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Trauma Devices

February 27, 2018

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Trauma Lines

This patient has four devices.

  1. There is an endotracheal tube that is malpositioned into the right mainstem bronchi.
  2. A right subclavian central line can be seen positioned in the right atrium
  3. A right sided chest tube is in good position
  4. Coursing up from the femoral area is a REBOA catheter.

What is a REBOA catheter?  REBOA = Resuscitative Endovascular Balloon Occlusion of the Aorta.  It is relatively new technology in which a specialized catheter is used with a balloon that occludes the aorta.  It is predominantly used in lieu of cross-clamping the aorta for severely ill trauma patients with uncontrolled abdominal hemorrhage as a temporizing device to allow time for transport to the OR and definitive control.

The patient’s lungs also appear with contusions and possibly a posterior hemothorax (patient is supine) on the left.

For a detailed discussion of REBOA including radiologic placement please refer to Life in the Fast Lane:

https://lifeinthefastlane.com/ccc/resuscitative-endovascular-balloon-occlusion-aorta-reboa/

Author:  Russell Jones, MD

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Trauma Lines

February 20, 2018

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Trauma Lines

Can you name all the lines and tubes on this patient?  HINT:  There four important devices, one is malpositioned.  Answer to follow.

 

Author:  Russell Jones, MD

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WWWTP #24 Answer…

July 1, 2015

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Trauma patient came in to the ED:

CXR 1

What’s Wrong With This Picture?

The patient’s chest tube is not inserted far enough.  It is also a bit high residing between ribs 3-4.

Chest tubes have a side port and a distal port for suctioning fluids, air from the pleural space.  There is a radiopaque line seen on the tube that is interrupted at the side port (see magnified image).  In this case the radiograph shows that the side port is subcutaneous and not inserted all the way into the pleural space.  The chest tube needs to be replaced!

Author:  Russell Jones, MD

Image Contributor:  David Barnes, MD

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Stabbed in the chest…

January 29, 2014

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This patient was stabbed in the chest multiple times.  Markers showing the external stab wounds to the lateral chest wall on the right side:

HemoPTX stabbed

This is a classic trauma chest xray with a hemopneumothorax on the right side.  This patient has a great indication for a large-bore chest tube!  Not only to reexpand his lung but to monitor hemothorax output and need for emergent thoracotomy to evaluate the source of bleeding.  Trauma recommendations from the Journal of Trauma in 2010 concerning hemothorax include:

1.  Patient physiology should be the primary indication for surgical intervention rather than absolute numbers of initial or persistent {chest tube} output (Level I recommendation)

2.  1500 ml via a chest tube in any 24-hour period regardless of mechanism should prompt consideration for surgical exploration (Level II recommendation)

3.  All hemothoracies, regardless of size, should be considered for drainage (Level III recommendation)

Please see the EAST Trauma Guidelines for further details:

Mowery NT, et. al.  Practice Management Guidelines for Management of Hemothorax and Occult Pneumothorax.  J Trauma 2011; 70 (2): 2011. 

Author:  Russell Jones, MD

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Answer: Can you find the abnormalities?

December 2, 2013

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I gave you this xray a couple days ago, can you find all the abnormalities?

GSW

1.  Intubated into the right mainstem bronchus

2.  Metallic foreign bodies coursing up the left chest to the neck

3.  Completely opacified left lung:  differential diagnosis of pulmonary contusion, hemothorax, or complete atelectasis from right mainstem intubation

4.  There is a chest tube in the right chest cavity, it looks to be in good position but could be coursing into the fissure between the left lobes

5.  Deep sulcus sign on the left side indicates possible pneumothorax vs. hemothorax

6.  Orogastric tube courses below the diaphragm in good position

7.  Subcutaneous emphysema in upper neck

8.  Two radiodense objects in the midline cardiac silhouette near the mid-portion of the coursing orogastric tube

Interestingly, this patient was shot in the chest coursing to the upper neck and the bullet was found in his posterior pharnyx.  He had a tooth found on chest CT (calcified opacity seen below) among other injuries.   Later EGD intraoperatively showed two tooth fragments in the stomach.  The radiodensities seen #8 above were presumed to be these teeth in the esophagus.

Tooth

Image Contributor:  Julie Phan, MD

Author:  Russell Jones, MD

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Can you find all the abnormalities?

November 28, 2013

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This patient came in after a reported gunshot wound.  Can you find all the abnormalities in this xray?

GSW

 

Answer to follow.

Image Contributor:  Julie Phan, MD

Author:  Russell Jones, MD

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Blunt Aortic Injury (BAI)

December 17, 2012

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One of my colleagues had a patient come in after a high-speed motor vehicle collision (MVC) and the patient turned out to have a blunt aortic injury (BAI).  Luckily she saved the images for EMREMS:

This first image is a portable AP Chest Xray.  There are multiple findings:

1.  The ETT tube is slightly high, this was corrected (see Post Intubation Eval)

2.  Chest tube is inserted in the left side and the patient has subcutaneous emphysema.  The chest tube could have been put in further but seems to be working.

3.  Notice the loss of normal contour of the aortic knob (aka “indistinct aortic knob”).

4.  The trachea is displaced to the patient’s right

5.  The upper mediastinum seems a little wide although not drastically.

6.  There is loss of the aortopulmonary window (AP window)

For comparison I have a normal AP Chest Xray and have arrows pointing to the normal AP window and aortic knob:

The patient’s Chest Xray is worrisome for traumatic aortic dissection.  Here is the patient’s Chest CT which confirms the diagnosis:

In the first image one can see a rough inner surface of the aorta indicating intimal disruption and hematoma.  A dissection flap can be seen in the second image.  Hematoma can be seen on both images surrounding the aorta and tracking in the mediastinum.

What are some other signs on Chest Xray that would get you worried about BAI? (Comments are encouraged)

Stay tuned in the future for a “Radiology Rules” 3X5 card with Chest Xray signs of BAI.

Author:  Russell Jones, MD

Image contributor:  Kendra Grether-Jones, MD

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Rugby is a rough sport…

October 16, 2012

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This young woman was playing rugby with “the boys” when she fell on one of the other player’s bent knee.  She has pleuritic chest pain and palpable tenderness along the right chest wall anterior axillary line below the armpit (right about where you’d put a chest tube…hint…hint).

This case demonstrates the power of knowing what you are looking for.  As you probably noticed she has a small, subtle pneumothorax best seen between ribs 3 and 4:

Its always a good idea to take the time when you are ordering radiology studies to help out your radiology friends and describe the area of concern and what you are looking for.  This can help them identify subtle findings such as this small pneumothorax.

The patient was treated with supportive care, observed over night, and discharged the next day after a repeat chest xray showing no significant progression.

Author:  Russell Jones, MD

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69-year-old male fell from a tree…

April 22, 2012

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69-year-old male fell from a tree

Contributor:  Russell Jones, MD

Date: 4/25/2012

This guy fell from a tree about 12 feet up…

Here is his Chest X-ray:

What is wrong with this picture?

Answer 

Pneumothorax!

On the right side of the radiograph subcutaneous air can be seen lateral to the chest wall. Subcutaneous air with no physical exam supporting a puncture or a laceration is highly suspicious of a pneumothorax. Other sources of subcutaneous air can be from tracheal or laryngeal injury but usually this is associated with large subcutaneous air tracking in the area of the neck (but can be extensive).

The radiograph, however, is indicative of a small pneumothorax. The right lung appears to be fully inflated and it doesn’t show a deep sulcus sign.

This guy was seen at a level I trauma center and thus trauma was notified and recommended a CT scan to look for concominant injuries. Specifically their concern was liver injury and multiple occult rib fractures. A CT of the chest and abdomen were ordered with IV contrast to evaluate for these injuries as well as to quantify the severity of the pneumothorax.

CT chest:

On the Chest CT under lung window a small anterior pneumothorax can be seen. Other findings included a small pulmonary contusion in the right lower lobe and 2 non-displaced rib fractures (7 and 8).

The question is…does this guy need a tube thoracostomy (chest tube)?

I’ll leave the management decisions up to you…

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