2009-07-14, chest on call cases

8/9/2019 2009-07-14, Chest on Call Cases

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Chest On Call

2007-07-14


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Effusions

Meniscoid Effusions

Flat effusions


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Pneumomediastinum

Continuous diaphragm sign

Rupture of major airways

Rupture of alveolus Air dissects back along perivascular sheaths

to hilum and mediastinum (Macklin effect)

Rupture of the esophagus pneumomediastinum and left pleural effusion


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"on a pediatric CXR, forget the

pneumonia, just don't miss ..."


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mediastinal hemorrhage

Mediastinal widening

Left Apical Cap

Obscuration of aortic arch Obscuration of paraspinal lines

Depression of left mainstem bronchus

Tracheal & NG tube deviation


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mediastinal hemorrhage

Aortic transection

Aortic dissection

Ruptured Aneurysm Any great vessel injury / bleeding

Thoracic spine injury

Get CT


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Tracheobronchial Tear

Death: high probably, many within 1st hour

inadequate airway

tension pneumothorax

accompanying injuries

Delayed Diagnosis:

two thirds of survivors

Late complications: airway stenosis,atelectasis, pneumonia, mediastinitis, sepsisand decreased pulmonary capacity.


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Diaphragmatic Injuries

Bowel gas in thorax

NGT in thorax

Dependent Viscera sign Abnormal diaphragmatic contours

Effusion


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Diaphragmatic Injuries

embryologic weak point: posterolateral

aspect, usually left.

MVC, falls, GSW Associated with blunt diaphragmatic injury:

Pelvic fractures in 40%

Splenic rupture in 25%

Liver laceration in 25%

Thoracic aortic tear in 5-10%


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First Rib Fracture

Mortality 20%

Aortic injury 20%

Bronchial fracture 80% Injury to the lung, pneumothorax

Subclavian artery

brachial plexus May also be inconsequential...


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Esophageal Perforation

Pneumomediastinum and subcutaneous

emphysema

pleural effusions (often left sided),pneumothorax and hydropneumothorax.

V sign: Air outlines left lower mediastinal

border and left medial hemidiaphragm

subcutaneous emphysema on neck

radiographs in cervical perforation.


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Esophageal Perforation

A contrast esophagogram should be performedin any patient with suspected perforation.

water-soluble contrast agent (Gastrografin)

should be the initial study of choice, then CT. A barium study should be undertaken

immediately afterward should the initial studyshow no evidence of perforation.

Barium has a higher sensitivity (90%) fordetecting small perforations but may (rarely)cause mediastinitis.


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Time Sensitive Chest CasesA.B.C.D.E.F.G.H.I.

Aorta

Bronchi

Cord injury, Child abuse

Diaphgram Esophagus

Flail chest, First rib, Foreign bodies

Gas (pneumothorax, pneumomediastinum,pneumoperitoneum, portal venous gas)

Heart Iatrogenic (tubes & catheters), Infection (bacterial

tracheitis, epiglottitis, mediastinitis + TB)

2009-07-14, chest on call cases

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