Chest x-ray in Trauma

Pearls and pitfalls Mats O. Beckman

Radiology Karolinska

Stockholm

3 chestmb08

4 chestmb08

5 chestmb08

6 chestmb08

7 chestmb08

8 chestmb08

Traumaroom

9 chestmb08

When to do AP chest?

•1 minute good

•3 minutes acceptable

•5 minutes doubtful

•10 minutes substandard

10 chestmb08

11 chestmb08

Normal AP chest

12 chestmb08

Evaluation algorithm

A irways, Tube

B Lung parenchyma, pneumothorax

C Chest bleeding

D Diaphragm, mediastinum

E Drains & linEs

F ractures, dislocations, soft tissues

13 chestmb08

Mind the positioning

14 chestmb08

Spineboard away!

With and without spineboard

15 chestmb08

Tension pneumothorax BLACK?

16 chestmb08

Tension pneumothorax

Medial border of

scapula

17 chestmb08

18 chestmb08

Skinfold

19 chestmb08

Action?

When?

Who?

How?

YES

Now

I (Jag, Minä, Jeg, я

сам , Yo, ,

Moi, Ich, Io, )

20 chestmb08

21 chestmb08

22 chestmb08

23 chestmb08

24 chestmb08

Metro

BLACK

?

25 chestmb08

B- Breathing

A young female falls 3m. Initially unconcious and

intubated on the spot.

On arrival to the hospital sat 96% with 40% oxygen.

Tympanistic percussionsound on the right thorax,

decreased breathing sounds on the left.

Immediate management?

26 chestmb08

B-Breathing

Chest X-ray reveals

right bronchial intubation,

a common finding in trauma patients intubated under stress.

27 chestmb08

MVC, driver

Stomach air!

28 chestmb08

Haemothorax and?

WHITE?

29 chestmb08

White

Haemothorax

+?

SC emfysema

30 chestmb08

Horse accident. Black& White? Positioning!

Haemothorax dx

Bilateral pntx

Upper rib fx

31 chestmb08

Stabbed in back. Prone examination.

32 chestmb08

33 chestmb08

Fluid?

34 chestmb08

Ultrasound!

35 chestmb08

Before and after drainage

36 chestmb08

Before and after drainage

37 chestmb08

Left tension

Pneumo

Haemothorax

Image courtesy www.trauma.org

and Karim Brohi

38 chestmb08

ETT should be level w upper aortic arch

central line in lower VCS

ROTATION!

39 chestmb08

ETT CVK

Introducer

Pigtail

Pigtail

Tubes and linEs

40 chestmb08

Rib fractures, humerus fracture

41 chestmb08

Flail Chest

2 or more contiguous ribs fractured in

2 or more places

42 chestmb08

Flail chest

43 chestmb08

Flail chest

44 chestmb08

Knife right upper quadrant

45 chestmb08

Liver, gallbladder injury.Operated. Postop CT.

46 chestmb08

Clinically diagnosed rib fracture 1 week ago

47 chestmb08

Clinically diagnosed rib fracture 1 week ago.

Ege enhanced.

48 chestmb08

Knifed. Pneumothorax sin

49 chestmb08

Pneumothorax sin+dx

50 chestmb08

Pneumothorax sin+dx

51 chestmb08

Dyspnoea…..

52 chestmb08

Action

53 chestmb08

Pedestrian hit by car.

54 chestmb08

Pedestrian hit by car.

55 chestmb08

Hit by lorry. Associated injuries?

Run over by lorry

56 chestmb08

Hit by lorry. Associated injuries? Run over by lorry

Do not dawdle, do CT

Or you might die DWD

Death Without Diagnosis

58 chestmb08

Pntx bilat, ribfx, flail, scapula, calvicle, thfx,

sternum

59 chestmb08

Old bullet wound, now new central line

60 chestmb08

Old bullet wound, now new central line

•Always be suspicious

when line is on the left!

•Tracheal deviation

after multiple right sided

punctures.

61 chestmb08

Several thoracic knife wounds

62 chestmb08

Diafragm, Collar sign (Dr Shan)

63 chestmb08

Trod upon by horse. Contusions , lacerations

64 chestmb08

Fractures significance

Any rib fracture or pulmonary contusion visible on the initial plain

CXR significantly increased the incidence of pulmonary morbidity

or mortality.

The presence of rib fracture in more than anatomic region

doubled the incidence of respiratory failure (24% vs. 12%; p =

0.002)

Livingstone et al J Trauma. 2008 Apr;64(4):905-11

65 chestmb08

Flail chest, contusions left

66 chestmb08

Contusion extension

67 chestmb08

Skeletal dislocations

68 chestmb08

69 chestmb08

MC, cannot lower right arm

70 chestmb08

Diaphragm rupture

72 chestmb08

Diaphragm

Left >>right> >>>bilateral

– (58-36-2)

Associerated

– Bleeding!!

– Spleen

– Liver

– Lung

– Bowel, kidney, fractures

73 chestmb08

Other rupture…

74 chestmb08

Perikardial rupture after blunt trauma

Morel-Lavalle 1864

3 patients thorax trauma fall from height

”Bruit de moulin”, 2/3 mortality; 1/3 symptomatic for 2 years

1958, autopsy study: incidence 3%

1991, retrospektive study 20 000 traumacasesl: incidence 0.1%

28% associated heart damage

left 50-76% > diafragma > hö-sidiga > mediastinal

Rupture often craniocaudally anterior to phrenic nerve.

75 chestmb08

Prognosis, action

Heart herniation can happen anytime within days- years

Small and large defects are treated conservatively

Midrange defects can be dangerous: all hernias occured if defects 8-12 cm long

Treatment: Suturing or perikardiotomi

Mortality: 53-64%

76 chestmb08

77 chestmb08

Looking at ancient trauma sites…

for the future

Thank you!