Trauma of CHEST

Pneumothorax: Simple• Erect AP/PA view best • Visceral pleural line • No vessels or markings • Variable degree of lung collapse • No shift... PNEUMOTHORAX: Supine• Supine AP view has lim

CHEST TRAUMA

MI Zucker, MD

A dr Z Lecture

• On Major Chest

Trauma

• In Three Parts

Chest trauma

• Blunt

• Penetrating

• Explosion Related

Chemical Agent Related

Biological Agent Related

Oh, yeah:

There’s a separate lecture on Traumatic Aortic Injury

But first:

A few comments on Trauma Imaging

Trauma Chest Radiograph

• Usually AP, often

supine, frequently in

poor inspiration

• So, a challenge to

interpret

CT Chest More sensitive and specific

Part the First:

BLUNT TRAUMA

Fractures and Dislocations

Flail Chest

• Multiple rib fractures,

especially if individual

ribs fractured more

than once, may cause

paradoxical motion

• The major problem

actually is associated

pulmonary contusion

Clavicle Injuries

• Fractures not usually

much of a problem

Sterno-Clavicular Dislocations

• Anterior: Not much of a problem

• Posterior: Less common; can injure great vessels

or trachea

Sterno-clavicle joint dislocation

Sterno-clavicle dislocation: CT

Shoulder Injuries

• Look particularly for

dislocations and

scapula fractures

CT Needed if Scapula Fracture

Seen

AIR where it shouldn’t be

• Simple

• Tension

• Open

PNEUMOTHORAX: CT

• Much more sensitive than plain films

• Even a small traumatic pneumothorax is

important, especially if patient mechanically ventilated or going to OR: A simple

pneumothorax can be converted into a

life- threatening tension pneumothorax

PNEUMOTHORAX: CT

Pneumothorax: Simple

• Erect AP/PA view best

• Visceral pleural line

• No vessels or markings

• Variable degree of lung collapse

• No shift

PNEUMOTHORAX: Simple

PNEUMOTHORAX: Tension

• Erect AP/PA view best

• Shift of mediastinum/heart/trachea away from PTX side

• Depressed hemidiaphragm

• Degree of lung collapse is variable

PNEUMOTHORAX: Tension

PNEUMOTHORAX: Tension

PNEUMOTHORAX: Supine

• Supine AP view has limited sensitivity: 50%

• Deep sulcus sign

• Too sharp heart border/hemidiaphragm sign

• Increased lucency over lower chest

• Subpulmonic air sign

• Can see vessels

PNEUMOTHORAX on Supine

View: Visceral pleural line

PNEUMOTHORAX on Supine

View: Deep sulcus sign

PNEUMOTHORAX on Supine View: Why vessels are visible

PNEUMOTHORAX on Supine

View: Subpulmonic sign

CT: subpulmonic sign explained

PNEUMOTHORAX: Open

• A large hole in the

chest caused by a large

low velocity missile

• Air enters the hole

rather than the trachea

causing hypoxia

• Usually from ruptured alveoli

• Can also be from trachea, bronchi, esophagus, bowel and neck injuries

Paratracheal lucencies

PNEUMOMEDIASTINUM: Continuous diaphragm sign

PNEUMOMEDIASTINUM: CT

Subcutaneous Emphysema

• Causes: Same as

pneumomediastinum

• Causes: penetrating

trauma

• Rare

seen on upright chest

film, but occasionally

are visible on supine

Pneumoperitoneum

Systemic Venous Air Embolism

• Tears in airspaces with

resulting communication

with veins; or outside

access to systemic veins

• Often lethal: Air block in

heart or coronary,

cerebral, mesenteric,

Systemic Venous Air Embolism

• Venous or arterial bleeding

• 60% controlled by chest tube, 40% need operative management

• Can miss hundreds of cc’s on supine film

• Can be tension

HEMOTHORAX

CT: HEMOTHORAX

PULMONARY CONTUSION

and LACERATION

• Contusion: Blood in intact lung parenchyma

• Laceration: Blood in torn lung parenchyma

• Can’t tell difference on chest film Contusions peak in 2-3 days, begin to resolve in a week;

lacerations take much longer to resolve and may leave scars

Pulmonary Contusion and

Laceration

Subtle contusions

Marked contusions

CT: Pulmonary Contusion

CT: Pulmonary laceration

The tear in the lung can

fill with blood or air

• Left clinically injured

more than right 60/40

• Sensitivity of Chest

• Hard signs: NGT through g.e junction then up into chest, and hollow viscus above diaphragm

• Soft signs: Indistinct diaphragm, effusion,

Diaphragm Injury

Diaphragm Injury: Position of

NG Tube

Diaphragm Injury: Gut in Chest

Part the Second:

PENETRATING TRAUMA

Gunshot Wounds

Gunshot Wounds

• Match all entrance and exit wounds

• Find the bullet(s) and keep looking until all are accounted for

• Estimate path of bullet, which may not be straight

• Estimate organs injured

INJURIES depend upon:

• Caliber, weight, construction of bullet

• Velocity

• Tissue impacted

Gunshot Wounds: some terms

• Rounds: the bullet and its casing, propellant and primer

• Bullet: the part of the round that is propelled from the weapon

• Firearms: pistol, rifle, shotgun

• “Blast” : a property of high explosives, not

firearms Don’t use with GSW

Rounds: Pistol and Rifle

trauma) and so a bigger wound.

GSW: Hemothorax, PTX

GSW: Tension

Hemopneumothorax

GSW: Lacerations, abnormal

Mediastinum, PTX

Gunshot Wounds: CT

• Experimental

• May be able to

establish bullet tract

and avoid surgery,

especially

thoraco-abdominal wounds

Knife wounds

• All low energy, small diameter wounds

Frequently, superficial stab or slash

• Look for lung laceration, pneumothorax,

hemothorax, pneumomediastinum, abnormal contour of mediastinum or heart

• Path of wound is straight

Knife Wound: PTX

Part the Third:

Explosions Chemical events Biological events

Since, so far, Los Angeles has experienced few of these events,

most of the images are simulations

Radiological Events

• We aren’t going to discuss these today

• An isotope combined with an explosive makes a Radiological Dispersion Device

• In an RDD event, all of the immediate casualties would be from the explosion

• Radiation injuries would be delayed to negligible, depending upon the type and amount of the

isotope

EXPLOSION Related Chest

Injuries

Accidental/Terrorist Event Conventional explosive device

• Blast wave: sudden increase in atmospheric

pressure High explosives only

• Blast wind: sudden expansion of hot gases High and low explosives

EXPLOSION Related Injuries

• Blast Wave: Lung

EXPLOSION: Blast Wave

causes blast lung

EXPLOSION: Blast Wave causes barotrauma/laceration

EXPLOSION: Blast wave causes abdominal injuries

• Pressure wave injures

bowel wall, causing

hematoma and

perforation, and so

pneumoperitoneum

EXPLOSION: Blast wave

causes SVAE

• Lacerated lung with

bronchovascular

fistulae cause systemic

venous air embolism

EXPLOSION: Blast Wind

• Displaces victim

causing blunt trauma

EXPLOSION: Blast Wind causes

structural collapse

EXPLOSION: Penetrating injury

EXPLOSION: Penetrating injury

EXPLOSION: Flying glass

CHEMICAL AGENTS

Accidental/Terrorist

CHEMICAL AGENTS

• Nerve agents: Sarin, soman, tabun, XV

• Blister agents: Lewisite, mustards

• Choking agents: Chlorine, phosgene

• Blood agents: Cyanides

CHEMICAL AGENTS

• Nerve agents inactivate acetylcholinesterase

• Blister and Choking agents cause acute airway and lung injury

• Blood agents inactivate cytochrome oxidase

causing cell hypoxia

NERVE AGENTS: Aspiration

CHOKING/BLISTER AGENTS:

Acute Lung Injury

BIOLOGICAL AGENTS

Accidental/terrorist

INHALATIONAL ANTHRAX

• Necrotizing

hemorrhagic

mediastinitis

PLAGUE: Bilateral pneumonia

TULAREMIA

• Pneumonia with

lymphadenopathy

• Bleeding into lung

parenchyma

People who liked this lecture also liked: “TRAUMATIC AORTIC

INJURY”

Available from your local Emergency

Radiology lecturer now!

But for now, GOODBYE

• Copyright 2004

MI Zucker