[Spiral computed tomography in chest injury]

The purpose of the study was to evaluate the potentialities of spiral computed tomography (SCT) in recognizing some symptoms of injury-induced chest changes, to define differential diagnostic signs of some complications occurring in the posttraumatic period. Thirty one studies were made in 23 victims with severe mixed chest injury upon their admissions and during follow-ups. CT data were analyzed on axial slices by means of multiplanar and three-dimensional reconstructions. CT angiography was applied in 8 cases. The CT picture of some pathological symptoms of chest injuries, injury complications, their differential diagnostic criteria were outlined.

[Initial evaluation of thoracic injuries. Comparison of pulmonary radiography and x-ray computed tomography]

OBJECTIVES

To investigate the contribution of computed tomography scan (CTS) to the initial évaluation of chest trauma.

PATIENTS AND METHODS

We carried out a two-year prospective study in all the chest trauma patients admitted to ICU. They underwent both Chest X-ray (CXR) and CTS within 24 jours of admission. CXR and CTS images were read by achieving a consensus between two radiologists who were unaware of the results of the other investigation. Then we compared these findings with the treatment received by the patients in the ICU.

RESULTS

From July 1, 1991 through July 1, 1993, 56 patients were included (21 with conventional CTS and 35 with helicoidal CTS). CTS demonstrated a significant number of pleural (p < 0.001), parenchymatous (p < 0.001), and mediastinal (p < 0.01) lesions that escaped detection on CXR (CTS+/CXR- lesions). Thoracic drainage was done in 16 patients because of abnormalities CTS+/CXR- (p < 0.01); six patients with CTS+/CXR- pulmonary contusions received Pressure Positive Ventilation (p < 0.01); and four CTS+/CXR- lesions were treated surgically (p < 0.05).

CONCLUSION

CTS adds significantly to the evaluation of chest trauma by allowing prompt, accurate assessment of lesions. In this study, over 50% of these lesions required specific treatment during the ICU stay.

Detection and evaluation of aerodigestive tract injuries caused by cervical and transmediastinal gunshot wounds

BACKGROUND

Aerodigestive tract penetrations occurring with gunshot wounds to the neck and thorax are uncommon but are frequently associated with multiple organ injury and contribute to significant morbidity.

METHODS

The selective management strategy used at our institution for suspected aerodigestive tract involvement with cervical, thoracic inlet, and transmediastinal gunshot wounds is reviewed with reference to eight clinical cases from 1989 to 1995.

RESULTS

Seven pharyngoesophageal and four laryngotracheal injuries are described with three patients sustaining combined aerodigestive organ wounds. Associated injuries occurred in seven of the eight cases. Diagnosis of aerodigestive tract penetrations were made by triple endoscopy in five patients, by contrast esophagography in one case, and at operation for associated injuries in two patients. No injuries were missed during endoscopy or contrast studies. Two patients suffered complications including delayed recognition of an esophageal injury and pneumonia in one case and dehiscence of a distal esophageal repair in another. An associated vascular injury resulted in a single death in the series.

CONCLUSIONS

A high index of suspicion must be maintained for aerodigestive tract involvement with cervicothoracic gunshot wounds. We advocate operative endoscopic inspection during emergent exploration in unstable patients or arteriography with endoscopy in stable patients. Adjunctive contrast pharyngoesophagography is performed to confirm equivocal endoscopic findings, evaluate the extent of leak, or completely exclude injury.

Trauma of the chest

Trauma to the chest may cause a wide range of injuries including fractures of the thoracic skeleton, contusion or laceration of pulmonary parenchyma, damage to the tracheobronchial tree, diaphragmatic rupture or cardiac contusion. Conditions affecting primarily extrathoracic sites may have indirect effects on the lungs causing adult respiratory distress syndrome or fat embolism. Laceration of the aorta is the typical and likewise most life threatening complication of massive blunt chest trauma necessitating immediate diagnosis and repair. Conventional radiography rather than cross-sectional imaging is the mainstay in diagnosing thoracic trauma. During the critical phase with often concomitant shock, pelvic and spinal injuries tailored radiographic views or even upright chest radiographs are impractical. The severely traumatized patient is usually radiographed in the supine position and suboptimal roentgenograms may have to be accepted for several reasons. It is well documented that many abnormalities detected on CT were not apparent on conventional radiographs, but CT is reserved for hemodynamical stable patients. Nevertheless certain situations like aortic rupture require further evaluation by CT and aortography. The value of conventional radiography, CT, MRI and aortography in chest trauma is reviewed and typical radiographic findings are presented.

Transmediastinal gunshot wounds. A reconsideration of the role of aortography

OBJECTIVE

To evaluate the contribution of aortography in the management of stable patients with transmediastinal gunshot wounds.

DESIGN

Retrospective review of clinical records.

SETTING

Level I urban trauma center.

PATIENTS

Forty-three patients with aortic or esophageal gunshot injuries.

INTERVENTIONS

Patients who were stable after initial resuscitation underwent aortography followed by esophagography.

MAIN OUTCOME MEASURES

Hemodynamic status on admission, time devoted to diagnostic workup, surgical (or autopsy) findings, morbidity, and mortality.

RESULTS

There were 24 esophageal injuries and 20 aortic injuries. Patients with aortic injuries were less often stable for aortography (10% vs 42%; P = .02), and fewer of them survived (15% vs 58%; P = .01). In no patient was the aortic injury initially detected by aortography. Stable patients with esophageal injuries experienced an average 11-hour interval between injury and surgery (nearly 3 hours attributable to aortography).

CONCLUSION

Esophageal evaluation should precede aortography in the workup of stable patients with transmediastinal gunshot wounds.

Thoracic gunshot wounds in children under 17 years of age

Over the past decade there has been a significant increase in the incidence of gunshot wounds (GSW) among Americans under 19 years of age. Despite the increase, pediatric GSW have received little attention in the literature, and no study has focused on pediatric victims of thoracic GSW. In the present study, the authors performed a retrospective review of the records of 51 patients under 17 years of age who were treated for thoracic GSW at adjoining level I pediatric and adult trauma centers between July 1987 and June 1995. The primary catchment area for these institutions is a lower socioeconomic, urban tenancy. The study population was 80.4% male and 86.3% black; the mean age was 12.4 years. The mean injury severity score and trauma score were 13.6 and 13.4, respectively. Although statistically significant differences could not be demonstrated with this population size, trends were evident when the group was subdivided by age group (< or = 12 years and > 12 years of age). The younger group was more likely to require a thoracic operation after injury (35.3% v 23.5%), to have unstable vital signs (41.2% v 26.5%), to have a higher total abbreviated injury score (AIS) for the chest (4.8 v 4.0); however, their total extrathoracic AIS was lower (2.1 v 3.1). The younger group spend more time in the hospital and in the intensive care unit (7.6 v 4.6 days and 2.0 v 0.9 days, respectively). The younger children were more likely to have sustained injury by unintentional crossfire (35.3% v 14.7%) and were never injured by intentional assault (0% v 47.2%). Overall, 50% of the patients required surgery, including 93.8% of the patients who had unstable vital signs at the time of arrival. All six deaths (11.8%) owing to the thoracic injury occurred in patients who had mediastinal injury that required an emergency-department thoracotomy (EDT). The authors conclude that among this predominantly black male population, there are different trends with respect to treatment, circumstances, and pattern of injury between the younger and older subpopulations.

Cardiac and mediastinal trauma

Injuries to the heart and mediastinal vessels comprise one of the leading causes of traumatic death. Although the presumed overall mortality rate of critical cardiac injury is very high, the survival rate of patients with cardiac trauma who arrive in the ED with vital signs has been reported to be significant, especially with penetrating as opposed to blunt chest trauma. Patients with lethal injury to the heart and great vessels may present with deceptively few signs or symptoms. The survival of these patients is entirely dependent on the ability of the emergency physician to make the correct diagnosis and expedite definitive surgical treatment. Thus, it is prudent for emergency physicians to maintain a high index of suspicion for these injuries in caring for patients with trauma to the chest. Other injuries, such as esophageal, diaphragmatic, tracheal, and bronchial wounds must also be considered.

Splenic odyssey. Traumatic retropharyngeal displacement of thoracoabdominal viscera

The retropharyngeal space (RPS) is a fascial compartment of the midline of neck, posterior to the pharynx, anterior to the spine. Pathologic involvement of RPS includes tumors, abscesses, and traumatic hematomas, all of which may dissect inferiorly into the thoracic compartment. We describe two cases in which severe trauma of the torso resulted in dissection of thoracoabdominal contents upward into the RPS--an apparently undocumented phenomenon.

Surgical management of penetrating mediastinal arterial trauma

Fifty-two patients with penetrating injury to the arteries caudal to the thoracic inlet and cephalad to the heart came under the care of the Durban Metropolitan Vascular Service, South Africa, over a 13-year period. The innominate artery was the commonest vessel injured (n = 23). Five patients (11%) had multiple vessel injuries, four of which involved the aortic arch, and 18 (34%) had arteriovenous fistulae. Mortality was greatest with injuries involving the aortic arch (n = 17) and ascending aorta (n = 4) in which intra-operative exsanguination was the leading cause of death (five patients). Injuries involving the inferior and posterior walls of the aortic arch and those located between the innominate and left common carotid origins were the most difficult to control. Seven patients with aortic injuries presented with cardiac tamponade, three of whom had associated injuries involving the atria. Seven of 21 (33%) patients with aortic injuries died compared to 2 of 31 (6%) with aortic arch branch injury (p < 0.05, chi-square) for an overall mortality of 17%.

Systematic transesophageal echocardiography for detection of mediastinal lesions in patients with multiple injuries

A prospective study assessing the interest in and the results of systematic transesophageal echocardiography (TEE) examination in nonselected intubated multiple injury patients was carried out from January 1992 through June 1993. Seventy patients were included and divided into two groups according to the results of admission screening, including clinical examination, EKG, CK-MB and chest radiograph. Group 1 (60 patients) had abnormalities on initial screening, while group 2 (10 patients) had no symptom of thoracic or mediastinal injury. TEE was performed within 48 hours following admission and its results were compared with those of the initial screening. TEE usefulness was evaluated on a score grade from 0 (no interest) to 4 (outstanding interest). Myocardial contusion was suspected in 25 patients. TEE invalidated 18 suspected and found 5 unsuspected myocardial contusions. Pericardial effusion was suspected in only one case, while TEE documented 13 additional cases. A mediastinal enlargement was seen in 13 patients, but TEE invalidated aortic lesions in all these cases and made an unsuspected diagnosis of aortic tears. Eight cases of severe hypovolemia and seven cases of left ventricle dysfunction were detected by TEE. The score of interest showed that TEE allowed new interesting diagnoses in 70% of group I patients and in 33% of group II patients. TEE is of utmost importance in multiple injury patients, with or without any evidence of thoracic or mediastinal injury, providing a safe and rapid examination of the mediastinal structures and an evaluation of the hemodynamic status.

Impalement injury of the thorax: report of a case

We report herein the case of a 33-year-old man who survived an impalement injury of the thorax involving the heart, esophagus, and spinal cord. The patient was transported to our hospital with the impalement object left in situ and it was extracted under cardiopulmonary bypass in an operating room. The important principles of surgical management contributing to the successful outcome of such patients are discussed following the presentation of this case.

Gunshot wounds traversing the mediastinum: guidelines for evaluation and management

When there is suspicion that a penetrating would to the chest has crossed the midline, it is incumbent upon the medical staff to actively exclude injuries to mediastinal structures such as the heart, aortic arch, bronchial tree, and esophagus, even though injury to such structures may not be immediately clinically apparent. The successful management of a patient with a gunshot wound apparently traversing the anterior mediastinum is presented; an esophagram identified an unsuspected through-and-through injury to the esophagus. The evaluation of this patient is discussed, and an algorithm for the evaluation and management of similar patients is proposed.

Diagnosis of traumatic mediastinal hematoma with transesophageal echocardiography

In patients with blunt chest trauma, early diagnosis of mediastinal hematoma is important, because it could be associated with thoracic vessel injury. Mediastinal hematoma is generally evoked because of a widened mediastinum on chest radiograph, but radiologic diagnosis may lead to excessive angiography being performed. Transesophageal echocardiography (TEE) provides accurate views of the mediastinum and can be rapidly performed at the bedside. Thus, we conducted a prospective study to define TEE signs of mediastinal hematoma. TEE was performed in 22 thoracic trauma patients (trauma group) and in 20 brain-dead patients without thoracic trauma (control group). The positive diagnosis of mediastinal hematoma was made using thoracic surgery or computed tomographic scan. The specificity of TEE was 75 percent and sensitivity was 100 percent. In the trauma group, there was only one false positive but angiography discovered a traumatic aneurysm of the proximal right subclavian artery. No false negative was noted. We described three different TEE signs of mediastinal hematoma: (1) an increased distance between the probe and the aortic wall; (2) a double contour of the aortic wall; and (3) visualization of the ultrasound signal between the aortic wall and the visceral pleura. The distance between the esophageal probe and the aortic wall was the most accurate sign because it could be easily obtained; the threshold value for this distance was 3 mm. TEE appears to be an accurate method to diagnose traumatic mediastinal hematoma.

Transesophageal echocardiography in the evaluation of a transmediastinal gunshot wound: case report

Transesophageal echocardiography is a safe, minimally invasive imaging modality that may be useful in the evaluation of transmediastinal gunshot wounds. In this report, we describe a hemodynamically stable patient who sustained a gunshot wound to the ascending aorta. Routine diagnostic evaluation, including aortography, failed to confirm the suspected diagnosis. Transesophageal echocardiography definitively detailed the injury to the aorta enabling definitive surgical repair.

Right-sided pneumothorax as a result of a left-sided chest tube

Chest tubes are inserted for a variety of reasons, and a number of complications have been associated with their use. We report a case of traumatic hemopneumothorax in which the chest tube crossed the mediastinum into the contralateral lung causing a pneumothorax. Its position was not apparent on portable chest radiographs.

An unusual injury to the mediastinum--case report

A six-year-old boy sustained an accidental penetrating missile injury to his chest. Imaging studies revealed a metallic foreign body lodged between the pulmonary infundibulum and the right atrium of the heart. No cardiovascular compromise was produced. Surgical exploration was not required. The foreign body remained stable and non-migratory over a 16-month follow-up period.

Radiology of thoracic trauma

Trauma is the leading cause of death in people less than 40 years of age. Blunt and penetrating chest trauma mechanisms and the resultant injuries and complications are reviewed in respect to the chest wall, pleura, lungs, mediastinum, and diaphragm. Recent literature reviewed includes a useful sign of flail chest, the costal "hook sign." New evidence suggests that traumatic aortic rupture may be more common in the pediatric population than was previously reported. The diagnostic evaluation of traumatic aortic rupture continues to be controversial, with imaging modalities ranging from chest radiographs and angiography to CT, MR imaging, and transesophageal echocardiography. Recent integration of these methods has brought to the literature a newly proposed algorithm for the work-up of suspected aortic rupture. Survival and modifying factors in adult respiratory distress syndrome and a comprehensive review of esophageal disease, including trauma, are also presented.

Traumatic esophageal rupture: unusual cause of acute mediastinal widening

We have presented the case of a 32-year-old man who sustained blunt trauma to the chest in a motor vehicle accident. Plain roentgenograms showed a widened mediastinum and pneumomediastinum, and an esophagogram with water-soluble contrast material showed an esophageal laceration at the T-4 level.

ABC of major trauma. Radiological assessment--II

Images

Minitracheotomy: complications and follow-up with fibreoptic tracheoscopy

Complications and changes in tracheal mucosa after minitracheotomy were evaluated in 28 patients. Tracheal mucosa was inspected fibreoptically after the insertion of a minitracheotomy cannula, and then at 3-day intervals until the cannula was removed. Thereafter, assessments were made every third day until the mucosa was considered normal. Three significant complications occurred: mediastinal puncture, paratracheal entrance of the cannula and subcutaneous emphysema. Difficulties at insertion of the minitracheotomy cannula were encountered in 15 of 28 patients (54%). Air flow detected through the cannula in one patient, and lack of air flow in another patient, were misleading signs of the position of the cannula. Passing a suction catheter in three patients and a normal end-tidal carbon dioxide tracing in one patient, were also found to be misleading. The correct position and possible complications could be verified only by fibreoptic tracheoscopy. Changes in the tracheal mucosa were independent of the duration of minitracheotomy therapy.

Fracture of the sternum in motor vehicle accidents and its association with mediastinal injury

Sternal fractures occurred in 78 out of 2097 consecutive victims of road traffic accidents who required to attend hospital; an incidence of 3.7 per cent. They were most common in restrained, front seat vehicle occupants involved in frontal collisions, and their frequency increased with age. There was a positive association with visceral chest injury but the latter was not thought to be the cause of death in any individual. Follow-up of survivors 2-4 years later revealed potential cardiac sequelae in 6 per cent.