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Trauma of CHEST
Trauma of CHEST
Trauma of CHEST
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:
• So, a challenge to
interpret.
CT Chest
More sensitive and specific
CT Chest: Reformat
BLUNT TRAUMA
Fractures and Dislocations
• Spine
• Ribs
• Clavicles
• Sternum
• Shoulders
Spine Injuries
• Look for loss of
alignment, fractures
and paraspinal
hematoma.
• 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
• 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
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.
• 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:
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
• Copyright 2004
MI Zucker