Chest x-ray in Trauma
Pearls and pitfalls Mats O. Beckman
Radiology Karolinska
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Traumaroom
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When to do AP chest?
•1 minute good
•3 minutes acceptable
•5 minutes doubtful
•10 minutes substandard
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Normal AP chest
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Evaluation algorithm
A irways, Tube
B Lung parenchyma, pneumothorax
C Chest bleeding
D Diaphragm, mediastinum
E Drains & linEs
F ractures, dislocations, soft tissues
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Mind the positioning
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Spineboard away!
With and without spineboard
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Tension pneumothorax BLACK?
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Tension pneumothorax
Medial border of
scapula
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Skinfold
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Action?
When?
Who?
How?
YES
Now
I (Jag, Minä, Jeg, я
сам , Yo, ,
Moi, Ich, Io, )
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Metro
BLACK
?
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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?
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B-Breathing
Chest X-ray reveals
right bronchial intubation,
a common finding in trauma patients intubated under stress.
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MVC, driver
Stomach air!
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Haemothorax and?
WHITE?
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White
Haemothorax
+?
SC emfysema
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Horse accident. Black& White? Positioning!
Haemothorax dx
Bilateral pntx
Upper rib fx
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Stabbed in back. Prone examination.
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Fluid?
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Ultrasound!
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Before and after drainage
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Before and after drainage
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Left tension
Pneumo
Haemothorax
Image courtesy www.trauma.org
and Karim Brohi
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ETT should be level w upper aortic arch
central line in lower VCS
ROTATION!
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ETT CVK
Introducer
Pigtail
Pigtail
Tubes and linEs
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Rib fractures, humerus fracture
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Flail Chest
2 or more contiguous ribs fractured in
2 or more places
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Flail chest
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Flail chest
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Knife right upper quadrant
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Liver, gallbladder injury.Operated. Postop CT.
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Clinically diagnosed rib fracture 1 week ago
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Clinically diagnosed rib fracture 1 week ago.
Ege enhanced.
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Knifed. Pneumothorax sin
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Pneumothorax sin+dx
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Pneumothorax sin+dx
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Dyspnoea…..
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Action
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Pedestrian hit by car.
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Pedestrian hit by car.
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Hit by lorry. Associated injuries?
Run over by lorry
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Hit by lorry. Associated injuries? Run over by lorry
Do not dawdle, do CT
Or you might die DWD
Death Without Diagnosis
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Pntx bilat, ribfx, flail, scapula, calvicle, thfx,
sternum
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Old bullet wound, now new central line
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Old bullet wound, now new central line
•Always be suspicious
when line is on the left!
•Tracheal deviation
after multiple right sided
punctures.
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Several thoracic knife wounds
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Diafragm, Collar sign (Dr Shan)
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Trod upon by horse. Contusions , lacerations
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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
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Flail chest, contusions left
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Contusion extension
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Skeletal dislocations
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MC, cannot lower right arm
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Diaphragm rupture
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Diaphragm
Left >>right> >>>bilateral
– (58-36-2)
Associerated
– Bleeding!!
– Spleen
– Liver
– Lung
– Bowel, kidney, fractures
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Other rupture…
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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.
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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%
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Looking at ancient trauma sites…
for the future
Thank you!