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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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What’s Wrong With This Picture #24 (WWWTP?)

June 26, 2015

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Trauma patient came in to the ED:

CXR 1

What’s Wrong With This Picture?

Author:  Russell Jones, MD

Image Contributor:  David Barnes, MD

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Student Corner: Air Everywhere

May 19, 2015

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This time, we have an interesting CXR to examine. There are three distinct places in the image below where air is in places it shouldn’t be. Can you identify them?

sp EGD 1

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Need a refresher on how to read a CXR? This post will help you out.

Scroll down further for the answer.

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PTX, SubQ, Pneumoperitoneum post EGD

Image Key: Blue arrows–supraclavicular subcutaneous emphysema; Purple arrows–pneumothorax; Red arrows = pneumoperitoneum

Pneumothorax: air in the pleural space

On an upright CXR, a pneumothorax is one of the more easily identifiable pathologies in the thoracic cavity. The presence of air separates the parietal pleura and visceral pleura, resulting in the lung tissue being pushed towards midline. This results in the edge of the lung tissue being easily identifiable (purple arrows). The rest of the cavity is devoid of lung markings.

It is important to note that the size of a pneumothorax can vary greatly. Therefore even if the absence of lung markings isn’t as striking as it is in this picture, the edges of the thoracic cavity should always be closely examined to see if there is any evidence of air. On the other extreme is a tension pneumothorax, which is defined as an expanding pocket of air in the thoracic cavity, which causes half of the lung to completely collapse and shift the mediastinal structures in the contralateral direction.

Pneumoperitoneum: air in the abdominal cavity

The presence of air in the abdominal cavity comes from two major sources: outside the body or the GI tract. Air from outside the body enters into the abdominal cavity through either iatrogenic (surgery, peritoneal dialysis) or traumatic (penetrating wound) routes. Air from the GI tract enters if any segment of the bowel is perforated (most commonly secondary to a duodenal ulcer). On an upright CXR, as is shown above, the air rises to the level of the diaphragm and can be identified.

Even though the subdiaphragmatic air in this picture is clearly evident, CXR’s are not the gold standard diagnostic test for pneumoperitoneum. Abdominal CT scans can pick up much smaller amounts of air that may be difficult to visualize on a plain film.

Subcutaneous Emphysema: air in subcutaneous tissue planes

The image above has distinct areas of radiolucency in the supraclavicular area as a result of air tracking in the subcutaneous tissue, which is defined as subcutaneous emphysema. The area is patchy from the infiltration of air into soft tissues.

Similarly to pneumomediastinum, the air comes from either inside the body (secondary to pneumothorax, pneumomediastinum) or outside the body (penetrating trauma, chest tube insertion site). The air travels along fascial planes between the dermal and muscular layers. Another, more serious, cause is necrotizing fasciitis. In this case, however, it is likely that the air entered into the subcutaneous tissues as a result of trauma, which also resulted in a pneumothorax.

Author: Jaymin Patel

Image Contributor: Katren Tyler, M.D.

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WWWTP #23 (What’s Wrong With This Picture?) Answer

March 12, 2015

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Patient presented with cough, fevers.  This Chest Xray was obtained:

WWWTP 21 1

One finding on this Xray is very concerning.  The Xray showed free air under the diaphragm.

A further diagnostic study was obtained (CT abdomen/pelvis):

WWWTP 21 2 WWWTP 21 3

Turns out this patient has pneumatosis cystoides intestinalis.  He has a history of this disorder and has had a prior laparoscopy showing multiple cystic structures in the intestinal walls.

Findings on imaging:

1.  Chest Xray:  Concern for free air underneath the diaphragm.  He also has a tracheostomy, pacemaker, scoliosis, and a right lower lung infiltrate.

2.  CT abdomen/pelvis:  The coronal imaging shows multiple cystic structures full of free air in the cecal area.  The cross-sectional imaging above shows a large amount of pneumoperitoneum.

Luckily this patient has a history of pneumatosis cystoides intestinalis.  He has had multiple abdominal CT’s showing similar findings.  Clinically he had no abdominal tenderness.  Keep this rare diagnosis in mind for the patient presenting with free air in the abdomen!  Information about pneumatosis cystoides intestinalis:

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3235639/

Author:  Russell Jones, MD

Image Contributor:  Mary Bing, MD

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Student Corner: A Cavitary Lesion

January 6, 2015

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Cavitary lesions in the lungs are gas or fluid filled compartments in an area of pathology, such as a consolidation or a mass. Interestingly, a specific set of pathologies are known to cause this specific finding. Cavitary lesions can be detected on a chest x-ray, as is shown below.

cavitary-mass with IDCavitary masscavitary mass lateral with IDCavitary mass 2

Legend: Red Ellipse–cavity (with margins), Blue Ellipse–air-fluid level

The lesion practically jumps out of the picture on the AP view, but the colored circles are there just to point out the entire area of pathology (blue) and the cavity within (red). The pathology is a bit harder to see on lateral view, but the cavity has an air-fluid level that is easily identified as a vertical line separating a lighter fluid filled portion from an air filled portion. This air-fluid interface is often called a meniscus. You might remember being in chemistry class and measuring water out of tall beakers where the water stuck to the sides of the glass creating a concave meniscus. The surface tension of water allows it to stick to both itself and surrounding surfaces. If you look close enough, you’ll notice that the air-fluid level in the image above, best visualized in the AP view, has a slightly concave shape because the liquid at the bottom is sticking to the solid sides of the cavity.

The underlying pathophysiology is an interesting concept to understand when discussing cavitary lesions. A cavity can form in lung tissue for various reasons, but infection is the major underlying cause. Abscesses are localized collections of pathogens, fluid and immune system components that are walled off from the surrounding tissue, therefore creating a fluid-filled cavity. Tuberculosis is a disease process that involves caseous necrosis, which results in coagulation of cell proteins and liquefaction of cellular components. Eventually, the liquid portion drains out through the lymph system or through the bronchi, leaving air pockets behind. Necrotizing pneumonia and non-infectious processes such as ischemia and neoplasm can also cause a similar picture. Rheumatologic diseases such as granulomatosis with polyangitis and sarcoidosis also cause cavitary lesions by causing localized inflammation, which in turn leads to an area of increased mass, which then in turn can cavitate once the inflammatory reaction recruits fluid to the area. In other words, most of these processes, even if they aren’t inherently related to one another, all converge on the same mechanism of causing a localized area of inflammation.

With such a wide array of categories to choose from, it is perhaps more important than usual to contextualize the radiographic image with information about the patient.

This particular patient is a 30 year old male who presents with a cough.  He has been traveling around the world to multiple continents including Sub-Saharan Africa.  The extensive travel history, including to continents with rare infectious diseases leaves infection at the top of the differential. Things like Staphylococcal pneumonia, fungal infections and even amebiasis are possible because of the patient’s travel history. For a complete list of the infectious causes of a cavitary lesion, check the first two references at the bottom of the page.

References/resources:

Gadkowski LB, Stout JE. Cavitary Pulmonary Disease. Clinical Microbiology Reviews 2008;21(2):305-333. doi:10.1128/CMR.00060-07. (LINK)

Ryu, Jay H. et al. Cystic and Cavitary Lung Diseases: Focal and Diffuse. Mayo Clinic Proceedings , Volume 78 , Issue 6 , 744 – 752. (LINK)

Good pathologic image of caseous necrosis with resulting cavitation

Image Contributor:  James Luz, MD

Author:  Jaymin Patel

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What valve has been replaced?

December 16, 2014

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Here is a patient with a cardiac valve…he did not know which valve was replaced.  Which one is it?

Valve AP Valve Lat

RadDaily.com helps with this dilemma:

http://www.raddaily.com/whitepaperarticle.php?articleTitle=Cardiac+Valves:+Assessment+and+Identification

If we apply the rules from RadDaily.com to our patient, it appears he has an aortic valve:

Valve Lat EditedValve Lat

Valve AP editValve AP

AV = Aortic Valve*

TV = Tricuspid Valve*

MV = Mitral Valve*

PV = Pulmonic Valve*

*These are anticipated locations.  The locations could be altered if the patient has anatomic variations such as chamber enlargement, cardiac rotation, etc.

RadDaily also has additional information using flow directional clues from the shape of the valves.  Check it out!

Author:  Russell Jones, MD

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What valve has been replaced?

December 10, 2014

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Here is a patient with a prosthetic cardiac valve…he did not know which valve was replaced.  Which one is it?

Valve AP Valve Lat

Answer to follow.

Author:  Russell Jones, MD

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How to identify a cardiac rhythm device with CXR…

September 25, 2014

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How many times have you had trouble with figuring out what type of cardiac device (e.g. pacemaker/defibrillator) a patient has implanted?  A patient presented to our ED with chest pain, palpitations.  He did not have his device card with them, no prior visits to our ED, and did not know the manufacturer of the device.  How do you decide which company to call for interrogation?

Here is an article I found with radiologic characteristics of devices that can help identify which company produced the device.  It has a great identification algorithm they coined the CaRDIA-X algorithm:

http://www.ianchristoph.com/physician-resources-2/device_id.pdf

There are 5 major manufacturers currently:  Medtronic, Boston Scientific, St. Jude, Biotronik, and Sorin Group.  Each device manufactured by these companies have certain differentiating characteristics of can shape, battery shape, alphanumeric codes, capacitor shadows, coil types, etc.  Turns out you can identify the manufacturer using the device characteristics on chest X-ray relatively easily.

In the case I was describing above the patient had an easily identifiable Medtronic device and we were able to get it interrogated.  Our ED now has the algorithm posted at our doctor’s station so we can utilize it for device identification.

Author:  Russell Jones, MD

References

Jacob S et al.  Cardiac Rhythm Device Identification Algorithm Using X-Rays: CaRDIA-X.  Heart Rhythm 2011; 8(6): 915-922.

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