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CHEST TRAUMA MI Zucker, MD. A dr Z Lecture On Major Chest Trauma In Three Parts.

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Presentation on theme: "CHEST TRAUMA MI Zucker, MD. A dr Z Lecture On Major Chest Trauma In Three Parts."— Presentation transcript:

1 CHEST TRAUMA MI Zucker, MD

2 A dr Z Lecture On Major Chest Trauma In Three Parts

3 Chest trauma Blunt Penetrating Explosion Related Chemical Agent Related Biological Agent Related

4 Oh, yeah: There’s a separate lecture on Traumatic Aortic Injury

5 But first: A few comments on Trauma Imaging

6 Trauma Chest Radiograph Usually AP, often supine, frequently in poor inspiration. So, a challenge to interpret.

7 CT Chest More sensitive and specific

8 CT Chest: Reformat The new MDCT scanners do awesome reformats without additional scanning.

9 Part the First: BLUNT TRAUMA

10 Fractures and Dislocations Spine Ribs Clavicles Sternum Shoulders

11 Spine Injuries Look for loss of alignment, fractures and paraspinal hematoma. The findings may be very subtle.

12 Rib Fractures In themselves, not too much of a problem, but may be an indicator of underlying pleura, lung, liver, spleen, kidney injuries.

13 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.

14 Clavicle Injuries Fractures not usually much of a problem

15 Sterno-Clavicular Dislocations Anterior: Not much of a problem Posterior: Less common; can injure great vessels or trachea

16 Sterno-clavicle joint dislocation

17 Sterno-clavicle dislocation: CT

18 Shoulder Injuries Look particularly for dislocations and scapula fractures

19 CT Needed if Scapula Fracture Seen

20 Sternum Fractures Not usually a problem. Controversial association with myocardial injury.

21 AIR where it shouldn’t be Pneumothorax Pneumomediastinum Subcutaneous emphysema Systemic venous air embolism Pneumopericardium Pneumoperitoneum/retroperitoneum

22 PNEUMOTHORAX Simple Tension Open

23 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.

24 PNEUMOTHORAX: CT

25 Pneumothorax: Simple Erect AP/PA view best Visceral pleural line No vessels or markings Variable degree of lung collapse No shift

26 PNEUMOTHORAX: Simple

27 PNEUMOTHORAX: Tension Erect AP/PA view best Shift of mediastinum/heart/trachea away from PTX side Depressed hemidiaphragm Degree of lung collapse is variable

28 PNEUMOTHORAX: Tension

29

30 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

31 PNEUMOTHORAX on Supine View: Visceral pleural line

32 PNEUMOTHORAX on Supine View: Deep sulcus sign

33

34 PNEUMOTHORAX on Supine View: Why vessels are visible

35 PNEUMOTHORAX on Supine View: Subpulmonic sign

36 CT: subpulmonic sign explained

37 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.

38 PNEUMOMEDIASTIUM Usually from ruptured alveoli. Can also be from trachea, bronchi, esophagus, bowel and neck injuries.

39 PNEUMOMEDIASTINUM: Signs Linear paratracheal lucencies Air along heart border “V” sign at aortic- diaphragm junction Continuous diaphragm sign

40 PNEUMOMEDIASTINUM: Paratracheal lucencies

41

42 PNEUMOMEDIASTINUM: Continuous diaphragm sign

43 PNEUMOMEDIASTINUM: CT

44 Trachea/bronchi injuries Tears occur within 2cm of carina Persistant pneumothorax Large pneumomediastinum “Fallen lung”

45 Subcutaneous Emphysema Causes: Same as pneumomediastinum

46

47 Pneumopericardium Causes: penetrating trauma Rare

48 Pneumoperitoneum Pneumoperitoneum and sometimes pneumo- retroperitoneum are seen on upright chest film, but occasionally are visible on supine chest radiograph.

49 Pneumoperitoneum

50 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.

51 Systemic Venous Air Embolism

52 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

53 HEMOTHORAX

54

55 CT: HEMOTHORAX

56 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

57 Pulmonary Contusion and Laceration

58 Subtle contusions

59 Marked contusions

60 CT: Pulmonary Contusion

61 CT: Pulmonary laceration The tear in the lung can fill with blood or air.

62 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

63 Diaphragm Injury

64 Diaphragm Injury: Position of NG Tube

65 Diaphragm Injury: Gut in Chest

66 Part the Second: PENETRATING TRAUMA Gunshot Wounds Stab Wounds

67 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

68 INJURIES depend upon: Caliber, weight, construction of bullet Velocity Tissue impacted

69 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.

70 Rounds: Pistol and Rifle

71 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

72 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.

73 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.

74 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.

75 Gunshot Wounds GSWs of the CHEST cause: pulmonary lacerations/contusions, hemothorax, pneumothorax, mediastinum/heart injuries, pneumomediastinum, fractures.

76 GSW: Hemothorax, PTX

77 GSW: Tension Hemopneumothorax

78 GSW: Lacerations, abnormal Mediastinum, PTX

79 GSW: Transmediastinum Bilateral chest tubes Angiography Pericardial window Triple endoscopy Esophagram Thoracic spine films

80 Gunshot Wounds: CT Experimental May be able to establish bullet tract and avoid surgery, especially thoraco- abdominal wounds

81 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.

82 Knife Wound: PTX

83 Part the Third: Explosions Chemical events Biological events

84 Since, so far, Los Angeles has experienced few of these events, most of the images are simulations

85 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.

86 EXPLOSION Related Chest Injuries Accidental/Terrorist Event Conventional explosive device Improvised explosive device

87 EXPLOSIVES High Explosives: TNT, dynamite, C-4, ANFO, RDX, PETN Low Explosives: Gun powder, smokeless propellant, fireworks

88 Explosions Blast wave: sudden increase in atmospheric pressure. High explosives only. Blast wind: sudden expansion of hot gases. High and low explosives.

89 EXPLOSION Related Injuries Blast Wave: Lung laceration, contusion, edema, barotrauma Penetrating Trauma Blast Wind: Displacement Crush, burns, inhalation injuries Primary Secondary Tertiary Quartanary

90 EXPLOSION: Blast Wave causes blast lung

91 EXPLOSION: Blast Wave causes barotrauma/laceration

92 EXPLOSION: Blast wave causes abdominal injuries Pressure wave injures bowel wall, causing hematoma and perforation, and so pneumoperitoneum

93 EXPLOSION: Blast wave causes SVAE Lacerated lung with bronchovascular fistulae cause systemic venous air embolism

94 EXPLOSION: Blast Wind Displaces victim causing blunt trauma

95 EXPLOSION: Blast Wind causes structural collapse

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

97 EXPLOSION: Penetrating injury

98

99 EXPLOSION: Flying glass

100 CHEMICAL AGENTS Accidental/Terrorist

101 CHEMICAL AGENTS Nerve agents: Sarin, soman, tabun, XV Blister agents: Lewisite, mustards Choking agents: Chlorine, phosgene Blood agents: Cyanides

102 CHEMICAL AGENTS Nerve agents inactivate acetylcholinesterase Blister and Choking agents cause acute airway and lung injury Blood agents inactivate cytochrome oxidase causing cell hypoxia

103 NERVE AGENTS: Aspiration

104 CHOKING/BLISTER AGENTS: Acute Lung Injury

105 BIOLOGICAL AGENTS Accidental/terrorist

106 BIOLOGICAL AGENTS Inhalational Anthrax Plague Tularemia Viral hemorrhagic fevers Ricin To be effective, agents must be aerosolized.

107 INHALATIONAL ANTHRAX Necrotizing hemorrhagic mediastinitis

108 PLAGUE: Bilateral pneumonia

109 TULAREMIA Pneumonia with lymphadenopathy

110 VHFs Bleeding into lung parenchyma

111 RICIN Biological toxin from castor bean Inhibits protein synthesis Causes pulmonary edema/ARDS

112 People who liked this lecture also liked: “TRAUMATIC AORTIC INJURY” Available from your local Emergency Radiology lecturer now!

113 But for now, GOODBYE Copyright 2004 MI Zucker


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