma; finally, it can present itself as an endocrine syndrome if adrenal gland failure occurs.

Intestinal malrotation is a congenital abnormal position of the bowel within the peritoneal cavity secondary to an arrest of normal rotation of any part of the intestinal tract during the first trimester of embryonic development. Malrotation is accompanied by abnormal bowel fixation, resulting in a narrow-based attachment of the mesentery and the presence of abnormal peritoneal bands (Ladd’s bands). These abnormalities lead to increased risks of bowel obstruction and midgut volvulus. Malrotation with volvulus is a true life-threatening emergency; delayed diagnosis can lead to necrosis of the midgut.

The hypertrophic pyloric stenosis (HPS) is not a rare condition due to a lack of relaxation of the pyloric muscle caused by hypertrophy and hyperplasia of the antropyloric muscular ring. HPS is the most common surgical cause of vomiting in infants, and it is a very frequent cause of access in emergency hospital.

Traumatic injury still remains the most common source of morbidity and mortality in children aged 1–14 years.

Peritonitis caused by an infection by the resident flora of the gastrointestinal tract resulting from a break of the integrity of the intestinal tract is a secondary peritonitis.