www.RiTradiology.com	

www.RiTradiology.com	

Imaging of Thoracic Trauma
Rathachai Kaewlai, MD
Ramathibodi Hospital, Mahid...
www.RiTradiology.com	

www.RiTradiology.com	

Introduction
•  Trauma leading cause of death in
developing countries | 4th ...
www.RiTradiology.com	

www.RiTradiology.com	

Introduction
•  Thoracic injuries
–  10-15% of all trauma
–  25% of trauma f...
www.RiTradiology.com	

www.RiTradiology.com	

Initial Assessment
•  Primary survey
– Airway (prevent hypoxia, stridor = UA...
www.RiTradiology.com	

www.RiTradiology.com	

Imaging Survey
•  Portable CXR
– Tube/line malposition
– Large pneumothorax,...
www.RiTradiology.com	

www.RiTradiology.com	

Portable Trauma CXR
•  Tube and line malposition – most critical
•  Large pn...
www.RiTradiology.com	

www.RiTradiology.com	

Tube/line Malposition
Right mainstem bronchial intubation
www.RiTradiology.com	

www.RiTradiology.com	

Tube/line Malposition
Left chest tube – chest wall placement
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www.RiTradiology.com	

Pneumothorax on Supine CXR
•  Deep sulcus
•  Hyperexpanded
hemithorax
•  Inc...
www.RiTradiology.com	

www.RiTradiology.com	

Pneumothorax on Supine CXR
12 hours later
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www.RiTradiology.com	

Tension Pneumothorax
•  One-way valve
•  Mediastinum displaced to other side...
www.RiTradiology.com	

www.RiTradiology.com	

Tension Pneumothorax
•  Hyperexpanded chest
•  Shift of mediastinum
•  Depre...
www.RiTradiology.com	

www.RiTradiology.com	

Flail Chest
•  Most significant chest wall injuries
•  Paradoxical movement ...
www.RiTradiology.com	

www.RiTradiology.com	

Flail Chest
Anterior rib fractures difficult to see on CXR
Pneumothorax does...
www.RiTradiology.com	

www.RiTradiology.com	

Hemothorax
•  Blood in pleural space
•  Source: chest wall, lung
parenchyma,...
www.RiTradiology.com	

www.RiTradiology.com	

Trauma Ultrasound: FAST
•  FAST includes pericardial and pleural
spaces eval...
www.RiTradiology.com	

www.RiTradiology.com	

Pericardial Evaluation
•  Presence of pericardial fluid
•  Source of blood
–...
www.RiTradiology.com	

www.RiTradiology.com	

Pleural Evaluation
•  Perihepatic and perisplenic views of FAST
must include...
www.RiTradiology.com	

www.RiTradiology.com	

Pleural Evaluation
Extended FAST (EFAST)
•  Best resolution of pleural inter...
www.RiTradiology.com	

www.RiTradiology.com	

Detection of Pneumothorax
•  Pneumothorax occult on CXR in 29-72%
•  EFAST c...
www.RiTradiology.com	

www.RiTradiology.com	

Detection of Pneumothorax:
Principles
•  “Air rises, water descends”
– Depen...
www.RiTradiology.com	

www.RiTradiology.com	

Normal Appearance:
Evaluate for Pneumothorax - EFAST
•  Sagittal view at mid...
www.RiTradiology.com	

www.RiTradiology.com	

Detection of Pneumothorax
•  Normal lung sliding
–  Twinkling at level of
pl...
www.RiTradiology.com	

www.RiTradiology.com	

Pneumothorax:
Loss of Lung Sliding
•  Sensitivity 80-100%
(lower in trauma)
...
www.RiTradiology.com	

www.RiTradiology.com	

Pneumothorax:
A line sign
•  Seeing A-line with loss of
lung sliding  suspe...
www.RiTradiology.com	

www.RiTradiology.com	

Looking for Pneumothorax on US
Lung
sliding?
Yes
Pneumothorax
ruled out
No
B...
www.RiTradiology.com	

www.RiTradiology.com	

Detection of Pneumothorax
•  Absent lung sliding
– Sensitivity 100%, specifi...
www.RiTradiology.com	

www.RiTradiology.com	

Pitfalls of US on Pneumothorax
•  “Loss of lung sliding” alone is not specif...
www.RiTradiology.com	

www.RiTradiology.com	

CT in Thoracic Trauma
•  Role of CT used to be for R/O thoracic
aortic injur...
www.RiTradiology.com	

www.RiTradiology.com	

Patient Preparation for CT
•  Hemodynamic – must be stable
•  NPO – should n...
www.RiTradiology.com	

www.RiTradiology.com	

CT Technique
•  Helical mode
•  Thinnest collimation possible and reformatte...
www.RiTradiology.com	

www.RiTradiology.com	

What Else We Are Looking For?
•  ABC’s of Jud W. Gurney (chestx-ray.com)
– S...
www.RiTradiology.com	

www.RiTradiology.com	

ABC’s Approach*
Aortic injury
Bronchial injury
Cord injury
Diaphragm injury
...
www.RiTradiology.com	

www.RiTradiology.com	

Cautions
•  Satisfaction of search
•  Subtle signs
•  CXR is a “screening” e...
www.RiTradiology.com	

www.RiTradiology.com	

Aortic Injury (TAI)
•  16% MVA fatalities
•  85-90% mortality prior to reach...
www.RiTradiology.com	

www.RiTradiology.com	

Azizzadeh A et al. J Vasc Surg 2009
www.RiTradiology.com	

www.RiTradiology.com	

Aortic Injury (TAI)
CXR Signs of TAI
Mediastinal widening (>8 cm at aortic
a...
www.RiTradiology.com	

www.RiTradiology.com	

Most common location = aortic isthmus (90%)
Pseudoaneurysm and periaortic he...
www.RiTradiology.com	

www.RiTradiology.com	

Aortic Injury (TAI)
•  Indirect CT signs
–  Periaortic hematoma
•  Direct CT...
www.RiTradiology.com	

www.RiTradiology.com	

Aortic Injury (TAI)
•  Periaortic mediastinal hematoma
–  Small veins in are...
www.RiTradiology.com	

www.RiTradiology.com	

Aortic Injury (TAI)
•  Transesophageal echocardiography (TEE)
–  Heart (for ...
www.RiTradiology.com	

www.RiTradiology.com	

(Tracheo)Bronchial Injury
•  1.5% of major thoracic trauma
•  30% missed
•  ...
www.RiTradiology.com	

www.RiTradiology.com	

(Tracheo)Bronchial Injury
•  Traumatic pneumomediastinum: must exclude
–  Ai...
www.RiTradiology.com	

www.RiTradiology.com	

Cord Injury
•  25% spine fractures
•  90% neurologic injury
•  Most common s...
www.RiTradiology.com	

www.RiTradiology.com	

•  On AP view, look at pedicles and spinous
processes
•  Everything no more ...
www.RiTradiology.com	

www.RiTradiology.com	

Injuries with paraspinal hematoma in upper T can simulate mediastinal wideni...
www.RiTradiology.com	

www.RiTradiology.com	

Diaphragmatic Trauma
•  5% blunt thoracic trauma
•  Left > right
•  70% init...
www.RiTradiology.com	

www.RiTradiology.com	

Diaphragmatic Trauma
CXR Signs
Diaphragmatic elevation
Abdominal organ in th...
www.RiTradiology.com	

www.RiTradiology.com	

Diaphragmatic Trauma
CT Signs
Direct discontinuity (“tear”) of
diaphragm
Her...
www.RiTradiology.com	

www.RiTradiology.com	

Esophageal Perforation
•  Very rare injury
•  Upper esophagus most common lo...
www.RiTradiology.com	

www.RiTradiology.com	

Flail Chest
Rib fractures
•  Most common findings after blunt
chest trauma
•...
www.RiTradiology.com	

www.RiTradiology.com	

Flail Chest
•  > 3 consecutive segmental
rib fractures
•  Anterior, posterio...
www.RiTradiology.com	

www.RiTradiology.com	

Gas (Pneumothorax)
•  15-40% of cases
CXR Signs on Supine View
Deep sulcus
S...
www.RiTradiology.com	

www.RiTradiology.com	

Heart Injury
•  Mostly myocardial contusion
•  Less common
– Pericardial lac...
www.RiTradiology.com	

www.RiTradiology.com	

Heart Injury
•  Hemopericardium
•  Pneumopericardium
•  Pericardial lacerati...
www.RiTradiology.com	

www.RiTradiology.com	

Conclusions
•  Portable CXR: Tube/line position, hemo-
pneumothorax, flail c...
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Imaging of Thoracic Trauma

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Imaging of Thoracic Trauma

  1. 1. www.RiTradiology.com www.RiTradiology.com Imaging of Thoracic Trauma Rathachai Kaewlai, MD Ramathibodi Hospital, Mahidol University, Bangkok Emergency Radiology Minicourse 2013 Slides available at RiTradiology.com or Slideshare.net/rathachai
  2. 2. www.RiTradiology.com www.RiTradiology.com Introduction •  Trauma leading cause of death in developing countries | 4th in first-world countries •  Loss of productive years of life – because most occur in young individuals •  Traffic accidents, falls, recreational, violence •  Rapid diagnosis important to avoid morbidity and mortality
  3. 3. www.RiTradiology.com www.RiTradiology.com Introduction •  Thoracic injuries –  10-15% of all trauma –  25% of trauma fatalities •  Blunt (70-80%) > penetrating –  Compression  thoracic wall injuries –  High velocity injury  visceral injuries •  Rx mostly conservative. Thoracotomy rate... –  <10% in blunt thoracic trauma –  15-30% in penetrating thoracic trauma Image from http://www.veomed.com/va041842172010
  4. 4. www.RiTradiology.com www.RiTradiology.com Initial Assessment •  Primary survey – Airway (prevent hypoxia, stridor = UAO) – Breathing (tension ptx, open ptx, flail chest) – Circulation (BP, pulse monitor, arrhythmia, massive hemothorax, cardiac tamponade) •  Secondary survey – Others Mainlyfromphysicalexam
  5. 5. www.RiTradiology.com www.RiTradiology.com Imaging Survey •  Portable CXR – Tube/line malposition – Large pneumothorax, hemothorax – Flail chest – Mediastinal widening (suspected aortic injury) •  Ultrasound (as a part of extended FAST) – Pericardial effusion (presumed hemopericardium) – Pneumothorax / hemothorax
  6. 6. www.RiTradiology.com www.RiTradiology.com Portable Trauma CXR •  Tube and line malposition – most critical •  Large pneumothorax •  Large hemothorax •  Flail chest •  Mediastinal widening •  Other important things: pneumomediastinum, diaphragm injury, unstable spine fractures
  7. 7. www.RiTradiology.com www.RiTradiology.com Tube/line Malposition Right mainstem bronchial intubation
  8. 8. www.RiTradiology.com www.RiTradiology.com Tube/line Malposition Left chest tube – chest wall placement
  9. 9. www.RiTradiology.com www.RiTradiology.com Pneumothorax on Supine CXR •  Deep sulcus •  Hyperexpanded hemithorax •  Increased lucency •  Increased sharpness of heart border •  Subcutaneous emphysema
  10. 10. www.RiTradiology.com www.RiTradiology.com Pneumothorax on Supine CXR 12 hours later
  11. 11. www.RiTradiology.com www.RiTradiology.com Tension Pneumothorax •  One-way valve •  Mediastinum displaced to other side – Decreasing venous return – Compressing opposite lung •  Clinical diagnosis! (air hunger, respiratory distress, tachycardia, hypotension, tracheal deviation, JVD, etc) •  Immediate decompression needed Image from freedictionary.com
  12. 12. www.RiTradiology.com www.RiTradiology.com Tension Pneumothorax •  Hyperexpanded chest •  Shift of mediastinum •  Depression of hemidiaphragm •  Sometimes we can see it on imaging –  Can be insidious, esp in mechanical ventilation Postmortem CXR. Image from trauma.org
  13. 13. www.RiTradiology.com www.RiTradiology.com Flail Chest •  Most significant chest wall injuries •  Paradoxical movement of a segment of chest wall •  Problems of underlying lung contusion and pain leading to hypoxia •  3 or more contiguous segmental rib fractures •  Variations include anterior flail, posterior flail and flail including sternum •  CXR may not show all fractures, esp anterior and lateral fractures Images from wikipedia
  14. 14. www.RiTradiology.com www.RiTradiology.com Flail Chest Anterior rib fractures difficult to see on CXR Pneumothorax doesn’t clear even after chest tube placement. 3D CT shows displaced right rib fractures (note absent rib attachment to the sternum (green arrows).
  15. 15. www.RiTradiology.com www.RiTradiology.com Hemothorax •  Blood in pleural space •  Source: chest wall, lung parenchyma, heart or great vessels •  Chest wall injuries can cause bleeding from intercostal and IMA •  As much as 1,000 mL of blood may be missed when viewing portable supine CXR (400-500 mL required for blunt CP angle on upright CXR) •  Massive hemothorax –  >1,500 mL of blood or –  > 1/3 of blood volume Supine CXR: apical capping, lateral extrapleural density
  16. 16. www.RiTradiology.com www.RiTradiology.com Trauma Ultrasound: FAST •  FAST includes pericardial and pleural spaces evaluation •  Fluid in acute trauma = blood until proven otherwise •  Straightforward, “Yes/No” answer •  Pericardial evaluation is very important and should be the first part of all FAST scans, esp. penetrating trauma
  17. 17. www.RiTradiology.com www.RiTradiology.com Pericardial Evaluation •  Presence of pericardial fluid •  Source of blood –  Great vessels –  Heart –  Pericardial vessels •  Tamponade physiology? –  Collapsed right heart chambers: right atrium – sensitive, right ventricle - specific –  Distended IVC (caval index = 1) •  Key elements of tamponade –  Rate of fluid accumulation –  Effectiveness of compensatory mechanisms Nypemergency.org
  18. 18. www.RiTradiology.com www.RiTradiology.com Pleural Evaluation •  Perihepatic and perisplenic views of FAST must include “pleural cavity”
  19. 19. www.RiTradiology.com www.RiTradiology.com Pleural Evaluation Extended FAST (EFAST) •  Best resolution of pleural interface with high- resolution probe and small footprint •  But most practical using same probe as FAST
  20. 20. www.RiTradiology.com www.RiTradiology.com Detection of Pneumothorax •  Pneumothorax occult on CXR in 29-72% •  EFAST can identify pneumothorax before CXR •  Identify contiguity of visceral and parietal pleura using simple US signs –  To exclude pneumothorax –  Extended FAST (EFAST) –  Normal = lung sliding (B), seashore sign (M mode) –  Abnormal = loss of lung sliding (B), stratosphere (M), lung point (B & M)
  21. 21. www.RiTradiology.com www.RiTradiology.com Detection of Pneumothorax: Principles •  “Air rises, water descends” – Dependent disorders: effusion, consolidation – Nondependent disorders: pneumothorax, interstitial process
  22. 22. www.RiTradiology.com www.RiTradiology.com Normal Appearance: Evaluate for Pneumothorax - EFAST •  Sagittal view at mid- clavicular line “bat- sign” – Lung sliding? – A-line sign? – Lung point?
  23. 23. www.RiTradiology.com www.RiTradiology.com Detection of Pneumothorax •  Normal lung sliding –  Twinkling at level of pleural line in real time –  Sliding of visceral against parietal pleura –  Relative motionless of chest wall to lungs –  Seashore appearance on M-mode
  24. 24. www.RiTradiology.com www.RiTradiology.com Pneumothorax: Loss of Lung Sliding •  Sensitivity 80-100% (lower in trauma) •  Specificity 83-100% •  Real-time US •  M mode = Barcode or stratosphere sign Barcode sign
  25. 25. www.RiTradiology.com www.RiTradiology.com Pneumothorax: A line sign •  Seeing A-line with loss of lung sliding  suspect pneumothorax •  One B-line can R/O pneumothorax where probe is applied Lung point •  Most specific sign •  At border between aerated lung and ptx, there is intermittent appearance of lung sliding during inspiration/ expiration
  26. 26. www.RiTradiology.com www.RiTradiology.com Looking for Pneumothorax on US Lung sliding? Yes Pneumothorax ruled out No B- lines? Yes No Lung Point? No Use other tools Yes Pneumothorax Adapted from Lichtenstein D.
  27. 27. www.RiTradiology.com www.RiTradiology.com Detection of Pneumothorax •  Absent lung sliding – Sensitivity 100%, specificity 78% •  Absent lung sliding + A line sign – Sensitivity 95%, specificity 94% •  Lung point – Specificity 100% •  EFAST more sensitive than portable CXR trauma Lichtenstein DA et al. Crit Care Med 2005
  28. 28. www.RiTradiology.com www.RiTradiology.com Pitfalls of US on Pneumothorax •  “Loss of lung sliding” alone is not specific for pneumothorax – Pleural adhesion/thickening – Atelectasis – Lobec/pneumonectomy – One-lung intubation •  Look for “Lung Point” •  Comparison with contralateral lung
  29. 29. www.RiTradiology.com www.RiTradiology.com CT in Thoracic Trauma •  Role of CT used to be for R/O thoracic aortic injury •  Now CT believed to be most accurate for diagnosis several thoracic trauma •  Yield of CT is higher when done after an abnormal initial CXR or performed selectively based on clinical criteria
  30. 30. www.RiTradiology.com www.RiTradiology.com Patient Preparation for CT •  Hemodynamic – must be stable •  NPO – should not wait •  IV contrast – a must (if conditions allow) •  Renal function test – risk/benefit ratio •  Pregnancy test - yes
  31. 31. www.RiTradiology.com www.RiTradiology.com CT Technique •  Helical mode •  Thinnest collimation possible and reformatted to 2-2.5 mm for viewing •  120 kV •  Automatic tube current modulation •  No plain scan •  Late arterial phase + delays at site of vascular injuries •  Routine coronal and sagittal reformations
  32. 32. www.RiTradiology.com www.RiTradiology.com What Else We Are Looking For? •  ABC’s of Jud W. Gurney (chestx-ray.com) – Systematic evaluation of blunt thoracic trauma – A, B, C, D, E, F, G, H, I •  Missed diagnosis – 4% died within 24 hours – 30% missed interpreted •  Aortic injury •  Diaphragmatic trauma •  Flail chest
  33. 33. www.RiTradiology.com www.RiTradiology.com ABC’s Approach* Aortic injury Bronchial injury Cord injury Diaphragm injury Esophageal tear Flail chest Gas (pneumothorax) Heart (cardiac injury) Iatrogenic tube/line malposition *Borrowed from Jud W. Gurney MD FACR
  34. 34. www.RiTradiology.com www.RiTradiology.com Cautions •  Satisfaction of search •  Subtle signs •  CXR is a “screening” exam. Rarely it is diagnostic of an injury
  35. 35. www.RiTradiology.com www.RiTradiology.com Aortic Injury (TAI) •  16% MVA fatalities •  85-90% mortality prior to reaching hospital – Survivors •  30% died within 6 hours •  50% died within 24 hours •  72% died within 8 days •  90% died within 4 months uvahealth.com
  36. 36. www.RiTradiology.com www.RiTradiology.com Azizzadeh A et al. J Vasc Surg 2009
  37. 37. www.RiTradiology.com www.RiTradiology.com Aortic Injury (TAI) CXR Signs of TAI Mediastinal widening (>8 cm at aortic arch level, or by visual assessment) Loss of AP window, descending T-aorta Tracheal shift to the right of T4 SP NG tube displacement to the right Widened paraspinal or right paratracheal stripes Left apical pleural cap sign Normal (10-15%) For CXR: PPV 10%, NPV 98% but TAI is life-threatening, keep low threshold for CT X-ray signs are related to mediastinal hematoma >8 cm
  38. 38. www.RiTradiology.com www.RiTradiology.com Most common location = aortic isthmus (90%) Pseudoaneurysm and periaortic hematoma
  39. 39. www.RiTradiology.com www.RiTradiology.com Aortic Injury (TAI) •  Indirect CT signs –  Periaortic hematoma •  Direct CT signs –  Pseudoaneurysm –  Intimal flap –  Intimal irregularity –  Pseudocoarctation –  Extravasation •  Term “traumatic dissection” is discouraged (confusing with aortic dissection related to hypertension) Pseudoaneurysm and periaortic hematoma
  40. 40. www.RiTradiology.com www.RiTradiology.com Aortic Injury (TAI) •  Periaortic mediastinal hematoma –  Small veins in area of injury or vasa vasorum –  Does not arise directly from aorta tear –  Usually adjacent to aoric arch and prox descending aorta, but may tracts down descending aorta to diaphragm (retrocrural) Retrocrural hematoma seen on abdominal CT without clear etiology (ie, spine fracture) should raise a concern for TAI
  41. 41. www.RiTradiology.com www.RiTradiology.com Aortic Injury (TAI) •  Transesophageal echocardiography (TEE) –  Heart (for contusion) and t-aorta –  More invasive than CT and usu requires sedation –  Blind spots: arch, arch vessels, distal ascending aorta –  May be used intraoperatively •  Catheter aortography –  Prior gold standard, now reserved for selected cases and for endovascular Rx
  42. 42. www.RiTradiology.com www.RiTradiology.com (Tracheo)Bronchial Injury •  1.5% of major thoracic trauma •  30% missed •  80% within 2.5 cm of carina J R Coll Surg Edin 1999 Persistent or Progressive Pneumothorax or Pneumomediastinum
  43. 43. www.RiTradiology.com www.RiTradiology.com (Tracheo)Bronchial Injury •  Traumatic pneumomediastinum: must exclude –  Airways injuries (larynx, tracheobronchus) –  Esophageal injuries •  Bronchoscopy gold standard •  However, most are benign –  Extension of pneumothorax through pleural tear –  Pulmonary alveolar rupture “Macklin effect”
  44. 44. www.RiTradiology.com www.RiTradiology.com Cord Injury •  25% spine fractures •  90% neurologic injury •  Most common site = T9-11 –  Critical zone –  Transition of facet joint orientation: T facets face inward, L facets face outward •  Difficult assessment on trauma CXR –  Portable technique –  Rule of 2’s Thoracic spine fractures often causes spinal cord injury because cord is large in relation to the canal Image from superhuman.net.au
  45. 45. www.RiTradiology.com www.RiTradiology.com •  On AP view, look at pedicles and spinous processes •  Everything no more than 2 mm from one level to the next –  Interspinous space –  Interpedicular distance •  Elevated paravertebral stripes –  Also sign of TAI
  46. 46. www.RiTradiology.com www.RiTradiology.com Injuries with paraspinal hematoma in upper T can simulate mediastinal widening (findings of TAI)
  47. 47. www.RiTradiology.com www.RiTradiology.com Diaphragmatic Trauma •  5% blunt thoracic trauma •  Left > right •  70% initially missed
  48. 48. www.RiTradiology.com www.RiTradiology.com Diaphragmatic Trauma CXR Signs Diaphragmatic elevation Abdominal organ in thorax NG tube in thorax Basilar lung opacities/ hemothorax Mediastinal shift Distorted diaphragm contour Lower rib fracures
  49. 49. www.RiTradiology.com www.RiTradiology.com Diaphragmatic Trauma CT Signs Direct discontinuity (“tear”) of diaphragm Herniation of abdominal contents above diaphragm Collar sign Dependent viscera sign Collar sign
  50. 50. www.RiTradiology.com www.RiTradiology.com Esophageal Perforation •  Very rare injury •  Upper esophagus most common location Suspect this injury when pneumomediastinum is present in a trauma patient --- Next step is CT or water-soluble contrast esophagogram
  51. 51. www.RiTradiology.com www.RiTradiology.com Flail Chest Rib fractures •  Most common findings after blunt chest trauma •  CXR sensitivity 18-50% •  Most common = rib 4-9 –  Rib 1-3  neurovascular injury –  Rib 9-12  liver, spleen, kidney •  Absence of fracture lines: –  In adults >65 years may warrant rib series. –  In children, it does not mean mild injuries because of pliable ribs
  52. 52. www.RiTradiology.com www.RiTradiology.com Flail Chest •  > 3 consecutive segmental rib fractures •  Anterior, posterior or costosternal segments •  Paradoxical motion of chest wall  respiratory compromise
  53. 53. www.RiTradiology.com www.RiTradiology.com Gas (Pneumothorax) •  15-40% of cases CXR Signs on Supine View Deep sulcus Sharp cardiac borders Basilar hyperlucency Visualized pericardial fat tags Deep sulcus sign
  54. 54. www.RiTradiology.com www.RiTradiology.com Heart Injury •  Mostly myocardial contusion •  Less common – Pericardial laceration – Rupture of myocardium – Rupture of valve – Laceration of coronary artery
  55. 55. www.RiTradiology.com www.RiTradiology.com Heart Injury •  Hemopericardium •  Pneumopericardium •  Pericardial laceration
  56. 56. www.RiTradiology.com www.RiTradiology.com Conclusions •  Portable CXR: Tube/line position, hemo- pneumothorax, flail chest, mediastinal widening •  US: hemothorax, pneumothorax •  CT: aortic injury, diaprhagm and tracheobronmchial injury •  Use CT with a lower threshold especially if initial CXR is abnormal –  IV contrast needed –  Coronal and sagittal reformats needed
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