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CHEST TRAUMA

dr. Sri Indah Aruminingsih, Sp.Rad.

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

Trauma Chest Radiograph


Usually AP, often
supine, frequently
in poor
inspiration.
So, a challenge to
interpret.

CT Chest
More sensitive and specific

CT Chest: Reformat

The new MDCT


scanners do
awesome
reformats without
additional
scanning.

Part the First:


BLUNT TRAUMA

Fractures and Dislocations

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.

AIR where it shouldnt be

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

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.

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

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.

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

Diaphragm Injury

Diaphragm Injury: Position


of NG Tube

Diaphragm Injury: Gut in


Chest

Part the Second:


PENETRATING TRAUMA
Gunshot Wounds
Stab 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. Dont use with GSW.

Rounds: Pistol and Rifle

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: Hemothorax, PTX

GSW: Tension
Hemopneumothorax

GSW: Lacerations, abnormal


Mediastinum, PTX

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.

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 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.

EXPLOSION Related Chest


Injuries
Accidental/Terrorist Event
Conventional explosive device
Improvised explosive device

EXPLOSIVES
High Explosives:

Low Explosives:

TNT, dynamite, C-4,


ANFO, RDX, PETN

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.

EXPLOSION Related Injuries


Blast Wave: Lung
laceration,
contusion, edema,
barotrauma
Penetrating Trauma
Blast Wind:
Displacement
Crush, burns,
inhalation injuries

Primary

Secondary
Tertiary
Quartanary

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
pneumoperitoneu
m

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
trauma
Metal fragments
from conventional
bomb housing
Scraps of metal,
nails attached to
Improvised
Explosive Device

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

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

People who liked this


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INJURY
Available from your local
Emergency Radiology lecturer
now!

But for now, GOODBYE

Copyright 2004
MI Zucker

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