CHEST TRAUMA

MI Zucker, MD
 A dr Z Lecture
• On Major Chest
Trauma
• In Three Parts
 Chest trauma
• Blunt

• Penetrating

• Explosion Related
Chemical Agent Related
Biological Agent Related
 Oh, yeah:

There’s a separate lecture on

Traumatic Aortic Injury
 But first:

A few comments on Trauma Imaging

 Trauma Chest Radiograph
• Usually AP, often
supine, frequently in
poor inspiration.

• So, a challenge to
interpret.
 CT Chest
More sensitive and specific
 CT Chest: Reformat

• The new MDCT

scanners do awesome
reformats without
additional scanning.
Part the First:

BLUNT TRAUMA
 Fractures and Dislocations
• Spine
• Ribs
• Clavicles
• Sternum
• Shoulders
 Spine Injuries
• Look for loss of
alignment, fractures
and paraspinal
hematoma.

• The findings may be

very subtle.
 Rib Fractures
• In themselves, not too
much of a problem,
but may be an
indicator of underlying
pleura, lung, liver,
spleen, kidney
injuries.
 Flail Chest
• Multiple rib fractures,
especially if individual
ribs fractured more
than once, may cause
paradoxical motion.
• The major problem
actually is associated
pulmonary contusion.
 Clavicle Injuries

• Fractures not usually

much of a problem
 Sterno-Clavicular Dislocations
• Anterior: Not much of a problem
• Posterior: Less common; can injure great
vessels or trachea
Sterno-clavicle joint dislocation
Sterno-clavicle dislocation: CT
 Shoulder Injuries
• Look particularly for
dislocations and
scapula fractures
CT Needed if Scapula Fracture
Seen
 Sternum Fractures

• Not usually a problem.

• Controversial
association with
myocardial injury.
 AIR where it shouldn’t be
• Pneumothorax
• Pneumomediastinum
• Subcutaneous emphysema
• Systemic venous air embolism
• Pneumopericardium
• Pneumoperitoneum/retroperitoneum
 PNEUMOTHORAX
• Simple
• Tension
• Open
 PNEUMOTHORAX: CT
• Much more sensitive than plain films.
• Even a small traumatic pneumothorax is
important, especially if patient
mechanically ventilated or going to OR: A
simple pneumothorax can be converted into
a
life- threatening tension pneumothorax.
PNEUMOTHORAX: CT
 Pneumothorax: Simple
• Erect AP/PA view best
• Visceral pleural line
• No vessels or markings
• Variable degree of lung collapse
• No shift
PNEUMOTHORAX: Simple
 PNEUMOTHORAX: Tension
• Erect AP/PA view best
• Shift of mediastinum/heart/trachea away
from PTX side
• Depressed hemidiaphragm
• Degree of lung collapse is variable
PNEUMOTHORAX: Tension
PNEUMOTHORAX: Tension
 PNEUMOTHORAX: Supine
• Supine AP view has limited sensitivity: 50%
• Deep sulcus sign
• Too sharp heart border/hemidiaphragm sign
• Increased lucency over lower chest
• Subpulmonic air sign
• Can see vessels
PNEUMOTHORAX on Supine
View: Visceral pleural line
PNEUMOTHORAX on Supine
View: Deep sulcus sign
PNEUMOTHORAX on Supine
View: Why vessels are visible
PNEUMOTHORAX on Supine
View: Subpulmonic sign
CT: subpulmonic sign explained
 PNEUMOTHORAX: Open

• A large hole in the

chest caused by a large
low velocity missile.
• Air enters the hole
rather than the trachea
causing hypoxia.
 PNEUMOMEDIASTIUM
• Usually from ruptured alveoli.
• Can also be from trachea, bronchi,
esophagus, bowel and neck injuries.
 PNEUMOMEDIASTINUM:
Signs
• Linear paratracheal
lucencies
• Air along heart border
• “V” sign at aortic-
diaphragm junction
• Continuous diaphragm
sign
PNEUMOMEDIASTINUM:
Paratracheal lucencies
PNEUMOMEDIASTINUM:
Continuous diaphragm sign
PNEUMOMEDIASTINUM: CT
 Trachea/bronchi injuries
• Tears occur within
2cm of carina
• Persistant
pneumothorax
• Large
pneumomediastinum
• “Fallen lung”
 Subcutaneous Emphysema
• Causes: Same as
pneumomediastinum
 Pneumopericardium

• Causes: penetrating
trauma
• Rare
 Pneumoperitoneum
• Pneumoperitoneum
and sometimes
pneumo-
retroperitoneum are
seen on upright chest
film, but occasionally
are visible on supine
chest radiograph.
Pneumoperitoneum
 Systemic Venous Air Embolism

• Tears in airspaces with

resulting communication
with veins; or outside
access to systemic veins
• Often lethal: Air block in
heart or coronary,
cerebral, mesenteric,
peripheral arteries.
Systemic Venous Air Embolism
 HEMOTHORAX
• Venous or arterial bleeding
• 60% controlled by chest tube, 40% need
operative management
• Can miss hundreds of cc’s on supine film
• Can be tension
HEMOTHORAX
CT: HEMOTHORAX
 PULMONARY CONTUSION
and LACERATION
• Contusion: Blood in intact lung
parenchyma
• Laceration: Blood in torn lung parenchyma
• Can’t tell difference on chest film.
Contusions peak in 2-3 days, begin to
resolve in a week; lacerations take much
longer to resolve and may leave scars
Pulmonary Contusion and
Laceration
Subtle contusions
Marked contusions
CT: Pulmonary Contusion
 CT: Pulmonary laceration
The tear in the lung can
fill with blood or air.
 DIAPHRAGM Injuries
• 5% of major blunt • Hard signs: NGT
trauma, also thoraco- through g.e. junction
abdominal penetrating then up into chest, and
trauma hollow viscus above
• Left clinically injured diaphragm
more than right 60/40 • Soft signs: Indistinct
• Sensitivity of Chest diaphragm, effusion,
film 40%. CT better, atelectasis
but still misses some
Diaphragm Injury
Diaphragm Injury: Position of
NG Tube
Diaphragm Injury: Gut in Chest
 Part the Second:

PENETRATING TRAUMA
Gunshot Wounds
Stab Wounds
 Gunshot Wounds
• Match all entrance and exit wounds
• Find the bullet(s) and keep looking until all
are accounted for
• Estimate path of bullet, which may not be
straight
• Estimate organs injured
 INJURIES depend upon:
• Caliber, weight, construction of bullet
• Velocity
• Tissue impacted
 Gunshot Wounds: some terms
• Rounds: the bullet and its casing, propellant and
primer
• Bullet: the part of the round that is propelled from
the weapon
• Firearms: pistol, rifle, shotgun
• “Blast” : a property of high explosives, not
firearms. Don’t use with GSW.
Rounds: Pistol and Rifle
 BULLET
• Size: diameter in millimeters or caliber
(fractions of an inch)
• Weight: in grains
• Construction: round nose, hollow point,
full metal jacket, semi-jacket, no jacket
 Injuries: Bullet
The larger the diameter of the bullet and the
more it weighs, the bigger the wound.

Hollow point and semi-jacket bullets

mushroom or fragment on impact and cause
bigger wounds than FMJ.
 Injuries: Velocity
• Hand guns are low velocity (1000 fps) and
cause a permanent wound channel (crush)
only.
• High-powered and assault rifles are high
velocity (3000 fps) and cause a permanent
wound channel and also temporary
cavitation (blunt or stretch trauma) and so a
bigger wound.
 Injuries: Tissue
• Lung is elastic and more resistant to injury
than solid organs. Bone is least resistant.
• Obviously, the more vital the organ the
more serious the injury.
 Gunshot Wounds
• GSWs of the CHEST cause: pulmonary
lacerations/contusions, hemothorax,
pneumothorax, mediastinum/heart injuries,
pneumomediastinum, fractures.
GSW: Hemothorax, PTX
 GSW: Tension
Hemopneumothorax
GSW: Lacerations, abnormal
Mediastinum, PTX
 GSW: Transmediastinum

• Bilateral chest tubes

• Angiography
• Pericardial window
• Triple endoscopy
• Esophagram
• Thoracic spine films
 Gunshot Wounds: CT

• Experimental
• May be able to
establish bullet tract
and avoid surgery,
especially thoraco-
abdominal wounds
 Knife wounds
• All low energy, small diameter wounds.
Frequently, superficial stab or slash.
• Look for lung laceration, pneumothorax,
hemothorax, pneumomediastinum,
abnormal contour of mediastinum or heart.
• Path of wound is straight.
Knife Wound: PTX
Part the Third:

Explosions
Chemical events
Biological events
 Since, so far, Los Angeles has
experienced few of these events,
most of the images are simulations
 Radiological Events
• We aren’t going to discuss these today.
• An isotope combined with an explosive
makes a Radiological Dispersion Device.
• In an RDD event, all of the immediate
casualties would be from the explosion.
• Radiation injuries would be delayed to
negligible, depending upon the type and
amount of the isotope.
EXPLOSION Related Chest
Injuries
Accidental/Terrorist Event
Conventional explosive device
Improvised explosive device
 EXPLOSIVES
• High Explosives: • Low Explosives:

TNT, dynamite, C-4, Gun powder, smokeless

ANFO, RDX, PETN propellant, fireworks
 Explosions
• Blast wave: sudden increase in atmospheric
pressure. High explosives only.
• Blast wind: sudden expansion of hot gases.
High and low explosives.
 EXPLOSION Related Injuries
• Blast Wave: Lung • Primary
laceration, contusion,
edema, barotrauma
• Penetrating Trauma
• Secondary
• Blast Wind:
Displacement • Tertiary
• Crush, burns,
inhalation injuries • Quartanary
EXPLOSION: Blast Wave
causes blast lung
 EXPLOSION: Blast Wave
causes barotrauma/laceration
 EXPLOSION: Blast wave
causes abdominal injuries

• Pressure wave injures

bowel wall, causing
hematoma and
perforation, and so
pneumoperitoneum
 EXPLOSION: Blast wave
causes SVAE

• Lacerated lung with

bronchovascular
fistulae cause systemic
venous air embolism
 EXPLOSION: Blast Wind
• Displaces victim
causing blunt trauma
EXPLOSION: Blast Wind causes
structural collapse
 EXPLOSION: Penetrating
trauma

• Metal fragments from

conventional bomb
housing
• Scraps of metal, nails
attached to Improvised
Explosive Device
EXPLOSION: Penetrating injury
EXPLOSION: Penetrating injury
EXPLOSION: Flying glass
CHEMICAL AGENTS

Accidental/Terrorist
 CHEMICAL AGENTS
• Nerve agents: Sarin, soman, tabun, XV
• Blister agents: Lewisite, mustards
• Choking agents: Chlorine, phosgene
• Blood agents: Cyanides
 CHEMICAL AGENTS
• Nerve agents inactivate
acetylcholinesterase
• Blister and Choking agents cause acute
airway and lung injury
• Blood agents inactivate cytochrome oxidase
causing cell hypoxia
NERVE AGENTS: Aspiration
CHOKING/BLISTER AGENTS:
Acute Lung Injury
BIOLOGICAL AGENTS

Accidental/terrorist
 BIOLOGICAL AGENTS
•Inhalational Anthrax
•Plague
•Tularemia
•Viral hemorrhagic fevers
•Ricin
To be effective, agents must be aerosolized.
INHALATIONAL ANTHRAX
• Necrotizing
hemorrhagic
mediastinitis
PLAGUE: Bilateral pneumonia
 TULAREMIA
• Pneumonia with
lymphadenopathy
 VHFs

• Bleeding into lung

parenchyma
 RICIN

• Biological toxin from

castor bean
• Inhibits protein
synthesis
• Causes pulmonary
edema/ARDS
People who liked this lecture also
liked: “TRAUMATIC AORTIC
INJURY”
Available from your local Emergency
Radiology lecturer now!
But for now, GOODBYE

• Copyright 2004
MI Zucker