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Chest trauma
Blunt
Penetrating
Explosion Related
Chemical Agent Related
Biological Agent Related
Oh, yeah:
Theres a separate lecture on
Traumatic Aortic Injury
But first:
A few comments on Trauma
Imaging
CT Chest
More sensitive and specific
CT Chest: Reformat
Spine
Ribs
Clavicles
Sternum
Shoulders
Spine Injuries
Look for loss of
alignment,
fractures and
paraspinal
hematoma.
The findings may
be very subtle.
Rib Fractures
In themselves,
not too much of a
problem, but may
be an indicator of
underlying pleura,
lung, liver, spleen,
kidney injuries.
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
Sternum Fractures
Not usually a
problem.
Controversial
association with
myocardial injury.
Pneumothorax
Pneumomediastinum
Subcutaneous emphysema
Systemic venous air embolism
Pneumopericardium
Pneumoperitoneum/retroperitoneum
PNEUMOTHORAX
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
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
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.
PNEUMOMEDIASTIUM
Usually from ruptured alveoli.
Can also be from trachea, bronchi,
esophagus, bowel and neck injuries.
PNEUMOMEDIASTINUM:
Signs
Linear paratracheal
lucencies
Air along heart
border
V sign at aorticdiaphragm junction
Continuous
diaphragm sign
PNEUMOMEDIASTINUM:
Paratracheal lucencies
PNEUMOMEDIASTINUM:
Continuous diaphragm sign
PNEUMOMEDIASTINUM: CT
Trachea/bronchi injuries
Tears occur within
2cm of carina
Persistant
pneumothorax
Large
pneumomediastin
um
Fallen lung
Subcutaneous
Emphysema
Causes: Same as
pneumomediastin
um
Pneumopericardium
Causes:
penetrating
trauma
Rare
Pneumoperitoneum
Pneumoperitoneum
and sometimes
pneumoretroperitoneum
are seen on
upright chest film,
but occasionally are
visible on supine
chest radiograph.
Pneumoperitoneum
HEMOTHORAX
Venous or arterial bleeding
60% controlled by chest tube, 40%
need operative management
Can miss hundreds of ccs 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
Cant 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
Subtle contusions
Marked contusions
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
Diaphragm Injury
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
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
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.
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.
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.
Gunshot Wounds
GSWs of the CHEST cause:
pulmonary lacerations/contusions,
hemothorax, pneumothorax,
mediastinum/heart injuries,
pneumomediastinum, fractures.
GSW: Tension
Hemopneumothorax
GSW: Transmediastinum
Bilateral chest
tubes
Angiography
Pericardial window
Triple endoscopy
Esophagram
Thoracic spine films
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.
Radiological Events
We arent 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.
EXPLOSIVES
High Explosives:
Low Explosives:
Gun powder,
smokeless
propellant,
fireworks
Explosions
Blast wave: sudden increase in
atmospheric pressure. High
explosives only.
Blast wind: sudden expansion of hot
gases. High and low explosives.
Primary
Secondary
Tertiary
Quartanary
EXPLOSION: Penetrating
trauma
Metal fragments
from conventional
bomb housing
Scraps of metal,
nails attached to
Improvised
Explosive Device
EXPLOSION: Penetrating
injury
EXPLOSION: Penetrating
injury
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
CHOKING/BLISTER AGENTS:
Acute Lung Injury
BIOLOGICAL AGENTS
Accidental/terrorist
BIOLOGICAL AGENTS
Inhalational Anthrax
Plague
Tularemia
Viral hemorrhagic fevers
Ricin
To be effective, agents must be
aerosolized.
INHALATIONAL ANTHRAX
Necrotizing
hemorrhagic
mediastinitis
PLAGUE: Bilateral
pneumonia
TULAREMIA
Pneumonia with
lymphadenopathy
VHFs
Bleeding into lung
parenchyma
RICIN
Biological toxin
from castor bean
Inhibits protein
synthesis
Causes
pulmonary
edema/ARDS
Copyright 2004
MI Zucker