Chest x-ray in Trauma Pearls and pitfalls. Mats O. Beckman. Stockholm

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1 Chest x-ray in Trauma Pearls and pitfalls Mats O. Beckman Radiology Karolinska University Hospital Stockholm

2 3 chestmb08 4 chestmb08

3 5 chestmb08 6 chestmb08

4 7 chestmb08 Traumaroom 8 chestmb08

5 When to do AP chest? 1 minute good 3 minutes acceptable 5 minutes doubtfulu 10 minutes substandard 9 chestmb08 10 chestmb08

6 Normal AP chest 11 chestmb08 Evaluation algorithm A irways B Lung parenchyma, pneumothorax C Chest bleeding D Diaphragm, mediastinum E Drains & lines F ractures, dislocations, soft tissues 12 chestmb08

7 Mind the positioning 13 chestmb08 Spineboard away! 14 chestmb08 With and without spineboard

8 Tension pneumothorax BLACK? 15 chestmb08 Tension pneumothorax Medial border of scapula 16 chestmb08

9 Action? When? Who? How? YES Now I (Jag, Minä, Jeg, я,,إيي إياي ي نفسي, Yo, сам Moi, Ich, Io, ) 17 chestmb08 18 chestmb08

10 19 chestmb08 20 chestmb08

11 21 chestmb08 Metro 22 chestmb08

Tympanistic percussionsound on the right thorax, decreased breathing sounds on the left.

12 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? 23 chestmb08 B-Breathing Chest X-ray reveals right bronchial intubation, a common finding in trauma patients intubated under stress. 24 chestmb08

13 MVC, driver Stomach air! 25 chestmb08 WHITE? Haemothorax and? 26 chestmb08

14 Hemothorax +? SC emfysema 27 chestmb08 Horse accident. Black& White? Positioning! Haemothorax dx Bilateral pntx Upper rib fx 28 chestmb08

15 Stabbed in back. Prone examination. 29 chestmb08 30 chestmb08

16 Fluid? 31 chestmb08 Ultrasound! 32 chestmb08

17 Before and after drainage 33 chestmb08 Before and after drainage 34 chestmb08

18 Left tension Pneumo Haemothorax 35 chestmb08 Image courtesy and Karim Brohi ETT should be level w upper aortic arch central line in lower VCS ROTATION! 36 chestmb08

19 Introducer Tubes and lines CVK ETT Pigtail Pigtail 37 chestmb08 Rib fractures, humerus fracture 38 chestmb08

$contiguous ribs fractured$ in 2 or more places 39

20 Flail Chest 2 or more contiguous ribs fractured in 2 or more places 39 chestmb08 Flail chest 40 chestmb08

21 Flail chest 41 chestmb08 Knife right upper quadrant 42 chestmb08

22 Liver, gallbladder injury.operated. Postop CT. 43 chestmb08 Clinically diagnosed rib fracture 1 week ago 44 chestmb08

$Clinically diagnosed rib fracture 1 week ago.$

23 Clinically diagnosed rib fracture 1 week ago. Ege enhanced. 45 chestmb08 Knifed. Pneumothorax sin 46 chestmb08

24 Pneumothorax sin+dx 47 chestmb08 Pneumothorax sin+dx 48 chestmb08

25 Dyspnoea.. 49 chestmb08 Action 50 chestmb08

26 Pedestrian hit by car. 51 chestmb08 Pedestrian hit by car. 52 chestmb08

27 Run over by lorry Hit by lorry. Associated injuries? 53 chestmb08 Run over by lorry Hit by lorry. Associated injuries? 54 chestmb08

28 Do not dawdle, do CT Or you might die DWD Death Without Diagnosis Pntx bilat, ribfx, flail, scapula, calvicle, thfx, sternum 56 chestmb08

29 Old bullet wound, now new central line 57 chestmb08 Old bullet wound, now new central line Always be suspicious when line is on the left! Tracheal deviation after multiple right sided punctures. 58 chestmb08

30 Several thoracic knife wounds 59 chestmb08 Diafragm, Collar sign (Dr Shan) 60 chestmb08

$Fractures significance Any rib fracture or$ plain CXR significantly increased the

$The presence of rib fracture in more than$ anatomic region doubled the incidence of

31 Trod upon by horse. Contusions, lacerations 61 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) 002) Livingstone et al J Trauma Apr;64(4): chestmb08

32 Flail chest, contusions left 63 chestmb08 Contusion extension 64 chestmb08

33 Skeletal dislocations 65 chestmb08 66 chestmb08

34 MC, cannot lower right arm 67 chestmb08 Diaphragm rupture 68 chestmb08

$Bowel, kidney, fractures$ chestmb08

35 Diaphragm Left >>right> >>>bilateral ( ) Associerated Bleeding!! Spleen Liver Lung Bowel, kidney, fractures 69 chestmb08 Diaphragm Left >>right> >>>bilateral ( ) Associerated Bleeding!! Spleen Liver Lung Bowel, kidney, fractures 70 chestmb08

36 Other rupture 71 chestmb08 Perikardial rupture after blunt trauma Morel-Lavalle 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 traumacasesl: incidence 0.1% 28% associated heart damage left 50-76% > diafragma > hö-sidiga > mediastinal Rupture often craniocaudally anterior to phrenic nerve. 72 chestmb08

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

37 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% 73 chestmb08 74 chestmb08

38 Looking at ancient trauma sites for the future u 75 chestmb08 Thank you!

Postoperative chest x-ray May Mats Beckman Emergency Radiology. Shutter use!

Postoperative chest x-ray May 2009 Mats Beckman Emergency Radiology Shutter use! 2Postoperative chest x-ray May 2009 Exposure/ window settings Quick resorption of infiltrations= water logged lung 3Postoperative