23PNEUMOTHORAX: 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 alife- threatening tension pneumothorax.
50Systemic Venous Air Embolism Tears in airspaces with resulting communication with veins; or outside access to systemic veinsOften lethal: Air block in heart or coronary, cerebral, mesenteric, peripheral arteries.
56PULMONARY CONTUSION and LACERATION Contusion: Blood in intact lung parenchymaLaceration: Blood in torn lung parenchymaCan’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
61CT: Pulmonary laceration The tear in the lung can fill with blood or air.
62DIAPHRAGM Injuries5% of major blunt trauma, also thoraco-abdominal penetrating traumaLeft clinically injured more than right 60/40Sensitivity of Chest film 40%. CT better, but still misses someHard signs: NGT through g.e. junction then up into chest, and hollow viscus above diaphragmSoft signs: Indistinct diaphragm, effusion, atelectasis
66PENETRATING TRAUMA Gunshot Wounds Stab Wounds Part the Second:PENETRATING TRAUMAGunshot WoundsStab Wounds
67Gunshot Wounds Match all entrance and exit wounds Find the bullet(s) and keep looking until all are accounted forEstimate path of bullet, which may not be straightEstimate organs injured
68INJURIES depend upon: Caliber, weight, construction of bullet Velocity Tissue impacted
69Gunshot Wounds: some terms Rounds: the bullet and its casing, propellant and primerBullet: the part of the round that is propelled from the weaponFirearms: pistol, rifle, shotgun“Blast” : a property of high explosives, not firearms. Don’t use with GSW.
71BULLET Size: diameter in millimeters or caliber (fractions of an inch) Weight: in grainsConstruction: round nose, hollow point, full metal jacket, semi-jacket, no jacket
72Injuries: BulletThe 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.
73Injuries: VelocityHand 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.
74Injuries: TissueLung 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.
75Gunshot WoundsGSWs of the CHEST cause: pulmonary lacerations/contusions, hemothorax, pneumothorax, mediastinum/heart injuries,pneumomediastinum, fractures.
79GSW: Transmediastinum Bilateral chest tubesAngiographyPericardial windowTriple endoscopyEsophagramThoracic spine films
80Gunshot Wounds: CT Experimental May be able to establish bullet tract and avoid surgery, especially thoraco-abdominal wounds
81Knife woundsAll 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.
83Explosions Chemical events Biological events Part the Third:ExplosionsChemical eventsBiological events
84Since, so far, Los Angeles has experienced few of these events, most of the images are simulations
85Radiological 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.
86EXPLOSION Related Chest Injuries Accidental/Terrorist EventConventional explosive deviceImprovised explosive device