> [!Key Points]
> 1. air bronchograms in trauma patient suggests [[Chest trauma radiology#air bronchograms vs general increased opacity|pulmonary haemorrhage]] rather than [[#haemothorax]]
> 2. [[#Apical capping]]: signs of mediastinal haematoma
2 types of chest trauma:
- Penetrating
- blunt trauma
- 3m fall = ~30km/hour
- shearing -- rapid acceleration/deceleration (eg aortic injury, DAI, etc). **nb:** can have no damage to other organs, but still significant shearing injury to vital organ (case for angiography)
# CXR
## What to look for
1. Hard evidence of trauma
1. [[#Rib fractures]]
2. [[#Subcutaneous emphysema| air in the wrong place]]
3. other signs (eg scapula fracture)
2. obvious density differences
1. [[#haemothorax]]
2. [[#tension pneumothorax]]
3. lower zone density ([[#ruptured diaphragm]])
4. upper zone density ([[#Apical capping]])
3. Assess any interventions (eg ICC, etc)
> Do **not** focus on looking for a widened mediastinum -- rotation, AP makes false postives. need [[#CT]] for this.
| pathology | cxr radiology finding |
| :------------------ | :-------------------------------- |
| haemothorax | generalised increased density |
| pulmonary contusion | focal density, cannot see vessels |
| pneumothorax | deep sulcus, sharp diaphragm |
| diaphragm rupture | cannot see diaphragm |
| apical capping | mediastinal haematoma |
## Considerations
- supine vs. upright
- inflation of lungs
- anterior vs. posterior
- rotation (look for clavicle overlapping spinous process)
- ![[Pasted image 20230412110500.png|look for clavicle overlap]]
## Rib fractures
- follow superior and inferior cortex
- compare left and right edges
- very difficult to detect posterior rib fractures on CXR; need CT
- often associated with transverse process fractures
### examples
![[Pasted image 20230412111843.png]]
^ right sided rib fractures + clavicle fracture
![[Pasted image 20230412111950.png]]
^ left-sided 3-5th rib fractures (see cortical step displacement) + scapula fracture.
![[Pasted image 20230412112438.png]]
Flail segment (missed; progress after several days with lung collapse)
### Internal fixation of rib fractures
![[Pasted image 20230412112637.png]]
- benifits debateable; ?improve pain + LOS, unclear if mortality benefit
- eg [Rib fixation in non-ventilator-dependent chest wall injuries: prospectivetrial](https://pubmed.ncbi.nlm.nih.gov/35081599/) , [Rib fixation: who, what, when?](https://pubmed.ncbi.nlm.nih.gov/29766079/)
## Subcutaneous emphysema
![[Pasted image 20230412113230.png]]
## Obvious density differences
See also [[Radiology signs with names]]
### haemothorax
![[Pasted image 20230412122745.png]]
^ addequate supine AP film, not rotated. obvious density difference between two hemithoracies in this patient. right sided haemothorax 2/2 rib fractures on right . vessels trace all the way out, no deep sulcus sign; no evidence of ptx.
> note, in haemothorax in supine patient, we expect a **uniform** increase in density; if you see focal density in lower zone and you cannot see line of diaphragm, beware of [[#ruptured diaphragm]]
CT of same patient:
![[Pasted image 20230412123036.png]]
![[Pasted image 20230412123107.png]]
Sits posterior in chest, which is why on CXR it is just generalised opacity
![[Pasted image 20230412123253.png]]
^ posterior displaced fractures not seen on CXR; big intercostal vessels here, likely the source of haemothorax
### air bronchograms vs. general increased opacity
- when adding opacity into alveolar space (eg consolidation, pulm contusion), instead of seeing vessels, can see bronchi well -- air bronchograms
- in cases of preserved lung parenchyma but increased opacity (eg a [[#haemothorax]] ), there is normal aerated lung, so no air bronchograms and can still see pulmonary vessels well.
![[Pasted image 20230412123508.png]]
![[Pasted image 20230412123817.png]]
^ in this pic, left sided pneumothorax and subcutaneous emphysema. air bronchograms, suggesting pulmonary haemorrhage/contusion. bilat ICC and ETT
Same patient CT:
![[Pasted image 20230412124733.png]]
^ note 1. air bronchograms , 2. enhancing vessels running through the consolidation, suggesting collapsed lung rather than haemothorax. ==this is example of pulmonary haemorrage, NOT haemothorax. ==
![[Pasted image 20230412124926.png]]
^ close up of pulmonary vessels confirming atelectasis rather than haemothorax
### tension pneumothorax
![[Pasted image 20230412130127.png]]
^ note increased lucency, increased rib-spacing on right compared to left (suggests mass effect of increased pressure in thorax) and depression of right hemidiaphragm
post chest tube:
![[Pasted image 20230412130350.png]]
^ right hemidaphragm back up, mediastinum midline again, normal rib spacing again. some residual atelectasis
### Deep sulcus sign
![[Pasted image 20230412130729.png]]
^ no obvious pneumothorax, but left side hyper-lucency costo-phrenic recess
![[Pasted image 20230412130942.png]]
^ right side with increased lucency and sharper hemidiaphragm, likely pnuemothorax (also note sub-cut emphysema)
### ruptured diaphragm
![[Pasted image 20230412132525.png]]
^ mass effect, cannot trace diaphragm, increased density in lower zone is not uniform, mediastinal shift to right creating mass effect.
ICC going into small bowel in this patient on CT:
![[Pasted image 20230412132712.png]]
coronal view:
![[Pasted image 20230412132741.png]]
### Apical capping
![[Pasted image 20230412133135.png]]
^ increased density isolated to the lung apex bilaterally, cannot see lung markings going through these. implies ==extra-pleural fluid at lung apices== (outside of pleural space) ddx rib fracture (eg 1st rib fracture), **aortic injury** with mediastinal haematoma, or upper thoracic fractures
this XR also note left sided scapular fracture, hard evidence of trauma.
==get angiography of aorta if see apical capping on CXR==
### another example apical capping
![[Pasted image 20230419102023.png]]
^ paediatric, not same as prior and below. Also not left-sided haemothorax. Concern for aortic injury in context of blunt chest injury
This patient had thoracic spinal fracture:
![[Pasted image 20230412133722.png]]
### third example apical capping
![[Pasted image 20230513142400.png]]
^ on the left. also note 1st rib fracture
## Assess interventions
- ETT
- ICC -- eg kinks, whether it goes down a fissure, where it terminates, etc
## Definitions
**flail chest** - A flail chest is radiologically defined as 3 or more adjacent ribs with segmental fractures and/or more than 5 adjacent rib fractures.
# CT
@ 37 mins in video
## Mediastinum assessment
![[Pasted image 20230412140749.png]]
^ pseudoaneurysm of descending aorta. fixation point between aorta and left pulmonary artery of **ligamentum arteriosum** is fixation point for **sheering injury**
saggital view of pseduoaneurysm:
![[Pasted image 20230412141215.png]]
note the patient has a calcified ligamentum arteriosum which pulled on aorta to cause sheering injury:
![[Pasted image 20230412141254.png]]
## Blunt traumatic aortic injury
> need arterial phase CT chest to see
| severity | size | management |
| :-------------------- | :----------------------- | :--------------------------------------------------------------------------------------------- |
| minimal aortic injury | <10mm intimal flap | - conservative <div>- BP control</div><div>- monitor for evolution</div> |
| severe aortic injury | all other injuries | - BP control<div>- treat life-threatening injuries first</div><div>- endovascular repair</div> |
## mediastinal haematoma
![[Pasted image 20230412143419.png]]
^ note that there is a widening here; look for sternal fracture (see below image)
![[Pasted image 20230412143508.png]]
example of normal mediastinal triangle without haematoma:
![[Pasted image 20230412143559.png]]
### another example aortic pseudo aneurysm
![[Pasted image 20230419103024.png]]
![[Pasted image 20230419103142.png]]
^ paediatric case from mark's teaching
### contrast extravasation
![[Pasted image 20230412143746.png]]
^ mediastinal haematoma with active contrast extravasation from aortic arch
## Sternum fracture
- look for this when mediastinum haematoma but there is not evidence of an aortic injury
![[Pasted image 20230513200328.png]]
^ in this example, you can see the sternum fracture, and also the "fake" sternum fracture that is a result of motion artifact lower dower (evienced by the steps in the skin at the same level as the apparent steps in the sternum)
## pulmonary contusion vs. aspiration
- in aspiration, expect to see in just one lobe.
- in contusion, expect to see in multiple lobes
## pneumomediastinum
See also [[Pneumomediastinum]]
![[Pasted image 20230412171921.png]]
^ note air surrounding aortic arch. however, normal fat triangle anterior mediastinum; no evidence of mediastinal haematoma
![[Pasted image 20230412172003.png]]
^ same patient, mediastinal air
**CXR**
![[Pasted image 20230412173348.png]]
^ same patient, very subtle, but note the **continuous diaphragm**, which is abnormal!
![[Pasted image 20230412173630.png]]
^ CT demonstrating the same continuous diaphragm sign
## pulmonary interstitial emphysema
![[Pasted image 20230412172239.png]]
^ same patient as pneumomedastinum case above. note the air **surrounding** bronchovascular structures in area of contused lung. also note traumatic pneumatocele. air disects up into mediastinum. This tells you that the pneumomedastinum is NOT due to an oesophageal rupture, but from right lung. Can do a swallow test to prove the pneumonedastinum is not from oesophagus, but unlikely given the finding of pulmonary interstitial emphysema
**note** in oesophageal rupture, usually have pleural space collections.
## pneumopericardium vs. pneumomediastinum
**pneumomedastinum**
![[Pasted image 20230412172826.png]]
bubbly appearance of air (bubbly means it is not in pericardium OR in pleura)
**pneumopericardium**
![[Pasted image 20230412173121.png]]
- smooth appearance of air in pericardium
# physiology
## hypertension
- if not in shock, baroreceptors malfunction, get elevated bp (like [[Aortic dissection]] )
- Esmolol, metoprolol if esmolol unavailable
#trauma #radiopaedia
# Related Questions
## aortic dissection
- [x] 7Q: [Chest Pain](x-devonthink-item://73409C77-B2FA-4E0A-AEB3-5EB284457F0C?page=13) -- [Answer](x-devonthink-item://5A848952-80E3-4184-B553-368412A69917?page=9) -- [prop](x-devonthink-item://2A1F4A99-92AE-4C8E-B325-AE448BD46AC6?page=4)
## blunt chest injury
- [x] 9Q: [Fall From Roof](x-devonthink-item://7FCD3940-4BB4-45FE-86A6-E5707E82D5B5?page=1) -- [Answer](x-devonthink-item://3263A68A-96A6-43EC-985B-43260C3509BF?page=0)
## chest trauma
- [x] 10Q: [Chest trauma](x-devonthink-item://B257662E-D069-4044-AF7A-736487B5CA99?page=5) -- [Answer](x-devonthink-item://1658DB69-4D34-47EF-9495-B6B43E0BE3BE?page=6) -- [prop](x-devonthink-item://51B63B5B-D684-4BF3-8B62-95FCA5EF7503?page=3)
- [x] 11Q: [Penetrating Chest Trauma](x-devonthink-item://5DC0999B-D537-4002-86AF-FD7B54B45E2E?page=42) -- [Answer](x-devonthink-item://406AF611-5CD4-4B3B-9795-327E8F4E3626?page=19)
- [x] 12Q: [Chest and Head Trauma](x-devonthink-item://834C484F-DDAA-4819-8DF0-84AE5E70DA1D?page=2) -- [Answer](x-devonthink-item://D46998FE-62E2-4A3A-860D-C32C94B86E42?page=0) -- [prop](x-devonthink-item://834C484F-DDAA-4819-8DF0-84AE5E70DA1D?page=64)
- [x] 13Q: [High Speed Motor Vehicle Collision](x-devonthink-item://C4CCEB12-61D5-4308-AA41-5078F3D96CC0?page=2) -- [Answer](x-devonthink-item://75D8E35B-EE77-4D1B-A665-438451C976AE?page=11) -- [prop](x-devonthink-item://E34679F3-102F-4E16-AF81-9D679412EDAC?page=7)
- [x] 14Q: [Chest Trauma](x-devonthink-item://2504F01B-CEAF-41E8-803B-B3AE1B07A49E?page=13) -- [Answer](x-devonthink-item://00427DF6-6D28-4FEB-A0CA-DF96DBBBCE97?page=28) -- [prop](x-devonthink-item://AB9BDA6D-9CA8-4E73-9D15-B6105225A1B4?page=13)
## chest tube
- [x] DUPLICATE Q: [Penetrating Chest Trauma](x-devonthink-item://5DC0999B-D537-4002-86AF-FD7B54B45E2E?page=42) -- [Answer](x-devonthink-item://406AF611-5CD4-4B3B-9795-327E8F4E3626?page=19)
## clavicle fracture
- [x] 15Q: [Clavicle fracture](x-devonthink-item://F0498813-9350-484C-AD5B-6FF7C3AE9015?page=43) -- [Answer](x-devonthink-item://A491A3F6-FD6D-492F-BCBE-7F7BAE101EDF?page=46)
## ct chest
- [x] DUPLICATE Q: [Chest and interscapular pain](x-devonthink-item://F0498813-9350-484C-AD5B-6FF7C3AE9015?page=14) -- [Answer](x-devonthink-item://A491A3F6-FD6D-492F-BCBE-7F7BAE101EDF?page=12)
- [x] DUPLICATE Q: [Chest Pain](x-devonthink-item://73409C77-B2FA-4E0A-AEB3-5EB284457F0C?page=13) -- [Answer](x-devonthink-item://5A848952-80E3-4184-B553-368412A69917?page=9)
## cxr
- [x] 19Q: [Pneumothorax](x-devonthink-item://4134DDB3-6E12-474A-9F6F-64135C0C6048?page=49) -- [Answer](x-devonthink-item://AC92B5F1-8EE6-461A-B03E-F70AE7DC1275?page=49) -- [prop](x-devonthink-item://68EA6F60-334D-4A94-8327-78286C5F1AED?page=12)
- [x] 20Q: [Shotgun wounds](x-devonthink-item://CA0CC973-6102-4C33-AB59-A43A87724DF0?page=10) -- [Answer](x-devonthink-item://9F437E5A-02D4-43FC-B795-5386EDE954F3?page=8) -- [prop](x-devonthink-item://281EC7A9-8E5A-461A-AA34-3FF490AA0EC2?page=2)
- [ ] 21Q: [Pneumothorax](x-devonthink-item://B9C99BB4-DAF8-4D15-BBD3-40E82B279902?page=13) -- [Answer](x-devonthink-item://DF848F67-27AB-450A-988B-159784B72957?page=13) -- [prop](x-devonthink-item://D2415799-57A6-4B32-BE9A-0120DF5500A1?page=2)
- [x] DUPLICATE Q: [Chest trauma](x-devonthink-item://B257662E-D069-4044-AF7A-736487B5CA99?page=5) -- [Answer](x-devonthink-item://1658DB69-4D34-47EF-9495-B6B43E0BE3BE?page=6)
- [ ] 22Q: [Unwell infant](x-devonthink-item://85167CB5-A7B5-4BF3-9BC7-AC46D5538A42?page=10) -- [Answer](x-devonthink-item://5B03E66C-E043-4EB7-A5F6-7389CB927BD7?page=14) -- [prop](x-devonthink-item://D0A460D5-938B-4002-A684-EFD9189B08C1?page=12)
- [ ] 23Q: [Pneumothorax](x-devonthink-item://1A2C485F-D4AD-4821-AFF2-452BA753717F?page=4) -- [Answer](x-devonthink-item://FD716379-1A77-4B5B-B257-1154995ECA6E?page=1) -- [prop](x-devonthink-item://1A2C485F-D4AD-4821-AFF2-452BA753717F?page=61)
- [ ] 24Q: [Motorbike accident](x-devonthink-item://1A2C485F-D4AD-4821-AFF2-452BA753717F?page=46) -- [Answer](x-devonthink-item://FD716379-1A77-4B5B-B257-1154995ECA6E?page=30) -- [prop](x-devonthink-item://1A2C485F-D4AD-4821-AFF2-452BA753717F?page=65)
- [x] 25Q: [Decompression illness](x-devonthink-item://F0498813-9350-484C-AD5B-6FF7C3AE9015?page=32) -- [Answer](x-devonthink-item://A491A3F6-FD6D-492F-BCBE-7F7BAE101EDF?page=32)
- [ ] 26Q: [Pneumonia](x-devonthink-item://1442A590-B32E-40BE-9C29-6401A71DC2DC?page=3) -- [Answer](x-devonthink-item://0C9617AB-8E16-4A75-ADF0-AB06FA726B0A?page=1) -- [prop](x-devonthink-item://D5D52721-F021-4ABC-B6EA-727BF54DF6B9?page=1)
- [ ] 27Q: [Respiratory Failure](x-devonthink-item://4AD9F692-A113-4718-94B0-7292F2273B1F?page=1) -- [Answer](x-devonthink-item://A10DE51E-92FA-42D1-8AA0-7AE68C2FA743?page=20) -- [prop](x-devonthink-item://B864660E-6598-4555-ACA9-B87F41ED4C3A?page=12)
- [ ] 28Q: [Headache and Collapse with Abnormal CT](x-devonthink-item://3D57C3FE-3B52-42E0-9FBD-E4034F60C5B7?page=11) -- [Answer](x-devonthink-item://75D8E35B-EE77-4D1B-A665-438451C976AE?page=25) -- [prop](x-devonthink-item://E34679F3-102F-4E16-AF81-9D679412EDAC?page=13)
- [ ] 29Q: [Pneumothorax](x-devonthink-item://EE0B8625-5F19-46CF-8208-56D79DC48BC5?page=9) -- [Answer](x-devonthink-item://6F751245-A36C-447A-8AE7-599AD5871C71?page=13) -- [prop](x-devonthink-item://308BBEF4-A83E-4972-8F63-9249898FC8E8?page=10)
## dissection
- [ ] 32Q: [Aortic dissection](x-devonthink-item://85167CB5-A7B5-4BF3-9BC7-AC46D5538A42?page=7) -- [Answer](x-devonthink-item://5B03E66C-E043-4EB7-A5F6-7389CB927BD7?page=10) -- [prop](x-devonthink-item://D0A460D5-938B-4002-A684-EFD9189B08C1?page=11)
## fall
- [ ] 33Q: [Elderly Collapse](x-devonthink-item://F0498813-9350-484C-AD5B-6FF7C3AE9015?page=50) -- [Answer](x-devonthink-item://A491A3F6-FD6D-492F-BCBE-7F7BAE101EDF?page=54)
- [ ] 34Q: [Complex Elderly Presentation](x-devonthink-item://CA4D5561-277D-47A1-9EC2-E0DB4C59DCFD?page=6) -- [Answer](x-devonthink-item://2551B51B-0E7C-448E-9FB5-3B547E74974A?page=6)
## pneumomediastinum
- [ ] 44Q: [Missed CXR finding](x-devonthink-item://1A2C485F-D4AD-4821-AFF2-452BA753717F?page=18) -- [Answer](x-devonthink-item://FD716379-1A77-4B5B-B257-1154995ECA6E?page=11)
## pneumothorax
- [x] DUPLICATE Q: [Pneumothorax](x-devonthink-item://4134DDB3-6E12-474A-9F6F-64135C0C6048?page=49) -- [Answer](x-devonthink-item://AC92B5F1-8EE6-461A-B03E-F70AE7DC1275?page=49)
- [ ] 45Q: [Pneumothorax ultrasound](x-devonthink-item://8A1FC024-FD4E-4202-A93D-77C4E8234DC5?page=18) -- [Answer](x-devonthink-item://7EEBE66F-C2B1-4EF7-B29C-FB52D469C8CD?page=17) -- [prop](x-devonthink-item://47692A18-39D4-4FDD-9F24-8F946DAF9CAB?page=1)
- [x] DUPLICATE Q: [Pneumothorax Ultrasound](x-devonthink-item://8A1FC024-FD4E-4202-A93D-77C4E8234DC5?page=18) -- [Answer](x-devonthink-item://7EEBE66F-C2B1-4EF7-B29C-FB52D469C8CD?page=17)
- [x] DUPLICATE Q: [Pneumothorax](x-devonthink-item://B9C99BB4-DAF8-4D15-BBD3-40E82B279902?page=13) -- [Answer](x-devonthink-item://DF848F67-27AB-450A-988B-159784B72957?page=13)
- [ ] 46Q: [Pneumothorax](x-devonthink-item://5DD7C01C-AB9B-4F0E-9CC4-266700BD94E8?page=4) -- [Answer](x-devonthink-item://7CE81625-E4A6-40C1-BAEB-7E44C75B1E60?page=4)
- [x] DUPLICATE Q: [Pneumothorax](x-devonthink-item://1A2C485F-D4AD-4821-AFF2-452BA753717F?page=4) -- [Answer](x-devonthink-item://FD716379-1A77-4B5B-B257-1154995ECA6E?page=1)
- [x] DUPLICATE Q: [Decompression illness](x-devonthink-item://F0498813-9350-484C-AD5B-6FF7C3AE9015?page=32) -- [Answer](x-devonthink-item://A491A3F6-FD6D-492F-BCBE-7F7BAE101EDF?page=32)
- [x] DUPLICATE Q: [Chest and Head Trauma](x-devonthink-item://834C484F-DDAA-4819-8DF0-84AE5E70DA1D?page=2) -- [Answer](x-devonthink-item://D46998FE-62E2-4A3A-860D-C32C94B86E42?page=0)
- [ ] 47Q: [Penetrating chest trauma](x-devonthink-item://A8F2D7A0-9A26-4012-AF42-19D640D674B4?page=2) -- [Answer](x-devonthink-item://A10DE51E-92FA-42D1-8AA0-7AE68C2FA743?page=1) -- [prop](x-devonthink-item://B864660E-6598-4555-ACA9-B87F41ED4C3A?page=2)
- [x] DUPLICATE Q: [Pneumothorax](x-devonthink-item://EE0B8625-5F19-46CF-8208-56D79DC48BC5?page=9) -- [Answer](x-devonthink-item://6F751245-A36C-447A-8AE7-599AD5871C71?page=13)
- [x] DUPLICATE Q: [Chest Trauma](x-devonthink-item://2504F01B-CEAF-41E8-803B-B3AE1B07A49E?page=13) -- [Answer](x-devonthink-item://00427DF6-6D28-4FEB-A0CA-DF96DBBBCE97?page=28)
## tension pneumothorax
- [x] 50Q: [Chest Trauma](x-devonthink-item://1EA9311E-0B9E-49F7-8D6E-4C4187A838C4?page=58) -- [Answer](x-devonthink-item://B1CB2E8F-5D04-49EE-8274-043871389D28?page=38)
## trauma
- [ ] 52Q: [Traumatic arrest](x-devonthink-item://1A14F7A1-E434-47A6-BC68-AF2DD1A7C090?page=16) -- [Answer](x-devonthink-item://736EC9CD-AC9C-4588-BA1E-F4AD190CBA47?page=38)
- [ ] 53Q: [Open ankle fracture](x-devonthink-item://09493372-578D-4C97-972A-EEC617B38B53?page=8) -- [Answer](x-devonthink-item://A0D348CE-FCD4-4ECD-BE21-6CA73F6DE8CD?page=4)
- [x] DUPLICATE Q: [Motorbike accident](x-devonthink-item://1A2C485F-D4AD-4821-AFF2-452BA753717F?page=46) -- [Answer](x-devonthink-item://FD716379-1A77-4B5B-B257-1154995ECA6E?page=30)
- [ ] 54Q: [Motorcycle Vs Kangaroo](x-devonthink-item://73409C77-B2FA-4E0A-AEB3-5EB284457F0C?page=36) -- [Answer](x-devonthink-item://5A848952-80E3-4184-B553-368412A69917?page=25)