[Can diagnosis and subsequent trauma management of the multiple trauma patient with blunt thoracic trauma be improved by early computerized tomography of the thorax?]

OBJECTIVE

The aim of this prospective study was to evaluate, whether early thoracic computed tomography (TCT) is superior to routine chest x-ray (CXR) in the diagnostic work up of blunt thoracic trauma and whether these additional informations influence subsequent therapeutical decisions in the early management of severely injured patients.

PATIENTS AND METHODS

In a prospective study of 103 consecutive patients with clinical or radiological signs of chest trauma (94 multiple injured patients with chest trauma, 9 patients with isolated chest trauma) with an average ISS of 30 and an average AIS thorax of 3 initial CXR and TCT were compared after first assessment in our emergency department of a level I trauma center.

RESULTS

In 67 patients (65%) TCT detected major complications of chest trauma, that have been missed on CXR [lung contusion (n = 33), pneumothorax (n = 27), residual pneumothorax after chest tube placement (n = 7), hemothorax (n = 21), displaced chest tube (n = 5), diaphragmatic rupture (n = 2), myocardial rupture (n = 1)], in 11 patients only minor additional pathologic findings (dystelectasis, small pleural effusion) were visualized on TCT and in 14 patients CXR and TCT showed the same pathological results. 11 patients had both CXR and TCT without pathological findings. The TCT scan was significantly more effective than routine CXR in detecting lung contusions (p < 0.001), pneumothorax (p < 0.005) and hemothorax (p < 0.05). In 42 patients (41%) the additional TCT findings resulted in a change of therapy: chest tube placement or chest tube correction of pneumothoraces or large hemothoraces (n = 31), change in mode of ventilation and respiratory care (n = 14), influence on the management of fracture stabilization (n = 12), laparotomy in cases of diaphragmatic lacerations (n = 2), bronchoscopy for atelectasis (n = 2), exclusion of aortic rupture (n = 2), endotracheal intubation (n = 1), pericardiocentesis (n = 1).

CONCLUSIONS

TCT is highly sensitive in detecting thoracic injuries after blunt chest trauma and is superior to routine CXR in visualizing lung contusions, pneumo- and hemothorax. Early TCT influences therapeutic management in a considerable subset of patients. We therefore recommend TCT in the primary diagnostic work up of multiple injured patients with suspected chest trauma, because early and exact diagnosis of all thoracic injuries along with sufficient therapeutic consequences may reduce complications and improve outcome of severely injured patients with blunt chest trauma.

[CT quantification of pleuropulmonary lesions in severe thoracic trauma]

PURPOSE

Computed quantification of the extent of pleuropulmonary trauma by CT and comparison with conventional chest x-ray--Impact on therapy and correlation with mechanical ventilation support and clinical outcome.

METHOD

In a prospective trial, 50 patients with clinically suspicious blunt chest trauma were evaluated using CT and conventional chest x-ray. The computed quantification of ventilated lung provided by CT volumetry was correlated with the consecutive artificial respiration parameters and the clinical outcome.

RESULTS

We found a high correlation between CT volumetry and artificial ventilation concerning maximal pressures and inspiratory oxygen concentration (FiO2, Goris-Score) (r = 0.89, Pearson). The graduation of thoracic trauma correlated highly with the duration of mechanical ventilation (r = 0.98, Pearson). Especially with regard to atelectases and lung contusions CT is superior compared to conventional chest x-ray; only 32% and 43%, respectively, were identified by conventional chest x-ray.

CONCLUSION

CT allows rapid classification and quantification of pulmonary lesions after thoracic trauma and provides higher sensitivity and reliability. Because of the great correlation with the extent of artificial respiration in respect of duration and pressure, prognosis of the individual patient, as well as a differential therapy, appear possible.

Resistive index of the intrascrotal artery in scrotal inflammatory disease

PURPOSE

To investigate the utility of the resistive indices (RIs) of the epididymal and intratesticular arteries, and to establish diagnostic criteria for scrotal inflammatory disease on the basis of quantitative color Doppler sonography.

MATERIAL AND METHODS

We prospectively examined 29 consecutive patients with scrotal pain, and 15 normal control subjects. The RIs of the intratesticular and epididymal arteries were obtained from color Doppler sonographs.

RESULTS

The RIs of the testicular artery in epididymoorchitis were significantly lower than those in normal control subjects and in epididymitis (p < 0.01) while the RIs of the testicular artery in epididymitis and control subjects were similar (p > 0.5). With a cut-off value of RI = 0.5, sensitivity, specificity, accuracy, and positive and negative predictive values were 91%, 94%, 94%, 83%, and 77% respectively. The mean RI of the epididymal arteries in epididymitis and epididymoorchitis was 0.49 +/- 0.11. A high level of diagnostic accuracy in scrotal inflammatory disease was achieved when the RIs of the intratesticular and epididymal arteries were less than 0.5 and 0.7 respectively.

CONCLUSION

The RI of the intrascrotal artery would give a more objective evaluation than subjective assessment and could provide diagnostic criteria for scrotal inflammatory disease.

Blunt bowel and mesenteric injury: diagnostic performance of CT signs

PURPOSE

Our goal was to determine the sensitivity and specificity of various CT signs of blunt bowel and mesenteric injury.

METHOD

The CT findings of 31 patients with blunt abdominal trauma were retrospectively assessed by three observers in consensus. All patients had laparotomy within 24 h of CT. The study group consisted of 19 patients with surgically proven bowel and/or mesenteric injury. The control group consisted of 12 traumatized patients who had no bowel or mesenteric injury. The CT signs assessed were presence, location, and extent of intraperitoneal fluid, extraluminal air, bowel wall thickening, bowel wall discontinuity, mesenteric streaking, and mesenteric hematoma.

RESULTS

In the 12 cases of bowel injury (9 transmural injury, 3 partial thickness injury), the CT sign of bowel wall thickening had sensitivity of 50% and specificity of 84% and the CT sign of bowel wall discontinuity had sensitivity of 58% and specificity of 95%. Extraluminal air was a specific but relatively insensitive sign of transmural bowel injury (sensitivity 44%, specificity 100%). In the 13 patients with mesenteric injuries, the CT sign of mesenteric hematoma had sensitivity of 54% and specificity of 94%. Isolated mesenteric streaking was a less specific sign of mesenteric injury (sensitivity 77%, specificity 44%). The finding of peritoneal fluid with no visible solid organ injury was a useful sign of bowel or mesenteric injury, occurring in 11 of 19 (58%) study patients and none of the controls (p < 0.001).

CONCLUSION

Bowel wall thickening, bowel wall discontinuity, extraluminal air, and mesenteric hematoma are reasonably specific CT signs of bowel and mesenteric injury following blunt abdominal trauma. The presence of a moderate to large volume of intraperitoneal fluid without visible solid organ injury is an important sign of bowel or mesenteric injury.

[Ultrasound scanning of abdominal contusions in children: experience at the Yopougon CHU (Ivory Coast)]

Ultrasound scans were used to study 23 cases of abdominal contusion in children, between January 1992 and December 1993. Thirteen boys and 10 girls were studied. They were all aged between 4 and 14 years, with a mean age of 6 years. The main causes of their injuries were road accidents (12 cases) and play (11 cases). Ultrasound scans were normal in 6 patients and pathological in 17 patients. The most frequently observed injuries were visceral effects (12 cases), almost always associated with hemoperitoneum. In three cases, hemoperitoneum was detected in the absence of visceral effects. The spleen (4 cases) and the liver (4 cases) were the most frequently injured organs. The other injuries detected included renal hematoma, bladder rupture and parietal hematoma. Diagnosis on the basis of ultrasound scans was found to be incorrect in three cases where diagnosis was repeated after the scan. One case involved a blocked perforation of the rectum, one a benign cyst and the other a mesenteric cyst. Despite these misdiagnoses, ultrasound scanning is a highly sensitive and specific method for examination of contusions in children. It is very useful and often sufficient for accurate diagnosis, particularly in units with only modest technical support.

Concrete induced cardiac contusion

A previously fit 22 year old man was struck in the chest by a concrete block dropped through the windscreen of his car while he was driving on the motorway. He suffered extensive chest wall trauma and lung contusion, which subsequently precipitated acute respiratory distress. On admission ECG showed right bundle branch block and left axis deviation. Three days later QRS duration was normal but there was anterior ST segment elevation and subsequent T wave change. There was a large rise in creatine kinase, and echocardiography revealed septal and apical hyokinesis as well as a mobile mass attached to the left side of the interventricular septum, which had the echogenic texture of myocardium. The patient had fixed perfusion defects in the areas of hypokinesis on thallium scanning but the coronary arteries were unobstructed at angiography. He was treated with warfarin in the short term and an angiotensin converting enzyme inhibitor in the longer term and has made an asymptomatic recovery. Outpatient echocardiography two months after the injury demonstrated some recovery in overall left ventricular systolic function and no evidence of the intracardiac mass. This case illustrates some of the typical features of non-fatal cardiac contusion associated with non-penetrating cardiac trauma, and was complicated by partial thickness avulsion of a strip of the myocardium in the interventricular septum.

Subpleural sparing: a CT finding of lung contusion in children

PURPOSE

To evaluate the presence of subpleural sparing as an aid in differentiation of contusion from other causes of lung opacification in children.

MATERIALS AND METHODS

In 29 children, the computed tomographic (CT) features of 40 lung contusions were reviewed for the presence of subpleural sparing. Other CT characteristics of lung contusion such as location, shape, and confluence were also evaluated. The presence of subpleural sparing was also evaluated in cases of atelectasis, pulmonary laceration, and a control group of CT scans obtained in 45 patients with bacterial pneumonia and no history of trauma.

RESULTS

Subpleural sparing was seen at CT in 38 (95%) of the lung contusions and none of the cases of atelectasis, laceration, or pneumonia (P = .0001). Lung contusions tended to be posterior (60%), crescentic (50%), or amorphous (45%) and have confluent and nodular components (70%).

CONCLUSION

The presence of subpleural sparing on CT scans enables accurate identification of lung contusion and differentiation of contusion from other causes of lung opacification in children after trauma.

Pulmonary contusion: review of the clinical entity

Pulmonary contusion is a common lesion occurring in patients sustaining severe blunt chest trauma. Alveolar hemorrhage and parenchymal destruction are maximal during the first 24 hours after injury and then usually resolve within 7 days. The diagnosis of traumatic lung injury is usually made clinically with confirmation by chest x-ray films. The chest computed tomography scan is highly sensitive in identifying pulmonary contusion and may help predict the need for mechanical ventilation. Respiratory distress is common after lung trauma, with hypoxemia and hypercarbia greatest at about 72 hours. Although management of patients with pulmonary contusion is supportive, pneumonia and adult respiratory distress syndrome with long-term disability occur frequently.

Resuscitation of pulmonary contusion: effects of a red cell substitute

OBJECTIVE

To determine the impact of a vasoactive red cell substitute, diaspirin cross-linked hemoglobin, on respiratory derangements after traumatic lung injury.

DESIGN

Randomized, controlled animal experiment.

SETTING

Large-animal laboratory.

SUBJECTS

Mechanically ventilated, anesthetized young Yorkshire male swine (15 to 20 kg).

INTERVENTIONS

Pigs (n = 6/group) received two pneumatic blasts to the right thoracic cage at baseline, were hemorrhaged 30 mL/kg from t = 0 to 20 mins, resuscitated with 0.9% saline (group 1, 90 mL/ kg) or diaspirin cross-linked hemoglobin (group 2, 15 mL/kg) from t = 20 to 40 mins, and then observed to t = 240 mins.

MEASUREMENTS AND MAIN RESULTS

Serial pulmonary and systemic hemodynamic measurements, total thoracic compliance assessment, spiral three-dimensional computed tomography scan, and lung weights (n = 3/group) were used to assess lesion size and lung water. Mean arterial pressure was restored in both animal groups. Mean pulmonary arterial pressure was significantly higher after resuscitation in animals receiving the red cell substitute. Oxygenation worsened mildly in both groups. Compliance diminished in both groups but was significantly worse at the end of the experiment in animals infused with diaspirin cross-linked hemoglobin. Right lung weights and right thoracic computed tomography scan volume were higher with diaspirin cross-linked hemoglobin than with saline.

CONCLUSIONS

After pulmonary contusion, resuscitation with diaspirin cross-linked hemoglobin led to pulmonary hypertension, greater pulmonary contusion lesion size, and stiffer lungs in this porcine model.

[The application of Ultrasound Biomicroscope in anterior segment contusion]

PURPOSE

To study the clinical value of Ultrasound Biomicroscope in anterior segment contusion.

METHODS

Seven eyes with anterior segment contusion were examined by regular ophthalmic examination, ophthalmic B-scan, and Ultrasound Biomicroscope.

RESULTS

Ultrasound Biomicroscope can show angle recession, cyclodialysis, iridodialysis, zonular breaking, lens dislocation and vitreous protrusion to posterior chamber. In most cases cyclodialysis and shallow detachment of choroid can not be diagnosed because shallow anterior chamber and hypton.

CONCLUSION

The result suggests that Ultrasound Biomicroscope has high clinical value in diagnosis of anterior segment contusion, especially in cornea edema, hyphemia, hypton, Ultrasound Biomicroscope can refer precise diagnosis of anterior segment contusion.

[Blunt thoracic trauma with aortic rupture and lung contusion caused by hoof kick in a 15-year-old girl. Diagnostic and therapeutic management]

The number of published cases of adolescents surviving thoracic aortic injuries with accompanying severe thoracic injuries is small. Only 20-30% of all these patients reach the trauma center alive. In the present case we demonstrate the diagnostic, operative and intensive care management in a 15-year-old girl. The exact interpretation of the AP thoracic X-ray in connection with a typical mechanism of injury led to the detection of a haemomediastinum. This is very important in the further development of diagnostics, because the conventional X-ray picture does not show significant signs in the case of an incomplete aortic rupture. Diagnostic hints have to be derived from the detection of the haemomediastinum. The girl was operated on under left heart bypass. Spinal ischaemia was absent after surgery, and renal failure also did not occur. The adjacent severe lung confusion healed under kinetic therapy with a kinetic treatment table without pulmonary complications.

[A case of isolated lung contusion]

A case of the isolated lung contusion is presented. A possibility of such a trauma in young individuals with elastic thoracic covers has been noted. The necessity of chest X-rays within short period following trauma to detect a source of contusion is stressed because of the dynamic changes in the contused lung tissue. Proper treatment produces a remission of pathologic lesions in lung parenchyma within 4-10 days.

[Acute diagnosis of thoracic injuries of therapeutic relevance in severely injured and polytraumatized patients]

PURPOSE

To determine the value of supine chest radiography in comparison to orientating chest CT in the initial diagnostic evaluation of severely polytraumatised patients.

MATERIAL AND METHODS

303 patients with primary indication for a cranial CT following trauma were investigated between 1988 and 1993. After performing the cranial CT all patients underwent a chest CT with an average of 6 CT slices without changing the position of the patient and with a median scan time of 4 minutes. The results of the chest CT were correlated with the findings of the supine chest radiography in regard to therapeutically relevant pathological changes.

RESULTS

The sensitivity in detection of pneumothorax in supine chest radiography was 53% versus 97% in CT, atelectasis 20% versus 94%, lung contusion 79% versus 99%, haemotothorax 62% versus 97%. More fractures were found conventionally (sensitivity 94%) than by chest CT (sensitivity 44%).

CONCLUSION

Supine chest radiography of polytraumatised patients is clearly inferior to orientating chest CT in demonstrating posttraumatic lesions; obtaining therapeutically relevant information justifies the additionally needed small amount of time.

The posttraumatic pulmonary mass

Each year approximately 2 million people are seriously injured in traffic accidents. Injuries to the chest play a major role in the mortality and morbidity of these patients. One-third to one-half of motor vehicle crash victims suffer blunt thoracic trauma. The spectrum of injuries is broad but posttraumatic pulmonary masses are rarely noted. The proper use of radiographic imaging procedures allows documentation of pulmonary hematoma and exclusion of more ominous lesions.

The usefulness of transesophageal echocardiography in diagnosing cardiac contusions

OBJECTIVES

To assess the usefulness of transesophageal echocardiography in diagnosing cardiac contusions in patients with blunt trauma.

BACKGROUND

For more than a decade, noninvasive tests, including ECGs, cardiac enzymes, nuclear studies, and transthoracic echocardiography have been utilized in an attempt to identify trauma patients with cardiac injuries. These tests have been imperfect in identifying the patients at high risk for mortality.

METHODS

We retrospectively reviewed the charts in 22 patients with transesophageal echocardiographically diagnosed cardiac contusions noting age, race, sex, transthoracic echocardiographic examinations, study quality, and outcome. We also noted the Injury Severity Score, which is a measure of the severity of illness in trauma patients. Higher scores correlate more severe injury and higher mortality. We defined cardiac contusions as presence of wall motion abnormality, including either or both ventricles, in the absence of transmural myocardial infarction on ECG following nonpenetrating chest trauma.

RESULTS

Over a 30-month period, 81 transesophageal echocardiographic examinations were performed on trauma patients. Among this group, 22 patients were diagnosed as having cardiac contusions. There were 15 patients with right ventricular contusions, 7 patients with left ventricular contusions, and 2 patients with both ventricles involved. We compared this group with all ICU trauma patients admitted to the hospital during this time period. Overall, the contusion patients had an average Injury Severity Score of 27 and a mortality of 27% compared with the overall trauma group with an Injury Severity Score of 33 and a corresponding mortality of 9% (p < 0.001). Corresponding ECGs were nondiagnostic in 73% of patients with cardiac contusion. There were no complications related to the transesophageal examinations.

CONCLUSIONS

Transesophageal echocardiographically diagnosed cardiac contusion in trauma patients carries a high mortality rate. Transesophageal examinations are safe and provide excellent quality images where transthoracic examinations were inadequate. Right ventricular contusions are approximately twice as common as left ventricular contusions.

[Spiral CT of the thorax in primary diagnosis and intensive treatment of polytrauma patients]

The performance of a rapid spiral chest CT scan during primary diagnosis and intensive care leads, in a high percentage of cases, to clinically relevant diagnoses. In particular, occult ventral (tension-) pneumothoraces and lung contusions have been found in one third of polytraumatized patients both initially and during the sequential course. Additional insertion of chest tubes has been observed to be the major consequence.

Traumatic chest lesions in patients with severe head trauma: a comparative study with computed tomography and conventional chest roentgenograms

In patients with severe craniocerebral trauma, who need a continuous positive-pressure breathing, the detection of pulmonary and mediastinal traumatic lesions, especially pneumothorax, may alter the management. The aim of this study is to evaluate the efficiency and accuracy of conventional supine chest roentgenograms to detect the associated traumatic chest lesions in severe craniocerebral trauma and to compare their value as a diagnostic method for the identification of unsuspected lesions with a limited chest computed tomographic (CT) examination. Forty-seven consecutive patients with severe craniocerebral trauma underwent head CT and a prospective limited CT examination of the thorax in the same session. Nine patients (19.1%) presented a pneumothorax, bilateral in one case. Six pneumothoraces (60%) were identified both on conventional chest roentgenograms and CT, whereas in four cases (40%), the lesion was only detectable on CT. The CT study also showed 31 areas of pulmonary parenchymal contusions in 19 subjects (40%), whereas the conventional chest roentgenograms demonstrated 17 areas of contusions in 11 (23%) subjects. One thoracic aorta and one right diaphragm rupture were detected on CT study. On the conventional chest roentgenograms the mediastinal vascular injury was overlooked, whereas the right diaphragmatic rupture was highly suspected. The limited chest CT examination supplied additional information in 30% of patients. In 12.7% of patients, this information was clinically significant enough to alter the management. In patients with severe craniocerebral trauma evaluation of associated chest trauma by a supplementary limited chest CT, examination provides more and precise information about the size and severity of mediastinal and pulmonary lesions with a superior detectability of pneumothorax.

Bone scintigraphy findings in Lisfranc joint injury

Three-phase bone scintigraphy diagnosis of Lisfranc injury in a patient after foot trauma is discussed. Early diagnosis of Lisfranc joint injury is frequently missed and radionuclide bone scintigraphy may show a specific pattern where the x-rays are inconclusive.

Formation and resolution of bilateral traumatic pulmonary pseudocysts

A case of bilateral traumatic pulmonary pseudocysts, an uncommon complication of blunt chest trauma, is presented. The radiologic changes were followed over 6 months until spontaneous resolution had occurred. The mechanism of formation of traumatic pseudocysts and the diagnostic implications are discussed.

Systemic gas embolism complicating pulmonary contusion. Diagnosis and management using transesophageal echocardiography

Systemic air embolism has been frequently reported after penetrating thoracic trauma. In blunt thoracic trauma, systemic air embolism has been rarely diagnosed, and then only after an invasive procedure such as thoracotomy. Transesophageal echocardiography has been recently introduced for the early assessment of trauma patients and is considered a sensitive noninvasive procedure to diagnose air embolism. We report three cases of systemic air embolism in patients with pulmonary contusion secondary to a blunt thoracic trauma requiring controlled ventilation. Transesophageal echocardiography was performed for evaluation of hemodynamic instability, and it showed air bubbles in the left atrium and left ventricle during the insufflation phase, which disappeared during apnea. A decrease in airway pressure (release of PEEP, low tidal volume, high frequency jet ventilation) significantly reduced the systemic air embolism. We concluded that systemic air embolism can occur after blunt thoracic trauma, and transesophageal echocardiography enables a rapid and accurate diagnosis that may be useful for therapeutic management.

[Thoracic trauma in childhood. Radiologic findings]

In childhood blunt trauma to the chest wall is more frequent than penetrating injuries. Most of these are the result of traffic accidents. Solitary or serial rib fractures are seen more often than fractures of the sternum. Complications of thoracic injuries are pulmonary contusion, hemothorax and, less frequently, pneumothorax. Pulmonary contusion can result in post-traumatic pneumatocele or chronic pulmonary hematoma. Injuries of the heart, the great vessels and bronchotracheal rupture, presenting initially with pneumothorax, followed by atelectasis, rarely occur. Blunt thoracic trauma is frequently associated with further injuries (head and/or blunt abdominal trauma). The prognosis also depends on the concurrent injuries. The initial evaluation of an injured child is based on the chest X-ray and abdominal ultrasound examination. Additional information can be obtained by a CT scan in mediastinal injuries.

Gallbladder injury secondary to blunt trauma: CT findings

OBJECTIVE

Our objective was to determine CT findings of gallbladder injury secondary to blunt trauma.

MATERIALS AND METHODS

Computed tomography scans and medical records of seven patients diagnosed with gallbladder injury secondary to blunt trauma, including six surgically confirmed cases and one presumptive diagnosis based on CT findings, were reviewed retrospectively to delineate CT findings associated with gallbladder injury. Evaluation of CT scans included assessment of gallbladder distention, wall thickness and contour, intraluminal contents, presence of pericholecystic fluid, and associated injuries. Data obtained included age, gender, mechanism of injury, surgical and pathologic findings when available, treatment, morbidity, and mortality.

RESULTS

Four patients had gallbladder contusions and three had either gallbladder laceration, partial avulsion, or intraluminal hemorrhage. The spectrum of CT findings included pericholecystic fluid (seven), ill defined contour of the gallbladder wall (four), high density intraluminal hemorrhage (four), mass effect on the duodenum (three), and gallbladder collapse (one). No combination of findings was specific for the type of injury. The most common associated injuries were pericholecystic liver lacerations and duodenal hematoma or perforation.

CONCLUSION

The CT finding of an ill defined contour of the gallbladder wall, a collapsed lumen, or high density intraluminal hemorrhage, especially in the presence of pericholecystic fluid, strongly suggests primary gallbladder injury.

Trauma radiology: part II. Diagnostic imaging of thoracic trauma: review and update

Frontal chest radiographs are the principal diagnostic imaging study to detect, verify, or exclude acute thoracic injury after trauma, and they should be obtained as quickly as possible without compromising clinical assessment and resuscitation. Chest radiographs provide important information about potentially life-threatening conditions, such as tension pneumothorax, major hemothorax, and major arterial injury. In many patients, chest radiographs also provide helpful clues to the presence of such conditions as diaphragmatic rupture, pulmonary contusion/laceration, and tracheobronchial injury. In selected patients, computed tomography scans can supplement information provided by radiography, particularly for detection of mediastinal hemorrhage, aortic pseudoaneurysm, subtle pneumothorax, and delineation of complex pleuroparenchymal processes. On occasion, magnetic resonance imaging can be used to assess integrity of the hemidiaphragms and visceral herniation when other diagnostic studies are equivocal. We consider typical imaging findings associated with a variety of acute thoracic injuries, as well as the most appropriate use of available imaging techniques in different clinical scenarios.

[Phase analysis of gated blood pool scintigraphy in traumatic myocardial contusion]

It is not easy to make a diagnosis of myocardial contusion following blunt chest trauma, because most patients have many other concurrent injuries with diverse symptoms. The usefulness of phase analysis of gated blood pool scintigraphy (GBPS) for myocardial contusion following blunt chest trauma was evaluated. Thirty-eight patients who had been strongly suspected of having myocardial contusion from clinical symptoms and electrocardiograms underwent phase analysis of GBPS. The results of phase analysis were compared with those of two-dimensional echocardiography (2-D Echo) and CPK-MB fraction measurement in all patients, with those of 201TlCl myocardial scintigraphy in 35 patients and with those of 99mTc-pyrophosphate scintigraphy in 10 patients. In 29 patients (76.3%), the results of phase analysis matched those of 2-D Echo. Two patients (5.3%) who were judged as positive by 2-D Echo and as negative by phase analysis had only rupture of the chordae. Only one of two other patients who were judged as negative by 2-D Echo and as positive by phase analysis was judged as positive by 201TlCl myocardial scintigraphy. The results of both 2-D Echo and phase analysis were not well correlated with those of CPK-MB fraction measurement and 99mTc pyrophosphate scintigraphy. It is concluded that phase analysis of GBPS, as well as 2-D Echo, is useful for diagnosing myocardial contusion, and that phase analysis is most useful for diagnosing myocardial contusion in patients who cannot be examined by 2-D Echo because of the presence of pneumothorax and/or subcutaneous emphysema in the anterior chest wall.

Trauma of the fatty tissue

Contusions of soft tissues are frequently encountered but the more often without any major consequence. However, trauma of the fat may induce complications ranging from mere lymphatic effusion to the apparition of pseudo lipoma or even, exceptionally, of fat embolism. Although rare, one must be aware of these complications as they appear sometimes long after the trauma.

Diagnosis of myocardial contusion

From July 1988 to July 1990, 159 consecutive cases of major blunt chest injury were evaluated prospectively for myocardial contusion with serial electrocardiographic monitoring, cardiac isoenzyme studies, and two-dimensional echocardiography. One hundred and forty-seven cases in the series were assessable; 97 of the patients were male, and 50 were female. They ranged in age from 2 to 97 years (average, 38.5 years). There were five deaths, none of cardiac origin. Total lactate dehydrogenase (LDH) values were elevated in 115 patients (78%); total creatine phosphokinase (CPK) values were elevated in 100 (68%). Cardiac isoenzyme patterns were consistent with myocardial contusion in 18 patients (12%). Seventy-five patients had abnormal electrocardiograms, and 10 of these had ectopic rhythms. Two-dimensional echocardiograms were completed in 58 cases; 12 of these (21%) were abnormal. Nineteen patients (25%) with abnormal rhythms had elevated LDH values, and 26 (35%) had elevated CPK values. One patient (10%) with ectopy had an abnormal echocardiogram. Two patients (11%) with abnormal isoenzyme patterns experienced dysrhythmias. Costs for hospitalization and studies amounted to $1,886 per patient. Given the poor predictive value of laboratory testing in patients with significant (ie, symptomatic) cardiac contusion, observation alone with electrocardiographic monitoring and treatment of symptomatic dysrhythmias is an adequate and cost-conscious treatment.

Bone scintigraphy in skeletal trauma

This article emphasizes the usefulness of radionuclide bone imaging (RNBI) throughout the clinical spectrum of osseous trauma and relates RNBI to the other imaging modalities available. Acute, stress, insufficiency, avulsion, and occult fracture detection are discussed and illustrated. Other traumatic lesions including the bone bruise, shin splints, tendinitis and epiphyseal injuries are included. Biomechanical lesions, the result of more chronic low level repetitive stress are discussed in detail, as is the use of RNBI in the detection of post-traumatic sequela such as the reflex sympathetic dystrophy syndrome. Technical aspects of RNBI are considered in the context of producing the quality of diagnostic images necessary for clinically complete consultative reporting.

An unusual presentation of liver laceration in a 13-yr-old football player

Abdominal injury occurs infrequently from athletic trauma, yet when it does occur, it can be very serious. Although rupture of a major blood vessel can lead to rapid loss of blood, insidious blood loss can also result from apparently insignificant injury of the spleen, liver, or kidney and lead to delayed problems. Awareness of the potential for such injury is vital because outcome can be adversely affected by a low index of suspicion, and this can be compounded by the fact that the initial physical examination is not always a reliable indicator of the severity of injury. Classic reports of these injuries describe splenic injury from a left-sided blow and hepatic injury from right-sided trauma. We present a case report of liver laceration in a young football player not only to comment on its unusual mechanism and presentation, but also to illustrate the importance of rapid assessment and transport of the athlete with a serious abdominal injury to avoid the consequences of delayed diagnosis and treatment.

Laterality of air volume in the lungs long after blunt chest trauma

To clarify a cause of the persistent decrease in lung capacity seen several years after blunt chest trauma, 17 patients with blunt chest trauma (10 with unilateral lung contusion, 7 with bilateral lung contusions; 11 of these with unilateral flail chest) inflicted 1 to 6 years previously and 10 normal volunteers (control) were studied. Lung air volumes (AV) were measured by spirometry (AVsp) and by computed tomographic (CT) scan (AVCT = AVCT.Rt+AVCT.Lt) under the same conditions. Hemithoracic spaces were also calculated by CT scan. The average AVsp in patients (76% +/- 8%) was lower than in the controls (98% +/- 5%). AVCT was consistent with AVsp in all the measurements. %AVCT.Rt and %AVCT.Lt, which were adjusted by the ratio of AVCT.Rt to AVCT.Lt in the controls, decreased significantly in unilateral contused lungs (71% +/- 8%). Fifty-eight percent of contused lungs showed small fibrous changes on the CT scans. The ratio of the hemithoracic space on the flail chest side to the opposite side was 0.95 +/- 0.05. These results suggest that the persistent decrease in AV long after blunt chest trauma might be caused by a constriction of contused lung resulting from fibrous changes.

Combined severe myocardial and pulmonary contusion: early diagnosis with transesophageal echocardiography and management with high-frequency jet ventilation: case report

We report the case of a 27-year-old patient with blunt thoracic trauma in whom transesophageal echocardiography enabled an early diagnosis of severe myocardial contusion. Conventional mechanical ventilation dramatically enhanced cardiogenic shock because of myocardial contusion, requiring increasing doses of catecholamine. High-frequency jet ventilation produced an immediate improvement in hemodynamic status, permitting a decrease in catecholamine administration.

Perioperative cardiovascular complications associated with blunt thoracic trauma

The purpose of this study was to examine the frequency and importance of intraoperative mortality, arrhythmias and hypotension in the presence of thoracic trauma and to determine the effect of myocardial contusion on these perioperative complications. Over a two-year period patients with evidence of blunt thoracic injury who required surgery within 24 hr of admission were studied. The anaesthetist filled in a questionnaire on intraoperative events. Patients were also studied for the presence of myocardial injury with radionuclide angiography (RNA), at autopsy or at thoracotomy. Two hundred and one patients were studied. The intraoperative and overall mortality was 7.9% and 22.9% respectively. Of the operating room survivors the incidence of intraoperative arrhythmias and hypotension was 3.8% and 26.5% respectively. Only 5.9% of patients had a suspected or confirmed myocardial contusion. Patients were divided into two groups, those without myocardial injury were designated Group I, while those with myocardial contusion were designated Group II. The Group II patients had a greater severity of injury and intraoperative mortality (54.4%) than those in Group I (4.6%) P < 0.05. Intraoperative deaths were attributed to, with one exception, non-cardiac causes. There were no differences in the incidences of arrhythmias and hypotension between patients with-or without myocardial injury surviving the operating room. All patients with blunt thoracic injury may develop intraoperative arrhythmias or hypotension.

[X-ray computed tomography of thoracic injuries. Apropos of 40 cases]

On chest radiographs, the precise assessment of thoracic injuries consecutive to blunt trauma is often compromised by the nonspecific appearance of many lesions. Furthermore, significant injuries are frequently overlooked. However, the management of the patients with chest trauma is still often based primarily upon clinical and radiographic findings and Computed Tomography (CT) is often performed secondarily on the basis of unexplained clinical signs or suspected radiographic abnormality. Some authors have reported that CT was a highly sensitive method for detecting thoracic lesions frequently not seen or underestimated on conventional supine chest radiographs. However, the value that these new CT findings could have in the therapeutic management of these patients, have not been systematically investigated to our knowledge, except in a limited series suggesting that the course of critically ill patients could be substantially altered after thoracic CT. In order to estimate the role of early CT in the management of patient care, we report the therapeutic consequences of CT findings in forty patients who we report the therapeutic consequences of CT findings in forty patients who had a thoracic CT within few hours following a chest injury. We showed that early thoracic CT scan in patients with blunt trauma detected significantly more lesions than did chest X-Ray and appreciably modified the treatment modalities in 70% of our patients. We then recommend that all the patients admitted in ICU after chest trauma undergo a thoracic CT scan as soon as possible in order to optimize their treatment modalities.

Significance of myocardial contusion following blunt chest trauma

A prospective study was undertaken at a regional trauma unit (RTU) to determine the significance of cardiac complications in patients with blunt chest trauma. Radionuclide angiographic (RNA) imaging was performed as soon as possible after admission and Holter monitors were applied for 72 hours. Routine investigations included serial cardiac enzyme measurements and 12-lead electrocardiograms. Dysrhythmias were classified and ventricular dysrhythmias were stratified by ventricular ectopic score (VES) as ventricular tachycardia (4) or greater than 100 premature ventricular contractions (PVCs)/hour (3). Three hundred twelve patients were entered into the study. Analysis of dysrhythmias revealed 18 patients with a VES of 4 and nine patients with a VES of 3; there were no serious consequences. The most significant dysrhythmia as a marker of outcome was atrial fibrillation (n = 9); five of these patients died, but all of associated noncardiac injuries. A review of abnormal RNAs revealed that all associated mortalities were attributed to noncardiac injuries. A review of postmortem reports and hospital records revealed that no deaths were attributed to cardiac failure or dysrhythmia. Thus the incidence of clinically significant dysrhythmias or other cardiac complications resulting from blunt trauma to the heart may be overestimated.

Diagnosis of myocardial contusion. Quantitative analysis of single photon emission computed tomographic scans

Prior studies from our institution have shown that single photon emission computed tomography is sensitive (100%) in predicting patients at risk for serious arrhythmias. However, the positive predictive value is low (15% to 20%). The purpose of this study was to determine if quantitative analysis of single photon emission computed tomographic defects could improve predictive value. One hundred seventy-five patients with positive single photon emission computed tomographic scans were studied. One hundred two patients developed arrhythmias, 42 of which were ventricular. Arrhythmias were associated with all defect loci and all defect sizes. The incidence of arrhythmias did increase with increasing size. Patients were at risk for arrhythmias up to 72 hours after trauma. The value of single photon emission computed tomography is its ability to predict patients at risk for arrhythmias. This study shows that any single photon emission computed tomographic defect, regardless of location or size, is a significant predictor of arrhythmias.

Chest injuries in children: an analysis of 100 cases of blunt chest trauma from motor vehicle accidents

One hundred twenty-eight cases of chest injury were seen in a Paediatric Trauma Unit over a 5 1/2-year period. One hundred patients sustained motor vehicle accident (MVA)-related blunt chest injuries, 91 of them as pedestrians. Nine children had blunt chest injuries from falls, 10 had stab wounds (3 assault, 7 accidental), and 9 had gunshot injuries (6 from birdshot used by police during civil disturbance). MVA-related injuries were studied separately, as an etiologically homogeneous group. Sixty-five of these patients were under the age of 6. All but 3 also had serious extrathoracic injuries. The mean injury severity score (ISS) in MVA-related injuries was 25. Eight patients died, all with an ISS of 34 or more, 7 of whom had fatal head injuries. In MVA-related injuries, pulmonary contusion (n = 73) was the most frequent lesion seen, followed by rib fracture (n = 62), posttraumatic effusion (n = 58), pneumothorax (n = 38), and pneumatocele (n = 5). In MVA-related injuries, 18 children required ventilation. Thirty-nine (69%) of 56 children with radiologically evident posttraumatic pleural effusion had intercostal chest drainage. Analysis suggests that lung injury is a central event in MVA-related blunt chest trauma. Primary lung injury, radiologically visible as contusion, is complicated by hematoma, posttraumatic effusion, and pneumothorax.

[Knee contusion with an interesting incidental finding]

During examination of a 42 year old male patient from Mauretania with an injured knee in the emergency ward, a dracunculiasis - Guinea worm disease - was incidentally diagnosed. As travelling is generally increasing, this disease might be encountered more frequently also in Europe.

[Compartment syndrome after femoral contusion. Case report and review of the literature]

Compartment syndromes of the lower arm and lower leg are quite well known by now and have been often described in the literature. Those of the upper arm and thigh are rarer and those after pure closed lesion of the soft parts of the thigh are the subject of only sporadic reports in the literature. A recently observed case of this kind prompted the present case report and review of the literature.

Head-injured patients who talk and deteriorate into coma. Analysis of 211 cases studied with computerized tomography

Of 838 patients with severe head injuries admitted since the introduction of computerized tomography, 211 (25.1%) talked at some time between trauma and subsequent deterioration into coma. Of these 211 patients, 89 (42.2%) had brain contusion/hematoma, 46 (21.8%) an epidural hematoma, 35 (16.6%) a subdural hematoma, and 41 (19.4%) did not show focal mass lesions. Thus, four of every five patients who deteriorated into coma after suffering an apparently nonsevere head injury had a mass lesion potentially requiring surgery: the mass was intracerebral in 52.3% of the cases and extracerebral in 47.6%. Patients aged 20 years or less had a 39% chance of having a nonfocal mass lesion (diffuse brain damage), a 29% chance of having an epidural hematoma, and a 32% chance of having an intradural mass lesion; patients over 40 years had only a 3% chance of having a nonfocal mass lesion, an 18% chance of having an epidural hematoma, and a 79% chance of having a intradural mass lesion. Sixty-eight (32.2%) patients died and 143 (67.8%) survived. The following were independent outcome predictors (in order of significance): Glasgow Coma Scale score following deterioration into coma, the highest intracranial pressure during the patient's course, the degree of midline shift, the type of intracranial lesion, and the age of the patient. In contrast, the mechanism of injury, the verbal Glasgow Coma Scale score during the lucid interval, and the length of time until deterioration or until operative intervention did not influence the final result.

Incidence of abnormal RNA studies and dysrhythmias in patients with blunt chest trauma

The incidence and significance of myocardial contusion and subsequent cardiac complications have recently been debated. A prospective study of patients with blunt chest trauma was undertaken at a Regional Trauma Unit between January 1, 1989 and March 31, 1990. One hundred ninety-one patients were entered into the study; 72-hour Holter monitoring was performed in 183 patients, and radionuclide angiography (RNA) was performed on 163 patients. All patients had CPK levels (with CPK-mb fractions) measured, and serial electrocardiographs. There were seven patients with abnormal RNA studies; five of the seven abnormal studies were attributable to previously undiagnosed coronary artery disease or myocardial infarction. Nine patients were diagnosed as having atrial fibrillation, seven of whom were in atrial fibrillation on admission. Ventricular dysrhythmias were classified by the number of premature ventricular contractions (PVCs) per hour or the presence of ventricular tachycardia. Twelve patients developed short runs of ventricular tachycardia, and clinically insignificant PVCs were common. Only one patient with ventricular dysrhythmias (frequent PVCs) was treated and there were no hemodynamically significant dysrhythmias. The incidence of clinically significant dysrhythmias or hemodynamically significant myocardial contusion appears to be low in this patient population. Aggressive investigation and monitoring solely for cardiac complications may not be indicated.