Tag Archives: Blunt Trauma

Kidney fracture with active extravasation…

March 31, 2013

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This patient came in shortly after a high speed motor-vehicle collision.  Here is the patient’s CT abdomen with IV contrast:

Kidney fx 3Kidney Fx 2Kidney fx 1

This is an interesting CT as it demonstrates “active extravasation” of IV contrast.  The patient has a large left kidney fracture.  You can see a hematoma surrounding the area where you would expect the kidney.  In that hematoma there is a mix of low attenuation material and high attenuation material.  Both of these represent blood; the high attenuation is contrast material that leaking into the hematoma (some of the high attenuation includes perfusing kidney fragments but most of it is extravasating contrast).  The low attenuation is blood that collected before IV contrast administration.

Practically speaking, this means that there is active bleeding into this hematoma.  This is BAD and represents a large amount of bleeding that needs to be stopped.  The patient was actually relatively stable and was taken to interventional radiology where the offending lesion was embolized.

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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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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