Author
Shabir Bhimji, MD
Locum Cardiothoracic and Vascular Surgeon
Saudi Arabia and Middle East Hospitals
Visiting Locum Surgeon
Tanzania Heart Center
Dar-es-Salaam, Tanzania
Disclosure: Shabir Bhimji, MD, has disclosed no relevant financial relationships.
Editors
Lennard A. Nadalo, MD
Clinical Professor
Department of Radiology
University of Texas Southwestern Medical School
Consulting Staff
Envision Imaging of Allen and Radiological Consultants Association
Dallas, Texas
Disclosure: Lennard A. Nadalo, MD, has disclosed no relevant financial relationships.
Editors (continued)
Lars Grimm, MD, MHS
House Staff
Department of Diagnostic Radiology
Duke University Medical Center Durham
North Carolina
Disclosure: Lars Grimm, MD, MHS, has disclosed no relevant financial relationships.
Reviewer
John A. McPherson, MD
Assistant Professor of Medicine
Division of Cardiovascular Medicine
Vanderbilt University School of Medicine
Nashville, Tennessee
Disclosure: John A. McPherson, MD, has disclosed no relevant financial relationships.
Patients with thoracic trauma may present with isolated rib fractures, chest contusions, or lacerations; however, significant thoracic trauma often involves multiple organ systems and several anatomic regions. Chest trauma from a motor vehicle collision may result in injury to the sternum, spine, ribs (yellow arrow), heart and great vessels, mediastinum, or lungs (black arrow). Chest radiographs are often obtained during the most critical moments of resuscitation to help localize an endotracheal tube (red arrow) or chest tube (blue arrow), as seen in this patient with flail chest. Computed tomography (CT) and sonography are important adjuncts in complex or difficult-to-manage cases.
A 45-year-old pedestrian was struck by a motor vehicle. His vital signs and oxygenation are stable, but he is complaining of mild chest discomfort. His radiograph is shown.
Based upon the primary abnormality on this radiograph, what is the next step in the patient’s evaluation?
A. Right chest tube
B. CT scan of chest
C. Electrocardiogram (ECG)
D. Cardiac enzymes
Answer: B. CT scan of chest
The radiograph showed a widened mediastinum due to blunt chest trauma; accordingly, the patient underwent a CT scan, which revealed an aortic dissection (blue arrow). CT scanning is primarily used for hemodynamically stable patients because it is not portable. CT scans provide the surgeon with critical information for surgical planning, including the type of lesion, location of the lesion, extent of the disease, evaluation of the true and false lumen, and whether hypothermic circulatory arrest is necessary for surgery. Note that when the false lumen is located on the left side of the aorta, patients generally tend to lose pulse in the left arm, left kidney, and left iliac artery.
A 55-year-old man fell from the roof of a two-story building. He sustained fractures of the pelvis and left femur. Chest radiograph (shown) revealed a hydropneumothorax. Aspiration of fluid from the chest revealed a pH < 6 and a high level of amylase.
What is the next step in the investigation?
A. CT of the abdomen
B. Barium swallow
C. Upper endoscopy
D. Gram stain of the fluid
Answer: B. Barium swallow
Hydropneumothorax is caused by a ruptured esophagus. The site of perforation in a spontaneous rupture is usually just above the diaphragm in the posterolateral wall of the esophagus. Perforations are usually longitudinal (0.6- to 8.9-cm long), with the left side more commonly affected than the right. Rupture of the distal esophagus usually produces a left-sided chest effusion; however, when the mid-esophagus ruptures (arrows), a right-sided effusion may occur. A full-thickness tear in the esophageal wall allows gastric contents, saliva, bile, and other substances to enter the mediastinum, resulting in mediastinitis.
A 36-year-old patient was stabbed in the chest. A radiograph (shown) was performed after insertion of a chest tube (arrow). The chest tube drainage is a milky white effusion with elevated levels of triglycerides.
What is the next step in management?
A. Thoracotomy
B. Total parenteral nutrition
C. Video-assisted thoracoscopy
D. Intravenous vasopressin
Answer: B. Total parenteral nutrition
The patient was most likely stabbed at the level of the fifth thoracic vertebra, where the thoracic duct crosses midline to enter the superior mediastinum and ascends behind the aortic arch and the thoracic part of the left subclavian artery (shown). The resulting chyle fistula can be initially managed by chest tube drainage, with chyle production reduced by total parenteral nutrition or a fat-restricted oral diet supplemented with medium-chain triglycerides. Thoracic duct leaks close spontaneously in 50% of patients.
A 27-year-old was stabbed in the right chest with a knife. He presented to the emergency department (ED) short of breath and diaphoretic; his chest radiograph is shown. His blood pressure is 105/77 mmHg, respiratory rate is 24, and his pulse is 100. His oxygenation on room air is 94%.
In which of the following cases should thoracotomy be performed?
A. Chest tube output is 200 cc/hour for 2 hours and slows down
B. Chest tube initially puts out 500 cc and then stops
C. Chest tube output is 100 cc/hour for 7 hours
D. Blood pressure is 90/65 and pulse is 110 bpm
Answer: C. Chest tube output is 100 cc/hour for 7 hours
Bleeding after a knife wound to the chest (shown) will stop spontaneously in the majority of cases and can be managed with a chest tube. In cases of traumatic hemothorax, surgical exploration should be performed if the patient experiences evacuation of more than 1 L of blood immediately after tube thoracostomy, has continued bleeding from the chest (150-200 mL/h for 2-4 hours), or requires repeated blood transfusions to maintain hemodynamic stability. Late sequelae of hemothorax (eg, residual clot, infected collections, trapped lung) require additional treatment, often including surgical intervention.
A 45-year-old trauma patient had a right chest tube placed for a hemothorax after a stab wound to the chest. After the procedure, the chest radiograph remains unchanged (shown) and mild subcutaneous emphysema is palpated on repeat examination.
What is the cause of the subcutaneous emphysema?
A. The chest tube is inserted too deeply
B. The chest tube is not sufficiently inserted
C. The chest tube is not large enough
D. The chest tube is not placed on suction
Answer: B. The chest tube is not sufficiently inserted
The chest tube side hole (arrow) is outside the chest cavity. Either the tube was not inserted far enough inside the chest cavity or the tube was not well secured and was pulled out. Another common reason for chest tube failure occurs when the tube is inserted into the major fissure. Chest tubes are best placed along the side of the chest wall or at the base of diaphragm.
A 26-year-old is involved in a motor vehicle collision and is hit in the chest with the steering wheel. His vital signs are stable in the ED. He is alert but tachypneic. His respiratory rate is 28 breaths/min and his oxygen saturation on 2-L nasal cannula is 92%.
Based on the shown chest radiograph, what is the cause of his underlying hypoxia?
A. Pulmonary contusion
B. Pulmonary embolism
C. Congestive heart failure
D. Aspiration pneumonitis
Answer: A. Pulmonary contusion
The forces associated with blunt thoracic trauma can be transmitted to the lung parenchyma and cause pulmonary contusion, as characterized by development of pulmonary infiltrates with hemorrhage into the lung tissue (arrows). Clinical findings in pulmonary contusion depend on the extent of injury. Patients present with varying degrees of respiratory difficulty. Physical examination demonstrates decreased breath sounds over the affected area. Other parenchymal injuries (eg, lacerations) can be produced by fractured ribs and, rarely, by deceleration mechanisms.
Answer D. Sling-and-swathe bandage
Scapula fractures are relatively uncommon and have a high association with other injuries, which may be multiple and/or life-threatening. As a result, diagnosis and treatment of scapular injuries may be delayed or suboptimal, leading to long-term functional impairment. Most scapula fractures can be treated with closed treatment. The thick, strong support provided by the surrounding soft tissues usually limits displacement. Short-term immobilization in a sling-and-swathe bandage can be provided for comfort. Early progressive range-of-motion exercises and use of the shoulder out of the sling should be initiated as pain subsides. Image courtesy of Wikipedia Commons.
A 26-year-old suffered blunt chest trauma from a motor vehicle collision. His blood pressure is 90/59 mmHg, pulse is 100 bpm, and oxygen saturation is 91% on room air. His chest radiograph is shown.
Besides placement of a right-sided chest tube, what should be the next step in this patient’s management?
A. Endotracheal intubation
B. Echocardiogram
C. Arterial blood gas
D. Bronchoscopy
Answer: B. Echocardiogram
The chest radiograph shows an enlarged cardiac silhouette (arrow), which should be evaluated via echocardiography; a CT scan should also be performed to evaluate the lungs. This patient’s echocardiogram revealed myocardial rupture. Blunt cardiac trauma can cause myocardial rupture as a result of cardiac compression between the sternum and the spine, direct impact, or deceleration injury. It may result in the rupture of papillary muscles, cardiac free wall, or ventricular septum. The cardiac chambers involved are, in decreasing order of frequency, the right ventricle, left ventricle, right atrium, and left atrium. However, among patients who reach the hospital alive, the right atrium is the most commonly involved chamber. In up to 30% of cases, the rupture involves more than one chamber.
Answer: D. Pulsus paradoxus
The echocardiogram reveals a large pericardial effusion (arrow) causing tamponade. Cardiac tamponade is a time-sensitive, life-threatening condition that requires prompt diagnosis and management. Beck’s triad includes hypotension, increased venous pressure, and a quiet heart. Subsequent studies have shown that these classic findings are observed in only a minority of patients with cardiac tamponade.
Pericardiocentesis (shown) is a blind syringe-and-needle technique in which fluid is aspirated from the pericardial space. It is used as a lifesaving measure for the prompt management of cardiac tamponade.
To avoid causing injury, where should the orientation of a needle be directed in a subxiphoid approach?
A. Left nipple
B. Left shoulder
C. Sternal notch
D. Towards the right side of the sternum
Answer: B. Left shoulder
Emergent pericardiocentesis is reserved for patients with life-threatening hemodynamic changes. A long needle is introduced through a skin incision and directed towards the left shoulder. The needle should be advanced while applying negative pressure on the syringe until a return of fluid is visualized, cardiac pulsations are felt, or an abrupt change in the ECG waveform is noted. If the ECG waveform shows an injury pattern, then the needle should be withdrawn as it may be in direct contact with the myocardium.
Author
Shabir Bhimji, MD
Locum Cardiothoracic and Vascular Surgeon
Saudi Arabia and Middle East Hospitals
Visiting Locum Surgeon
Tanzania Heart Center
Dar-es-Salaam, Tanzania
Disclosure: Shabir Bhimji, MD, has disclosed no relevant financial relationships.
Editors
Lennard A. Nadalo, MD
Clinical Professor
Department of Radiology
University of Texas Southwestern Medical School
Consulting Staff
Envision Imaging of Allen and Radiological Consultants Association
Dallas, Texas
Disclosure: Lennard A. Nadalo, MD, has disclosed no relevant financial relationships.
Editors (continued)
Lars Grimm, MD, MHS
House Staff
Department of Diagnostic Radiology
Duke University Medical Center Durham
North Carolina
Disclosure: Lars Grimm, MD, MHS, has disclosed no relevant financial relationships.
Reviewer
John A. McPherson, MD
Assistant Professor of Medicine
Division of Cardiovascular Medicine
Vanderbilt University School of Medicine
Nashville, Tennessee
Disclosure: John A. McPherson, MD, has disclosed no relevant financial relationships.
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