Chest Trauma

JB

ATLS
In cases of major trauma, a chest x-ray will be
part of the initial radiological survey.
Why?

Injuries to the thorax can be life threatening and

need quick diagnosis, both by radiological and
clinical means.

Blunt Chest Trauma

Assess Airway, Breathing and Circulation

Four vital questions:
1. What is the circulatory status?
2. What is the respiratory status?
3. Is there a tension pneumothorax?
4. Is there cardiac tamponade?

Further pathology that needs to be

identified

Flail chest
Pneumothorax
Heamothorax
Aortic rupture
Diaphragmatic rupture
Myocardial contusion

Flail chest

A segment of the thoracic cage is pulled away

from the chest wall, therefore unable to
contribute to lung expansion.
Indicates underlying pulmonary contusion
Identified clinically by paradoxical movement of
the chest wall and associated crepitus.
Possible blood gas analysis
Likely associated injuries

Radiological appearances

Usually an obvious appearance but check for

underlying pathology.
More commonly involving 4th-10th ribs
Associated respiratory failure
Identify which ribs are fractured
Watch for the Mach effect of overlying vessels

http://www.itim.nsw.gov.au/images/Right_Flail1.jpg

Pneumothorax

Presence of air in the pleural space

Traumatic, iatrogenic or spontaneous
Most commonly men between 20-40
Reduced air entry

Radiological appearances

Visibility of visceral pleural edge

Mediastinal shift (see tension pneumothorax)
No bullae present
Apical origin
Loss of lung markings
Mach effect of skin fold
Possible deep sulcus sign with supine patients

http://www.itim.nsw.gov.au/images/Right_Pneumothorax_Xray.jpg

Deep sulcus sign

Haemothorax

A collection of blood in the pleural space caused

by blunt or penetrating trauma.
Lacerated pulmonary vessels
Not detectable by physical examination unless
the haemothroax is large.
Decreased chest expansion
No mediastinal shift

Radiological appearances

Erect position
Fluid level with a meniscus
400-500mls of blood required to obliterate
costophrenic angle

Haemopneumothorax

Aortic rupture

Blunt trauma
90% of tears are of the aortic isthmus, just distal
to the left subclavian artery
Low sensitivity of CXR
Rapid deceleration force
80-90% die before hospital

Radiological appearances

Widening of mediastinum Mediastinal width

of over 8cm. Alternatively, where the
mediastinum forms more than 25% of
the chest at this level.
Indistinct contour of aortic arch
Rightward deviation of trachea
Downward displacement of left main bronchus
NG tube displaced to the right
Absence of aortic pulmonary window

Tracheal & Major Airway Damage

Major trauma may disrupt
the trachea or major
airways to the segmental
bronchial level with the left
or right main bronchial
being of most significance.

Disruption may be noted at early or

late stages, the latter following a
continued lung collapse. Most tracheo
- bronchial ruptures are in patients
presenting with fractures to the upper
3 ribs, sternum or thoracic spine.

Early diagnostic features include:

Pneumomediastinum - most often seen in the tracheal or proximal
main stem ruptures
Ipsilateral pneumothorax - 80% of cases will have a large
pneumothorax with bronchial ruptures. Persistent air leaks will mean
resolution is poor
The fallen lung sign where the lung sags from the end of the main
stem bronchus into the bottom of the pleural cavity

Tracheal & Major Airway Damage

Later features may be noted

related to impaired ventilation
or following the laying down of
scar tissue in bronchial walls.
The changes indicated above may
create a persistent lung collapse that
will not respond to physiotherapy or
suction. Bronchoscopy may be the
only way in which expansion Where
partial disruptions occur they heal &
cause strictures leaving the patient
susceptible to atelectasis &
pneumonias.

Diaphragmatic rupture

Blunt trauma or penetrating injury

Most commonly on the left
Associated injuries

Radiological appearances

Herniated viscera
Irregularity of the diaphragm contour
Elevated hemi-diaphragm
More common on left side

Post RTA: interthoracic herniation of the stomach

But..

What about other hernias?

Hernia through the oesophageal

hiatus

Through congenital weakness in oesophageal hiatus

Obesity and pregnancy linked
Retrocardiac mass containing air or air fluid level
Seen on lateral projection

Hiatus hernia

Hernia through the Foramen of

Bochdalek

Common in infants
75-90% on left side
In some cases, entire abdominal contents could
be in the left hemithorax
Smaller ones more common in adults over 40
Focal bulge of hemidiaphragm
Mass adjacent to hemidiaphragm
Can resemble soft tissue mass, may need CT

Hernia through the Foramen of

Morgangni

Rare
More commonly right sided
Overweight, middle aged women
Smooth, well defined opacity in the right
cardiophrenic angle of homogenous density
Asymptomatic or epigastric discomfort

Look at the history!

Whats eventration of the Diaphragm?

LT

Image courtesy of Airedale General Hospital

Myocardial contusion

Blunt trauma
Diagnosed by ECG

Pulmonary contusions

Most common pulmonary complication of chest

trauma
Traumatic extravasation of blood into the lung
parenchyma
Substantial tissue disruption
Cleared within 10 days

Radiological appearances

Varied
Can be irregular, patchy areas of air space
consolidation.
Can be extensive homogeneous consolidation
Do not conform to lobes or segments
Increase in size and loss of definition of vascular
markings due to oedema in interstitial tissue

Trauma to the Pulmonary Parenchyma

Blunt external trauma readily
contuses the underlying
lung tissue with more distal
changes being evident
following a contra coup
mechanism of injury.
Alveolar structural integrity
is maintained, however,
rupturing of the
microvessels causes the air
sacs to fill with blood so
generating a typical patchy
alveolar infiltrate type of
pattern. By the time the
chest radiograph is obtained
blood collection has reached
its peak.

Contusions are quick to clear from

the chest radiograph taking on
average between 24 - 48 hours to
resolve. Where a more severe
trauma has caused the injury,
elastic recoil of the damaged
parenchymal fissures encourages
blood collections to form into
spherical or ovoid shapes.
Where these spherical collections
are formed totally of blood they are
termed haematomata. Conversely, if
air fills them they are termed
pneumatocoeles. Frequently, fluid &
air are present in the space.

Trauma to the Pulmonary Parenchyma

As parenchymal haematomata are generally formed with a
surrounding contusion, identification may be difficult at first. As the
contusion resolves the haematoma becomes visible. Haematomas
may take months to resolve & could be mistaken for a more serious
condition if previous clinical information alluding to trauma is not
forthcoming. Cavitation at any time compounds the problem.
Pneumatocoeles also cause
relatively few problems whether
filled with air or as a mixture of
air & fluid. They differ from
abscesses & cavitating
neoplastic disease by
possessing a thin superior
border that is almost invisible.

Averaging between 2- 5 cm
pneumatocoeles & haematomas
may be over 10cm across. Lobar
boundaries fail to impress upon
extension, lesions often being
widespread & bilateral with most
severe damage being evident
under skeletal injury sites. CT
best displays the changes.

Note butterfly distribution

Pneumomediastinum

Presence of gas in the mediastinal space.

Can originate from lung, airway, oesophagus, the
neck or the abdomen.
Most commonly from the parenchyma of the
lung.
Related to an incident that leads to raise in
alvelolar pressure
Can produce subcutaneous emphysema

Radiological appearances

Radiolucent streaks or focal bubble like

collection of gas outlining mediastinal structures
Lateral displacement of the mediastinal pleura
Longitudinal line shadow parallel to the heart
border
Possible continuous diaphragm sign
Subcutaneous emphysema
Thymic sail sign

Cardiac tamponade

Compression of the heart caused by fluid

collection in the space between the myocardium
and the pericardium
Prevents ventricular expansion
Difficulty breathing, chest pains radiating to
neck and palpitations
Numerous possible causes, trauma being one
Life threatening!

Radiological appearances

Fluid in the pericaridal sac

Large globular heart

Surgical (subcutaneous) emphysema

Subcutaneous emphysema from air trapped in

the tissues during a surgical operation or by
injury
Chest drain insertion, gas gangrene, post surgery
Can make the face and neck appear blown up

Radiological appearances

Lozenge shaped areas of blackness representing

air in the soft tissue
Messy appearance
Can be confined to obvious soft tissue areas or
spread over the entire thorax

Tension pneumothorax

Medical emergency!!
Occurs when air enters, but does not leave the
pleural space
Chest pain, rapid breathing, cyanosis
Tachycardia
Anything that causes a pneumothorax, can cause
a tension pneumothorax

Radiological Appearances

Mediastinal shift away from the affected lung

Concave appearance of mediastinum
Affected lung appears large and black
Ipsilateral lung collapse at the hilum
Left hemi-diaphragm may be depressed

Lines, tunes and drains

Endotracheal tube (ET)

Central venous pressure (CVP)
Nasogastric tube (NG)
Chest drain
Hickman line

Oxygen tube

Mediastinal drain

ECG

Pulmonary artery catheter

Sternotomy wires

Endotrahceal tube
Interaortic balloon pump

Swann Ganz Catheter

NG tube

Mediastinal drain

WHAT IS A CENTRAL LINE

It is a catheter that
provides venous access
via the superior vena
cava or right atrium

Rib fractures and NAI

Bruising of chest area

Clavicle fractures
Rib fractures

Fractures
Even though rib fractures are generally considered to be of
relatively minor significance, certain patterns / incidences
should be considered in greater depth.
Childhood rib fractures
are usually of the
greenstick type &
difficult to detect.
Varying age of fracture
with prominent callus
formation should raise
the question of child
abuse

In the alcoholic multiple, bilateral

healed rib fractures are often
present. They vary in age & often
have prominent callus formation.
Remember the osteopenia that is
frequently associated in the
alcoholic skeleton. Plus, be aware
that other conditions may be
present that could contribute to the
overall patient presentation.

Radiological appearances

Multiple, bilateral and posterior

6th-11th rib
Callous formation

Inhaled foreign body

Visible on x-ray?
Stridor
Inability to speak
Choking
Clinical history

Radiological appearances

Visible opacity
Pre-vertebral swelling
Reversal of cervical lordosis
Most commonly seen in right lower lobe
Atelectasis
Obstructive pneumonitis
Lung volume distal to FB is decreased
Hyperinflation is rare

Calcified nodule

Atelectasis

Air trapped

Perforation

Numerous causes
Traumatic and non traumatic
Abdominal pain
Nausea and vomiting

Radiological appearances

Erect film, 10 minutes

Free air under diaphragm (right hemi-diaphragm)
Remember stomach bubble
Other signs will be covered in abdomen lecture

Knife, Gun & Blast Injuries

As a bullet passes
through the chest,
shock waves radiate
through the tissues
along the track of the
missile. Severity of
damage is dependent
upon calibre, speed &
whether the bullet
tumbles or not
following the striking
of structures inside
the thoracic cavity.

Most guns deliver a low velocity

missile producing entry &exit
wounds that are almost identical.
More rapid projectiles causes the
exit wound to be large & the
amount of damage along the track
of the bullet is large.
Shotgun discharges at close range
(by comparison) cause the majority
of their damage through gas &
large masses of shot exiting the
muzzle.

All injury severity, obviously, depend upon the likelihood of

the projectile damaging a vital structure.

Knife, Gun & Blast Injuries

Tracks of bullet wounds to the lung are often noted to
show a circumferential contusion pattern. Occasionally
this will fill with air & fluid & is best appreciated when seen
end on. Haemo & pneumothoraces are usually noted.
In peace time blast patterns are rarely seen. However, blast
injuries can be generated by gas explosions & the like.
Typically, there is bilateral pulmonary parenchymal trauma
with transmission of the shock waves by the airways
themselves.

Knife injuries do not create shock waves! Injury severity

depends on penetration of vital structures. Linked with the
penetrating wound is a strong association with pneumo &
haemothoraces.

Findings; CXR
shows clear lungs,
no rib fractures,
slightly low
positioned
endotracheal tube

See next film.

Lateral Cervical spine view

shows marked C7 and T1
dislocation!
Also there are fractures of
the posterior fossa.

The baby died from severe

brain injuries.

The End!!!!!!!!!!