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The ABCs of Chest X-Rays in Trauma

The ABCs of Chest X-Rays in Trauma. Joe Lex, MD, FACEP, MAAEM Temple University School of Medicine Philadelphia, PA USA. How Accurate Is Chest X-Ray?. Portable erect AP for detecting serious injuries: 78.7% sensitive Portable supine: 58.3% sensitive Missed (n=100) Bony injuries: 5

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The ABCs of Chest X-Rays in Trauma

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  1. The ABCs of Chest X-Rays in Trauma Joe Lex, MD, FACEP, MAAEM Temple University School of Medicine Philadelphia, PA USA

  2. How Accurate Is Chest X-Ray? Portable erect AP for detecting serious injuries: 78.7% sensitive Portable supine: 58.3% sensitive Missed (n=100) Bony injuries: 5 Pneumothorax: 1 Hemothorax: 7 ABC • Pulmonary contusion: 1 • Diaphragm rupture: 1 Hehir MD. Aust N Z J Surg 60(7):529, July 1990

  3. Additional Value of CT Pulmonary contusion: 15% Pneumothorax: 12% Hemothorax: 8% Rib fracture: 8% Aortic abnormalities: 4% Mediastinal hematoma: 3% Spine fracture: 3% ABC Omert L, et al. Am Surg 7:660, July 2001

  4. Traumatic Aortic Rupture ABC

  5. Traumatic Aortic Rupture 90% of ruptures at aortic isthmus 4% at branch vessels Chest x-ray 10% PPV 98% NPV ABC

  6. ABC

  7. Traumatic Aortic Rupture ABC

  8. Traumatic Aortic Rupture Nasogastric tube deviated to right Left main stem bronchus depressed Mediastinum wide Aortic arch obscured or irregular Left apical cap Aorto-pulmonic window opacified Trachea deviated to right 1st or 2nd ribs fractured ABC

  9. Traumatic Aortic Rupture Direct radiographic signs Aorta caliber change Intraluminal irregularity Abnormal contour: perivascular hematoma ABC

  10. Traumatic Aortic Rupture Rapid increase in size of the aorta on serial chest films Double shadow of aortic arch Intimal calcifications displaced by more than 6 mm (“calcium sign”) Tracheal deviation Left pleural effusion ABC

  11. Traumatic Aortic Rupture 86 patients; rupture in 15% Only signs associated with TAR: NG tube deviation and left mainstem bronchus depression Useful combination: NG tube / tracheal deviation, loss of aortic contour, loss of aortic knob ABC Marnocha HE. Am J Roent 144(1):19, 1985

  12. Traumatic Aortic Rupture No NG / tracheal deviation, loss of aortic contour, loss of aortic knob: 0% prevalence All but one with TAR had at least three signs Three of four signs also present in four patients without TAR ABC Marnocha HE. Am J Roent 144(1):19, 1985

  13. Traumatic Aortic Rupture ABC Apical cap

  14. Traumatic Aortic Rupture? Mediastinal hematoma without aortic rupture ABC

  15. How Wide Is Wide? 8.0 to 8.8 cm upper limit: x-ray techniques employed in 1970s Mean mediastinal width: 6.31 cm Average depth of board: 4.5 cm Distance between board and x-ray cassette beneath 6 different types of gurneys: 7.1 cm – 12.9 cm ABC Gleeson CE, et al. Emerg Med J 18:183, 2001

  16. How Wide Is Wide? Varies: Focus-to-Film Distance (FFD), cassette placement FFD 100 cm with cassette directly under patient (1970s): mean mediastinal width 7.5cm FFD 140 cm with cassette under spinal board: upper limit 9.68 cm. ABC Gleeson CE, et al. Emerg Med J 18:183, 2001

  17. Traumatic Aortic Rupture High-speed deceleration injury or side impact Multiple rib fractures or flail chest Pulse deficits Hypertension Systolic murmur over back Hoarseness without laryngeal injury Superior vena caval syndrome ABC

  18. Seat Belt Marks ABC

  19. Seat Belt Marks ABC

  20. Seat Belt Marks ABC

  21. How Wide Is Wide? Subjective interpretation of mediastinal widening more reliable than direct measurement ABC Lee FT Jr, et al. J Emerg Med 11:289, 1993.

  22. What Sign Is Best? Most sensitive Wide mediastinum Obscured aortic knob ABC Gleeson CE, et al. Emerg Med J 18:183, 2001

  23. What Sign Is Best? Most specific Opacified clear space between aorta and pulmonary artery Displaced NG tube Widened paratracheal stripe Widened right paraspinal interface ABC Gleeson CE, et al. Emerg Med J 18:183, 2001

  24. Bronchial Fracture ABC

  25. Bronchial Fracture In 1.5% major chest trauma 30% missed 80% within 2.5 cm of carina ABC Ramzy AI, et al. J Trauma. 1988 Sep;28(9):1353-7.

  26. Bronchial Fracture 4 P’s: Persistent or Progressive Pneumothorax or Pneumomediastinum ABC

  27. Bronchial Fracture ABC One tube…

  28. Bronchial Fracture ABC Two tubes…

  29. Bronchial Fracture Lung collapses toward bottom of chest cavity (“fallen lung”) ABC Wintermark M, et al. Eur Radiol. 2001;11(3):409-11.

  30. Bronchial Fracture ABC Bronchial stenosis after undetected tear

  31. Bronchial Fracture Diagnosis: bronchoscopy ABC

  32. Cord Injury ABC

  33. Cord Injury ABC

  34. Cord Injury Occurs in 3% major BCT 12% neurologically intact Thoracic facets face inward Lumbar facets face outward Critical location for fracture / dislocation / subluxation: T9 – T10 – T11 ABC van Beek EJ, et al. Injury. 2000 May;31(4):219-23.

  35. Cord Injury Rule of 2’s Maximum 2 mm difference for… …interspinous space …interpedicular distance …intrapedicular distance ABC

  36. Cord Injury Rule of 2’s Maximum 2 mm … …interspinous space …interpedicular distance …intrapedicular distance ABC

  37. Rule of 2’s: Maximum 2 mm difference in interpedicular distance on Antero-Posterior film Cord Injury ABC

  38. Cord Injury / Thoracic Spine Thoracic spine fractures emulate aortic rupture Mediastinal widening Left apical cap Deviated NG ABC Bolesta MJ, et al. J Bone Joint Surg Am. 1991 Mar;73(3):447-50.

  39. Pneumothorax PTX

  40. Pneumothorax Subtle signs on supine x-ray Deep sulcus Sharp cardiac borders Basilar hyperlucency Visualized pericardial fat tags PTX

  41. Pneumothorax: Deep Sulcus PTX

  42. Pneumothorax: Deep Sulcus PTX

  43. Pneumothorax Do we need both Inspiratory and Expiratory films? 233 patients with suspected pneumothorax Initially diagnosed in 54 Paired inspiratory and expiratory films increased accuracy by 8% PTX Aitchison F. Arch Emerg Med 10(4):343, 1993

  44. Pneumothorax Chest x-ray after tube placement PTX

  45. Pneumothorax Chest CT after tube placement PTX

  46. Pneumothorax 2.5-cm margin of gas peripheral to the collapsing lung corresponds to a pneumothorax of about 30% 400ml of blood may obliterate only the costophrenic angle PTX

  47. joe@joelex.net

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