Transcript Fairmont Chest Trauma

Role Of Imaging
In
Thoracic Trauma
BY
Dr. Wassim M El Gendy, MD
Consultant Radiologist
Military Medical Academy
Chest Trauma
 Blunt Trauma
accounts for 20% of trauma related deaths.
MVA accounts for 75% of blunt chest trauma.
Most serious is acute traumatic aortic injury.
Most common injury is Rib #s followed by Pulmonary contusions.
 Penetrating Chest Injuuries
 Modality Based Imaging issues
• Chest Radiograph: screening sensitive but not specific.
• MDCT: replaces X Ray and is 95% sensitive for all life
threatening chest injuries.
 Anatomy Based Imaging Issues
Starts with most life threatening injuries like acute
traumatic aortic injury.
• Patient stabilization is of utmost importance.
 Delayed diagnosis
• More than 30 days reveals:
• 5% aortic transection.
• 40% bronchial tears.
• 60% diaphragmatic tears.
Of patients dying within the first 24hours:
30% of the radiographs are misinterpreted:
Missed injuries like aortic transection.
Diaphragmatic herniation.
Flial Chest
Chest Injuries Include:
A: Aortic Transection.
B: Bronchial tear.
C: Cord Injury.
D: Diaphragmatic tear.
E: Esophageal tear.
F: Flial Chest and Fractured Ribs.
G: Gas Collection.
H: Heart (Cardiac) Injury.
I: Iatrogenic.
Aortic Transection:
Most common location at aortic isthmus.
Radiograph will not show transection Rather
displays leakage of blood leading to mediastinal
widening.
If suspected:….. MD CTAngiography or
Aortography
Bronchial Tear:
– Most common location 2.5 cm off the carina.
– Radiograph does not show tear rather
displays air leakage leading to the “P” sign ie:
Persistent Progressive Pneumothorax.
– If suspected:…. CT or Bronchoscopy for
diagnosis.
Cord Injury:
– Most common location at Functional Thoracolumbar junction which is the transition zone
between thoracic facet and lambar facet
orientation (D 9-11).
– Radiographs may not show the spinal #,
rather shows paraspinal mass / collection,
mal-alignment of spinous processes and
pedicles.
– If suspected CT and / or MRI for diagnosis.
Diaphragmatic Tear:
– Most common location through the posterlateral central tendon of the left hemidiaphragm.
– Herniation may be delayed due to Positive
Pressure Ventillation that hinder the
abdominal contenets from intrathoracic
herniation.
– If suspected: Barium studies but less utilized;
– However CT / MRI is diagnostic in Coronal
and Sagittal images rather than axial images
which are less sensitive (90%).
Esophageal Tear:
– Left postero-lateral wall of the esophagogastric junction is the most common location.
– Radiograph will not show tears but gas and
irritant fluid leakage at left costo-veretbral
junction.
– If suspected esophagogram with Non ionic
contrast media.
Flail Chest:
– Chest radiograph will not show paradoxical
motion of the chest wall.
– Radiograph is sensitive for acute rib fractures.
– Suspected flail chest if more than 5 contiguos
rib fractures or more than 3 contiguois
segmental rib fractures (2 or more #s in each
rib).
– 1st rib fracture signifies sevre trauma.
Gas Collection:
– Supine portable CXR is less sensitive than
Upright CXR for pneumothorax.
– Air collects in non dependant location, in
supine position in inferior lateral hemithorax
(deep sulcus).
– Subtle air collection is the first hint for
esophageal, bronchial and diaphragmatic tear
– Simple pneumothorax may convert to tension
pneumothorax when patients ventillated.
– if suspected CT or Upright XR.
Heart (Cardiac) Injury:
– CXR will not show heart injury but guides to
signs of cardiac dysfunction.
– Suspected especially with sudden
development of pulmonary edema especially
in young.
– If susepcted Echocardiography is best, CT
and MRI less useful.
Iatrogenic (Misplaced Tubesand
Catheters):
– Hurried and hectic environment of trauma
may lead to misplaced tubes.
– All lines and tubes must be accounted for.
– NG tube course is often a guide for aortic
transection in CXR (displaced from aortic
arch), or diaphragmatic tear (courses into the
abdomen or herniated stomach).
Case presentation
Healed Rib Fractures (old)
Healed lateral ribs fractures
Lateral dislocation of D12 over L1
Intramural hematoma obstructing
2nd portion of Du
Subdiaphragmatic air
(ruptured stomach)
Incomplete filling of 3rd DU from
mural hematoma on Ba meal and
CT Abd.
Penetrating bullet injury courses
top to bottom
Subcutaneous Bullet shots
Bullet course left posteroantero-lateral through post
stomach and liver
Bomb blast contusion
Bomb blast contusion with air
under diaphragm