trauma of chest
DESCRIPTION
SDSDTRANSCRIPT
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CHEST TRAUMA
MI Zucker, MD
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A dr Z Lecture
• On Major Chest Trauma
• In Three Parts
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Chest trauma
• Blunt
• Penetrating
• Explosion Related
Chemical Agent Related
Biological Agent Related
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Oh, yeah:
There’s a separate lecture on Traumatic Aortic Injury
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But first:
A few comments on Trauma Imaging
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Trauma Chest Radiograph
• Usually AP, often supine, frequently in poor inspiration.
• So, a challenge to interpret.
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CT ChestMore sensitive and specific
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CT Chest: Reformat
• The new MDCT scanners do awesome reformats without additional scanning.
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Part the First:
BLUNT TRAUMA
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Fractures and Dislocations
• Spine
• Ribs
• Clavicles
• Sternum
• Shoulders
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Spine Injuries
• Look for loss of alignment, fractures and paraspinal hematoma.
• The findings may be very subtle.
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Rib Fractures
• In themselves, not too much of a problem, but may be an indicator of underlying pleura, lung, liver, spleen, kidney injuries.
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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.
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Clavicle Injuries
• Fractures not usually much of a problem
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Sterno-Clavicular Dislocations
• Anterior: Not much of a problem
• Posterior: Less common; can injure great vessels or trachea
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Sterno-clavicle joint dislocation
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Sterno-clavicle dislocation: CT
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Shoulder Injuries
• Look particularly for dislocations and scapula fractures
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CT Needed if Scapula Fracture Seen
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Sternum Fractures
• Not usually a problem.
• Controversial association with myocardial injury.
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AIR where it shouldn’t be
• Pneumothorax
• Pneumomediastinum
• Subcutaneous emphysema
• Systemic venous air embolism
• Pneumopericardium
• Pneumoperitoneum/retroperitoneum
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PNEUMOTHORAX
• Simple• Tension• Open
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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.
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PNEUMOTHORAX: CT
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Pneumothorax: Simple
• Erect AP/PA view best
• Visceral pleural line
• No vessels or markings
• Variable degree of lung collapse
• No shift
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PNEUMOTHORAX: Simple
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PNEUMOTHORAX: Tension
• Erect AP/PA view best
• Shift of mediastinum/heart/trachea away from PTX side
• Depressed hemidiaphragm
• Degree of lung collapse is variable
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PNEUMOTHORAX: Tension
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PNEUMOTHORAX: Tension
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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
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PNEUMOTHORAX on Supine View: Visceral pleural line
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PNEUMOTHORAX on Supine View: Deep sulcus sign
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PNEUMOTHORAX on Supine View: Why vessels are visible
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PNEUMOTHORAX on Supine View: Subpulmonic sign
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CT: subpulmonic sign explained
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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.
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PNEUMOMEDIASTIUM
• Usually from ruptured alveoli.
• Can also be from trachea, bronchi, esophagus, bowel and neck injuries.
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PNEUMOMEDIASTINUM: Signs
• Linear paratracheal lucencies
• Air along heart border• “V” sign at aortic-
diaphragm junction• Continuous diaphragm
sign
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PNEUMOMEDIASTINUM:Paratracheal lucencies
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PNEUMOMEDIASTINUM: Continuous diaphragm sign
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PNEUMOMEDIASTINUM: CT
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Trachea/bronchi injuries
• Tears occur within 2cm of carina
• Persistant pneumothorax
• Large pneumomediastinum
• “Fallen lung”
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Subcutaneous Emphysema
• Causes: Same as pneumomediastinum
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Pneumopericardium
• Causes: penetrating trauma
• Rare
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Pneumoperitoneum
• Pneumoperitoneum and sometimes pneumo-
retroperitoneum are seen on upright chest film, but occasionally are visible on supine chest radiograph.
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Pneumoperitoneum
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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, peripheral arteries.
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Systemic Venous Air Embolism
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HEMOTHORAX
• 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
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HEMOTHORAX
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CT: HEMOTHORAX
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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
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Pulmonary Contusion and Laceration
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Subtle contusions
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Marked contusions
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CT: Pulmonary Contusion
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CT: Pulmonary laceration
The tear in the lung can fill with blood or air.
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DIAPHRAGM Injuries
• 5% of major blunt trauma, also thoraco-abdominal penetrating trauma
• Left clinically injured more than right 60/40
• Sensitivity of Chest film 40%. CT better, but still misses some
• Hard signs: NGT through g.e. junction then up into chest, and hollow viscus above diaphragm
• Soft signs: Indistinct diaphragm, effusion, atelectasis
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Diaphragm Injury
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Diaphragm Injury: Position of NG Tube
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Diaphragm Injury: Gut in Chest
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Part the Second:
PENETRATING TRAUMA
Gunshot Wounds
Stab Wounds
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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
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INJURIES depend upon:
• Caliber, weight, construction of bullet
• Velocity
• Tissue impacted
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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.
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Rounds: Pistol and Rifle
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BULLET
• Size: diameter in millimeters or caliber (fractions of an inch)
• Weight: in grains
• Construction: round nose, hollow point, full metal jacket, semi-jacket, no jacket
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Injuries: Bullet
The larger the diameter of the bullet and the more it weighs, the bigger the wound.
Hollow point and semi-jacket bullets mushroom or fragment on impact and cause bigger wounds than FMJ.
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Injuries: Velocity
• Hand guns are low velocity (1000 fps) and cause a permanent wound channel (crush) only.
• High-powered and assault rifles are high velocity (3000 fps) and cause a permanent wound channel and also temporary cavitation (blunt or stretch trauma) and so a bigger wound.
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Injuries: Tissue
• Lung is elastic and more resistant to injury than solid organs. Bone is least resistant.
• Obviously, the more vital the organ the more serious the injury.
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Gunshot Wounds
• GSWs of the CHEST cause: pulmonary lacerations/contusions, hemothorax, pneumothorax, mediastinum/heart injuries,
pneumomediastinum, fractures.
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GSW: Hemothorax, PTX
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GSW: Tension Hemopneumothorax
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GSW: Lacerations, abnormal Mediastinum, PTX
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GSW: Transmediastinum
• Bilateral chest tubes• Angiography• Pericardial window• Triple endoscopy• Esophagram• Thoracic spine films
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Gunshot Wounds: CT
• Experimental• May be able to
establish bullet tract and avoid surgery, especially thoraco-abdominal wounds
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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.
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Knife Wound: PTX
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Part the Third:
Explosions
Chemical events
Biological events
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Since, so far, Los Angeles has experienced few of these events,
most of the images are simulations
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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.
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EXPLOSION Related Chest Injuries
Accidental/Terrorist Event
Conventional explosive device
Improvised explosive device
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EXPLOSIVES
• High Explosives:
TNT, dynamite, C-4, ANFO, RDX, PETN
• Low Explosives:
Gun powder, smokeless propellant, fireworks
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Explosions
• Blast wave: sudden increase in atmospheric pressure. High explosives only.
• Blast wind: sudden expansion of hot gases. High and low explosives.
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EXPLOSION Related Injuries
• Blast Wave: Lung laceration, contusion, edema, barotrauma
• Penetrating Trauma• Blast Wind:
Displacement• Crush, burns,
inhalation injuries
• Primary
• Secondary
• Tertiary
• Quartanary
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EXPLOSION: Blast Wave causes blast lung
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EXPLOSION: Blast Wave causes barotrauma/laceration
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EXPLOSION: Blast wave causes abdominal injuries
• Pressure wave injures bowel wall, causing hematoma and perforation, and so pneumoperitoneum
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EXPLOSION: Blast wave causes SVAE
• Lacerated lung with bronchovascular fistulae cause systemic venous air embolism
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EXPLOSION: Blast Wind
• Displaces victim causing blunt trauma
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EXPLOSION: Blast Wind causes structural collapse
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EXPLOSION: Penetrating trauma
• Metal fragments from conventional bomb housing
• Scraps of metal, nails attached to Improvised Explosive Device
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EXPLOSION: Penetrating injury
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EXPLOSION: Penetrating injury
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EXPLOSION: Flying glass
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CHEMICAL AGENTS
Accidental/Terrorist
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CHEMICAL AGENTS
• Nerve agents: Sarin, soman, tabun, XV
• Blister agents: Lewisite, mustards
• Choking agents: Chlorine, phosgene
• Blood agents: Cyanides
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CHEMICAL AGENTS
• Nerve agents inactivate acetylcholinesterase
• Blister and Choking agents cause acute airway and lung injury
• Blood agents inactivate cytochrome oxidase causing cell hypoxia
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NERVE AGENTS: Aspiration
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CHOKING/BLISTER AGENTS: Acute Lung Injury
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BIOLOGICAL AGENTS
Accidental/terrorist
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BIOLOGICAL AGENTS
• Inhalational Anthrax
• Plague
• Tularemia
• Viral hemorrhagic fevers
• Ricin
To be effective, agents must be aerosolized.
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INHALATIONAL ANTHRAX
• Necrotizing hemorrhagic mediastinitis
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PLAGUE: Bilateral pneumonia
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TULAREMIA
• Pneumonia with lymphadenopathy
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VHFs
• Bleeding into lung parenchyma
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RICIN
• Biological toxin from castor bean
• Inhibits protein synthesis
• Causes pulmonary edema/ARDS
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People who liked this lecture also liked: “TRAUMATIC AORTIC
INJURY”Available from your local Emergency
Radiology lecturer now!
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But for now, GOODBYE
• Copyright 2004
MI Zucker