Chest x-ray in Trauma Pearls and pitfalls Mats O. Beckman Radiology Karolinska University Hospital Stockholm
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When to do AP chest? 1 minute good 3 minutes acceptable 5 minutes doubtfulu 10 minutes substandard 9 chestmb08 10 chestmb08
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
Mind the positioning 13 chestmb08 Spineboard away! 14 chestmb08 With and without spineboard
Tension pneumothorax BLACK? 15 chestmb08 Tension pneumothorax Medial border of scapula 16 chestmb08
Action? When? Who? How? YES Now I (Jag, Minä, Jeg, я,,إيي إياي ي نفسي, Yo, сам Moi, Ich, Io, ) 17 chestmb08 18 chestmb08
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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
MVC, driver Stomach air! 25 chestmb08 WHITE? Haemothorax and? 26 chestmb08
Hemothorax +? SC emfysema 27 chestmb08 Horse accident. Black& White? Positioning! Haemothorax dx Bilateral pntx Upper rib fx 28 chestmb08
Stabbed in back. Prone examination. 29 chestmb08 30 chestmb08
Fluid? 31 chestmb08 Ultrasound! 32 chestmb08
Before and after drainage 33 chestmb08 Before and after drainage 34 chestmb08
Left tension Pneumo Haemothorax 35 chestmb08 Image courtesy www.trauma.org and Karim Brohi ETT should be level w upper aortic arch central line in lower VCS ROTATION! 36 chestmb08
Introducer Tubes and lines CVK ETT Pigtail Pigtail 37 chestmb08 Rib fractures, humerus fracture 38 chestmb08
Flail Chest 2 or more contiguous ribs fractured in 2 or more places 39 chestmb08 Flail chest 40 chestmb08
Flail chest 41 chestmb08 Knife right upper quadrant 42 chestmb08
Liver, gallbladder injury.operated. Postop CT. 43 chestmb08 Clinically diagnosed rib fracture 1 week ago 44 chestmb08
Clinically diagnosed rib fracture 1 week ago. Ege enhanced. 45 chestmb08 Knifed. Pneumothorax sin 46 chestmb08
Pneumothorax sin+dx 47 chestmb08 Pneumothorax sin+dx 48 chestmb08
Dyspnoea.. 49 chestmb08 Action 50 chestmb08
Pedestrian hit by car. 51 chestmb08 Pedestrian hit by car. 52 chestmb08
Run over by lorry Hit by lorry. Associated injuries? 53 chestmb08 Run over by lorry Hit by lorry. Associated injuries? 54 chestmb08
Do not dawdle, do CT Or you might die DWD Death Without Diagnosis Pntx bilat, ribfx, flail, scapula, calvicle, thfx, sternum 56 chestmb08
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
Several thoracic knife wounds 59 chestmb08 Diafragm, Collar sign (Dr Shan) 60 chestmb08
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. 2008 Apr;64(4):905-11 62 chestmb08
Flail chest, contusions left 63 chestmb08 Contusion extension 64 chestmb08
Skeletal dislocations 65 chestmb08 66 chestmb08
MC, cannot lower right arm 67 chestmb08 Diaphragm rupture 68 chestmb08
Diaphragm Left >>right> >>>bilateral (58-36-2) Associerated Bleeding!! Spleen Liver Lung Bowel, kidney, fractures 69 chestmb08 Diaphragm Left >>right> >>>bilateral (58-36-2) Associerated Bleeding!! Spleen Liver Lung Bowel, kidney, fractures 70 chestmb08
Other rupture 71 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. 72 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% 73 chestmb08 74 chestmb08
Looking at ancient trauma sites for the future u 75 chestmb08 Thank you!