Imaging of Acute Thoracic Injury: The Advent of MDCT Screening

Urgent and emergent pediatric cardiovascular imaging

The need for urgent or emergent cardiovascular imaging in children is rare when compared to adults. Patients may present from the neonatal period up to adolescence, and may require imaging for both traumatic and non-traumatic causes. In children, coronary pathology is rarely the cause of an emergency unlike in adults where it is the main cause. Radiology, including chest radiography and computed tomography in conjunction with echocardiography, often plays the most important role in the acute management of these patients. Magnetic resonance imaging can occasionally be useful and may be suitable in more subacute cases. Radiologists' knowledge of how to manage and interpret these acute conditions including knowing which imaging technique to use is fundamental to appropriate care. In this review, we will concentrate on the most common cardiovascular emergencies in the thoracic region, including thoracic traumatic and non-traumatic emergencies and pulmonary vascular emergencies, as well as acute clinical disorders as a consequence of primary and postoperative congenital heart disease. This review will cover situations where cardiovascular imaging may be acutely needed, and not strictly emergencies only. Imaging recommendations will be discussed according to the different clinical presentations and underlying pathology.

Diagnostic utility of multidetector CT scan in penetrating diaphragmatic injuries: A systematic review and meta-analysis

Penetrating diaphragmatic injuries pose diagnostic and management challenges. Computed tomography (CT) scans are valuable for stable patients, but concern exists for missed injuries and complications in nonoperatively managed cases. The objective of this study was to explore the diagnostic utility of multidetector CT scan (MDCT) in identifying diaphragmatic injuries resulting from penetrating trauma. A systematic review and meta-analysis were conducted, following established guidelines, by searching PubMed, Scopus, Web of Science, and Embase databases up to July 6, 2023. Eligible studies reporting MDCT's diagnostic accuracy in detecting penetrating diaphragmatic injuries were included. Relevant data elements were extracted and analyzed using STATA software. The study included 9 articles comprising 294 patients with confirmed penetrating diaphragmatic injuries through surgical procedures. MDCT's diagnostic performance revealed a pooled sensitivity of 74% (95% CI: 56%-87%) and a pooled specificity of 92% (95% CI: 79%-97%) (Fig. two), with significant heterogeneity in both sensitivity and specificity across the studies. The Fagan plot demonstrated that higher pre-test probabilities correlated with higher positive post-test probabilities for penetrating diaphragmatic injury diagnosis using MDCT, but even with negative results, there remained a small chance of having the injury, especially in cases with higher pre-test probabilities. This study highlights MDCT's effectiveness in detecting diaphragmatic injury from penetrating trauma, with moderate to high diagnostic accuracy. However, larger sample sizes, multicenter collaborations, and prospective designs are needed to address observed heterogeneity, enhancing understanding and consistency in MDCT's diagnostic capabilities in this context.

Severe non-cardiovascular thoracic trauma: diagnostic clues on computed tomography

OBJECTIVE

About 60% of multiple trauma patients have thoracic trauma, and thoracic trauma results in the death of 10% of these patients. Computed tomography (CT) is the most sensitive and specific imaging modality for the diagnosis of acute disease, and it helps in the management and prognostic evaluation of patients with high-impact trauma. This paper aims to show the practical points that are key for diagnosing severe non-cardiovascular thoracic trauma by CT.

CONCLUSION

Knowing the key features of severe acute thoracic trauma on CT is crucial to avoid diagnostic errors. Radiologists play a fundamental role in the accurate early diagnosis of severe non-cardiovascular thoracic trauma, because the patient's management and outcome will depend largely on the imaging findings.

Imaging findings of pulmonary contusions on multidetector CT: A retrospective study comparing adults and children

To describe imaging findings of pulmonary contusions (PC) in adults and children using multidetector computed tomography (CT) scanners. We conducted a retrospective single center study. All chest multidetector computed tomography (MDCT) scans of victims of blunt trauma admitted to the emergency unit of a reference trauma center of Brazil between January 2015 and December 2016 were reviewed in search of opacities compatible with PC. The CT images were analyzed in conjunction with medical records, that provided demographic and clinical data. The obtained data were analyzed in the overall population and comparing children and adults. Significant P value was defined as <.05. 52.7% of patients presented bilateral opacities. Middle third, posterior and peripheral portions of the lungs were more frequently affected, in the craniocaudal, anteroposterior and axial axes, respectively. A vast majority of patients (80.6%) presented multiple opacities, whereas a minority showed subpleural sparing (26.9%) and fissure crossing (22.6%), with similar frequencies in children and adults. Children, although, more frequently presented consolidation and more diffuse lesions in the anteroposterior axis compared to adults, with statistically significant differences. PC usually are multiple and predominate in middle, posterior and peripheral portions of the lungs. Subpleural sparing and fissure crossing seems to be infrequent and have similar frequencies between children and adults. Although, there are differences between these age groups, as younger people tend to have more consolidation and diffuse opacities in the anteroposterior axis than older ones.

Automated Detection, Segmentation, and Classification of Pleural Effusion From Computed Tomography Scans Using Machine Learning

OBJECTIVE

This study trained and evaluated algorithms to detect, segment, and classify simple and complex pleural effusions on computed tomography (CT) scans.

MATERIALS AND METHODS

For detection and segmentation, we randomly selected 160 chest CT scans out of all consecutive patients (January 2016-January 2021, n = 2659) with reported pleural effusion. Effusions were manually segmented and a negative cohort of chest CTs from 160 patients without effusions was added. A deep convolutional neural network (nnU-Net) was trained and cross-validated (n = 224; 70%) for segmentation and tested on a separate subset (n = 96; 30%) with the same distribution of reported pleural complexity features as in the training cohort (eg, hyperdense fluid, gas, pleural thickening and loculation). On a separate consecutive cohort with a high prevalence of pleural complexity features (n = 335), a random forest model was implemented for classification of segmented effusions with Hounsfield unit thresholds, density distribution, and radiomics-based features as input. As performance measures, sensitivity, specificity, and area under the curves (AUCs) for detection/classifier evaluation (per-case level) and Dice coefficient and volume analysis for the segmentation task were used.

RESULTS

Sensitivity and specificity for detection of effusion were excellent at 0.99 and 0.98, respectively (n = 96; AUC, 0.996, test data). Segmentation was robust (median Dice, 0.89; median absolute volume difference, 13 mL), irrespective of size, complexity, or contrast phase. The sensitivity, specificity, and AUC for classification in simple versus complex effusions were 0.67, 0.75, and 0.77, respectively.

CONCLUSION

Using a dataset with different degrees of complexity, a robust model was developed for the detection, segmentation, and classification of effusion subtypes. The algorithms are openly available at https://github.com/usb-radiology/pleuraleffusion.git.

Leukocytes are not Reliable in Predicting Possible Diaphragmatic Injury in Patients with Penetrating Left Thoracoabdominal Stab Wounds

BACKGROUND

The diaphragm is injured in approximately one-third of penetrating left thoracoabdominal stab wounds. Diagnostic laparoscopy or thoracoscopy is performed to reveal the diaphragmatic injury. This study investigated whether leukocytes, leukocyte subgroups, platelets, the neutrophil-to-lymphocyte ratio (NLR), and the thrombocyte-to-lymphocyte ratio (PLR) can be used to detect diaphragm injury without the need for diagnostic laparoscopy.

METHODS

Patients hospitalized between January 2010 and January 2020 due to penetrating left thoracoabdominal stab wounds were examined. Laparotomy was performed in patients who had indications for laparotomy, such as hemodynamic instability and peritonitis. Diagnostic laparoscopy was performed to reveal possible diaphragmatic injury in patients who did not require laparotomy after 48h of follow-up. Leukocytes, leukocyte subgroups, platelets, NLR, and PLR were measured both at admission and during follow-up, and the results were compared between patients with and without diaphragm injury during diagnostic laparoscopy.

RESULTS

The study included 108 patients with penetrating left thoracoabdominal stab wounds that did not require laparotomy after 48h of follow-up. Of these, 102 patients were male (94.44%), and the average age was 27.68 years (range 15-66 years). Diaphragm injury was detected in 31 patients (28.70%) in diagnostic laparoscopy, and the diaphragm was intact in 77 patients (71.30%). In the comparison of patients with and without diaphragmatic injury, no statistically significant difference was found in terms of age, gender, platelets, leukocyte values, NLR, and PLR both at admission and during follow-up.

CONCLUSIONS

Leukocytes, leukocyte subsets, platelets, NLR, and PLR were insufficient in the detection of asymptomatic diaphragmatic injuries caused by penetrating left thoracoabdominal stab wounds.

Venovenous extracorporeal membrane oxygenation as a bridge to traumatic bronchial fistula closure

Traumatic tracheobronchial injuries occur in 1% of patients with thoracic trauma, most of them dying at the site of the trauma. In this case report, we present a 26-year-old female patient admitted to the ICU due to a blunt chest trauma causing life threatening hypoxaemia and acidosis; deciding to implant percutaneous venovenous extracorporeal membrane oxygenation. The use of percutaneous venovenous extracorporeal membrane oxygenation, implemented with a lower anticoagulation target, allowed the diagnosis and treatment of a bronchopleural fistula under conditions of respiratory and hemodynamic stability without haemorrhagic complications, obtaining a fast and adequate assistance achieving the survival of the patient.

Pericardial injury with cardiac tamponade and bleeding from the pericardium confirmed using contrast-enhanced computed tomography: a case report

BACKGROUND

Simple pericardial injuries are asymptomatic in many cases and usually do not cause bleeding that leads to cardiac tamponade. In this study, however, we report a case involving a patient with pericardial injury, in whom extravasation in the pericardium was identified using contrast-enhanced computed tomography (CT).

CASE PRESENTATION

A 67-year-old man fell from a 3-m-high ladder and was injured and transported to our hospital. No pericardial effusion was observed on focused assessment with sonography for trauma (FAST) or plain CT on arrival, but pericardial effusion was detected on follow-up observation. Thereafter, his circulatory dynamics began to deteriorate. We then performed FAST to identify the bleeding source, but it was difficult to visualize on echocardiography. Thus, contrast-enhanced CT (CECT) was performed and extravasation was confirmed in the pericardium. We believed that the accumulation of pericardial effusion caused cardiac tamponade; hence, we performed emergent thoracotomy. When we released the cardiac tamponade, his circulatory dynamics improved, and we could stabilize the patient's condition by ligating the bleeding vessel from the pericardium.

CONCLUSION

If visualization is difficult on FAST, like in this case, CECT is useful for identifying the cause of pericardial effusion if circulatory dynamics can be determined. We were able to confirm that extravasation occurred from the pericardium using CECT; hence, we could confirm that pericardial injury caused bleeding and may cause cardiac tamponade. Thus, if cardiac tamponade is suspected, not only damage to the heart itself, but also damage caused by pericardial vascular injury should be considered. Further, if circulatory dynamics are stable, CECT should be performed.

The Role of Troponin in Blunt Cardiac Injury After Multiple Trauma in Humans

BACKGROUND

The incidence of cardiac injury in immediate fatalities after blunt trauma remains underestimated, and reliable diagnostic strategies are still missing. Furthermore, clinical data concerning heart-specific troponin serum levels, injury severity score (ISS), catecholamine treatment and survival of patients on admission to the hospital have rarely been interrelated so far. Therefore, the object of the present study was to identify predictive parameters for mortality in the context of blunt cardiac injury.

METHODS

This retrospective observational study included 173 severely injured patients with an ISS ≥25 admitted to the University Hospital of Ulm, a level 1 trauma center, during 2009-2013 . Furthermore, 83 blunt trauma victims who died before hospital admission were subjected to postmortem examination at the Institute of Legal Medicine, University of Ulm, during 2009-2014. ISS, cardiac injury and associated thoracic injuries were determined in both groups. Furthermore, in the hospitalized patients, serum troponin and IL-6 levels were measured.

RESULTS

Macroscopic heart injury was observed in 18 % of the patients who died at the scene and only in 1 % of the patients admitted to the hospital, indicating that macroscopic heart injury is associated with an immediate life-threatening condition. Troponin levels were elevated in 43 % of the patients after admission to the hospital. Moreover, troponin serum concentrations were significantly higher in patients treated with norepinephrine (26.4 ± 4 ng/l) and in non-survivors (84.9 ± 22.8 ng/l) compared to patients without catecholamines and survivors, respectively.

CONCLUSIONS

Macroscopic heart injury was 20 times more frequent in non-survivors than in survivors. Serum troponin levels correlated with mortality after multiple injury and therefore may represent a valuable prognostic marker in trauma patients.

Investigation of complications secondary to chest compressions before and after the 2010 cardiopulmonary resuscitation guideline changes by using multi-detector computed tomography: a retrospective study

Background

The purpose of this study was to identify the relationship between the deeper and faster chest compressions suggested by the 2010 cardiopulmonary resuscitation guidelines and complications arising from chest compressions, using multi-detector computed tomography.

Methods

We performed a retrospective analysis of prospective registry data. This study was conducted with in- and out-of-hospital cardiac arrest patients who underwent successful resuscitation in the emergency departments of two academic tertiary care centres from October 2006 to September 2010 (pre-2010 group) and from October 2011 to September 2015 (post-2010 group). We examined chest injuries related to chest compressions, classified as follows: rib fracture, sternal fracture, and other uncommon complications.

Results

We enrolled 185 patients in this study. The most frequent complication to occur in both groups was rib fracture: 27 (62.8%) and 112 (78.9%) patients in the pre-2010 and post-2010 groups, respectively (p = 0.03). However, we observed no statistical differences in sternum fracture, the second most common complication (p = 0.80). Retrosternal and mediastinal haematoma were not reported in the pre-2010 group but 13 patients (9.1%) in the post-2010 group were reported to have haematoma (p = 0.04). Nine serious, life-threatening complications occurred, all in the post-2010 group. Among the younger group (less than 65 years old), 8 (38.1%) patients in the pre-2010 group and 40 (64.5%) in the post-2010 group sustained rib fractures.

Discussion

The deeper and faster chest compressions for enhancing ROSC are associated with increased occurrence of complications. Additional studies are needed to compensate for the limitations of our study design.

Conclusions

This study found that the 2010 guidelines, recommending deeper and faster chest compressions, led to an increased proportion of rib fractures and retrosternal and mediastinal haematoma.

Cardiac Injuries: A Review of Multidetector Computed Tomography Findings

Trauma is the leading cause of death in United States in the younger population. Cardiac trauma is common following blunt chest injuries and is associated with high morbidity and mortality. This study discusses various multidetector computed tomography (MDCT) findings of cardiac trauma. Cardiac injuries are broadly categorized into the most commonly occurring blunt cardiac injury and the less commonly occurring penetrating injury. Signs and symptoms of cardiac injury can be masked by the associated injuries. Each imaging modality including chest radiographs, echocardiography, magnetic resonance imaging and MDCT has role in evaluating these patients. However, MDCT is noninvasive; universally available and has a high spatial, contrast, and temporal resolution. It is a one stop shop to diagnose and evaluate complications of cardiac injury. MDCT is an imaging modality of choice to evaluate patients with cardiac injuries especially the injuries capable of causing hemodynamic instability.

Comparison of complications secondary to cardiopulmonary resuscitation between out-of-hospital cardiac arrest and in-hospital cardiac arrest

OBJECTIVE

The aim of this study was to assess whether there was a significant difference in the complications of cardiopulmonary resuscitation (CPR) between out-of-hospital cardiac arrest (OHCA) and in-hospital cardiac arrest (IHCA) survivors using multidetector computed tomography (MDCT).

SUBJECTS AND METHODS

We performed a retrospective analysis of prospective registry data. We enrolled both OHCA and IHCA patients who underwent successful CPR. We classified chest injuries secondary to chest compression into rib fractures, sternum fractures, and uncommon complications such as lung contusions and extrathoracic complications. We compared these complications according to CPR locations. We also analysed risk factors for CPR complications using multiple regression analysis and classification and regression tree analysis.

RESULTS

During the study period, a total of 148 patients were included in the primary analysis. Rib fractures were detected more in OHCA survivors than in IHCA survivors (74 patients (83.2%) vs. 37 patients (62.7%), p=0.05), and frequency of multiple rib fractures was higher in OHCA survivors than IHCA survivors (69 patients (77.5%) vs. 34 patients (57.6%), p=0.01). Although other complications were not significantly different between the groups, there was a trend for OHCA survivors to sustain more serious and direct high-energy related complications. Older age, longer CPR, and OHCA were significantly associated with incidence of rib fractures, multiple rib fractures, and number of rib fractures.

CONCLUSIONS

Rib fractures were more likely to occur in OHCA survivors, and serious complications tended to occur more often in OHCA compared to IHCA survivors.

Identification of Cardiac and Aortic Injuries in Trauma with Multi-detector Computed Tomography

Blunt and penetrating cardiovascular (CV) injuries are associated with a high morbidity and mortality. Rapid detection of these injuries in trauma is critical for patient survival. The advent of multi-detector computed tomography (MDCT) has led to increased detection of CV injuries during rapid comprehensive scanning of stabilized major trauma patients. MDCT has the ability to acquire images with a higher temporal and spatial resolution, as well as the capability to create multiplanar reformats. This pictorial review illustrates several common and life-threatening traumatic CV injuries from a regional trauma center.

Evaluation of diaphragm in penetrating left thoracoabdominal stab injuries: The role of multislice computed tomography

INTRODUCTION

Penetrating left thoracoabdominal stab injuries are accompanied by diaphragmatic injury in 25-30% of cases, about 30% of which later develop into diaphragmatic hernia. This study aimed to determine the role of multislice computed tomography in the evaluation of left diaphragm in patients with penetrating left thoracoabdominal stab wounds.

MATERIALS AND METHODS

This study reviewed penetrating left thoracoabdominal stab injuries managed in our clinic between April 2009 and September 2014. The thoracoabdominal region was defined as the region between the sternum, fourth intercostal space, and arcus costa anteriorly and the vertebra, lower tip of scapula, and the curve of the last rib posteriorly. Unstable cases and cases with signs of peritonitis were operated with laparotomy; the remaining patients were closely monitored. Forty-eight hours later, a diagnostic laparoscopy was applied to evaluate the left hemidiaphragma in asymptomatic patients who did not need laparotomy. The preoperatively obtained multislice thoracoabdominal computed tomography images were retrospectively examined for the presence of left diaphragm injury. Then, operative and tomographic findings were compared.

RESULTS

This study included a total of 43 patients, 39 (91%) males and 4 (9%) females of mean age 30 years (range 15-61 years). Thirty patients had normal tomography results, whereas 13 had left diaphragmatic injuries. An injury to the left diaphragm was detected during the operation in 9 (1 in laparotomy and 8 in diagnostic laparoscopy) of 13 patients with positive tomography for left diaphragmatic injury and 2 (in diagnostic laparoscopy) of 30 patients with negative tomography. Multislice tomography had a sensitivity of 82% (95% CI: 48-98%), a specificity of 88% (71-96%), a positive predictive value of 69% (39-91%), and a negative predictive value of 93% (78-99%) for detection of diaphragmatic injury in penetrating left thoracoabdominal stab injury.

CONCLUSIONS

Although diagnostic laparoscopy is the gold standard for diaphragmatic examination in patients with penetrating left thoracoabdominal stab wounds, multislice computed tomography is also valuable for detecting diaphragmatic injury.

Fatal right coronary artery rupture following blunt chest trauma: detection by postmortem selective coronary angiography

Coronary artery injury is a rare complication following blunt chest trauma (BCT), and can be fatal. Here we report findings on postmortem selective coronary angiography of right coronary artery rupture after an assault involving blunt trauma to the chest. A woman in her 60s died after her son stomped on her chest. There were no appreciable signs of injury on external examination, and cause of death could not be determined by postmortem computed tomography (PMCT). Internal findings indicated that an external force had been applied to the anterior chest, as evidenced by subcutaneous hemorrhage and pericardial and cardiac contusions. Postmortem coronary angiography revealed irregularity of the intima and of the fat tissue surrounding the proximal part of the right coronary artery associated with a local filling defect. Histopathological examination suggested coronary rupture with dissection of the tunica media and compression of the lumen cavity. The key points in the present case are that no fatal injuries could be determined on external examination, and the heart and coronary artery injuries were not evident on PMCT. Criminality might be overlooked in such cases, as external investigation at the crime scene would be inadequate and could result in a facile diagnosis of cause of death. This is the first report of coronary artery rupture with dissection that was detected by CT coronary angiography, and provides helpful findings for reaching an appropriate decision both forensically and clinically.

Cumulative effective dose associated with computed tomography examinations in adolescent trauma patients

OBJECTIVES

The aims of this study were to analyze cumulative effective dose (cED) and to assess lifetime attributable risk (LAR) of cancer due to radiation exposure during computed tomography (CT) examinations in adolescent trauma patients.

METHODS

Between January 2010 and May 2011, the adolescent patients with trauma were enrolled in this study. Numbers of CT examinations and body regions examined were collated, and cEDs were calculated using dose-length product values and conversion factors. Lifetime attributable risk for cancer incidence and cancer-associated mortality were quantified based on the studies of survivors of the atomic bombs on Japan. Data were stratified according to severity of trauma: minor trauma, injury severity score of less than 16; and major trauma, injury severity score of 16 or greater.

RESULTS

A total of 698 CT scans were obtained on the following regions of 484 adolescent patients: head CT, n = 647; rest of the body, n = 41; and thorax, n = 10. Mean cED per patient was 3.4 mSv, and mean LARs for cancer incidence and mortality were 0.05% and 0.02%, respectively. The majority of patients (98.4%) experienced minor trauma, and their mean cED and LARs for cancer incidence and mortality (3.0 mSv and 0.04% and 0.02%, respectively) were significantly lower than those of patients with major trauma (24.3 mSv and 0.31% and 0.15%, respectively, all P values < 0.001).

CONCLUSIONS

The overall radiation-induced cancer risk due to CT examinations performed for the initial assessment of minor trauma was found to be relatively low in adolescent patients. However, adolescent patients with major trauma were exposed to a substantial amount of radiation during multiple CT examinations.

Thoraco-abdominal CT examinations for evaluating cause of cardiac arrest and complications of chest compression in resuscitated patients

The objective of the study is to describe the causes of cardiac arrest and complications of cardiopulmonary resuscitation (CPR) on thoraco-abdominal CT examinations for resuscitated patients in our institution. We evaluated the causes of cardiac arrest on thoraco-abdominal CT scans, which was compared with the final diagnosis (determined by consensus of two emergency physicians based on the clinical, imaging, and laboratory findings). Additionally, we evaluated the complications of CPR on thoraco-abdominal CT scans. From March 2005 to August 2011, 82 patients underwent CT of the thorax (n=77) and abdomen (n=23) within 24 h after CPR. Final diagnosis was as follows: cardiac (n=29), respiratory (n=28), metabolic (n=11), exsanguination (n=5), cerebral (n=2), sepsis (n=1), and indeterminate (n=6). In 25 patients (30 %), thoraco-abdominal CT scans made the role either as a definitive study (n=22) or as a supportive test (n=3) for the diagnosis. In particular, CT was critical in diagnosis of many respiratory causes (64 %) and all exsanguinations. The most common complications following CPR were skeletal chest injuries (n=48), followed by lung contusion (n=45). Thoraco-abdominal CT examinations are helpful for the diagnosis of cause of cardiac arrest and complications of CPR.

Multidetector CT and radiographic findings of lung injuries secondary to cardiopulmonary resuscitation

OBJECTIVES

Lung injury is one of the complications of cardiopulmonary resuscitation (CPR). This is the first study to describe the MDCT and radiographic findings of lung injuries secondary to CPR.

METHODS

A total of 44 patients who underwent CPR for a non-traumatic cause of cardiac arrest were retrospectively included in this study. We evaluated the presence of lung injuries in the initial chest radiograph and MDCT performed immediately after CPR and described the MDCT and radiographic findings of the CPR-associated lung injuries. Finally, we evaluated the temporal pattern of lung injury on the follow-up radiographies.

RESULTS

Chest CT demonstrated lung injury in 54 lungs of 35 patients, while initial chest radiography detected lung abnormality in 37 lungs of 28 patients. The most common patterns of lung injuries on chest CT were bilateral (n=19), ground-glass opacity (n=30) and consolidation (n=26), distributed along the bronchovascular bundles (n=13). Most of the abnormalities were located in the posterior part of both upper lobes and both lower lobes (n=29). Among seven patients who did not have abnormalities in the initial chest radiograph, lung abnormalities were detected on the follow-up radiographies (mean follow-up duration=1.6 days, range=1-3 days) in five patients, and 28 patients who had lung abnormalities on initial radiograph were improved (n=19) or aggravated (n=8) on the follow-up radiographies.

CONCLUSIONS

Lung injuries are frequent complications in patients who underwent CPR. Compared with radiography, MDCT has benefits for the detection and characterisation of CPR-associated lung injuries. The most common findings of lung injuries after CPR were bilateral ground glass opacity and consolidation, usually in the dependent area of both lungs.

Multidetector computed tomography of chest trauma: indications, technique and interpretation

Background

Chest traumas are a significant cause of mortality and morbidity, especially in the younger population.MethodsDiagnostic imaging plays a key role in their management. Multidetector computed tomography (MDCT) is the most important imaging method in this field. Its advantages include especially high speed and high geometric resolution in any plane.ResultsThe method allows us to view large parts of the body with minimal motion artifacts and to create accurate multiplanar and three-dimensional (3D) reformations, which make the diagnosis significantly more accurate. Because of its advantages MDCT has become the first-choice method in high-energy traumas.ConclusionThis article summarises the position of MDCT in the diagnostic algorithm of chest injuries, technical aspects of the examination and imaging findings in traumas of the individual chest compartments.

Teaching Points

• Diagnostic imaging plays a key role in the management of high-energy chest trauma.

• MDCT is the most important imaging method in this kind of injury, as detailed information can be acquired in a short acquisition time.

• Multiplanar and three-dimensional (3D) reformattings make the diagnosis significantly more accurate.

Role of imaging in penetrating and blunt traumatic injury to the heart

Cardiac injury due to blunt or penetrating chest trauma is common and is associated with significant morbidity and mortality. Understanding the mechanisms, types, and complications of cardiac injuries and the roles of various imaging modalities in characterizing them is important for appropriate diagnosis and treatment. These injuries have not been well documented at imaging, but there are now fast and accurate methods for evaluating the heart and associated mediastinal structures. The authors review the broad spectrum of injuries that can result from blunt or penetrating trauma to the chest, as well as the imaging modalities commonly used in the acute trauma setting for evaluation of the heart and mediastinal structures. A pictorial review of both common and, to date, rarely documented cardiac injuries imaged with a variety of modalities is also presented. While many imaging modalities are available, the authors demonstrate the value of multidetector computed tomography (CT) for the initial evaluation of patients with blunt or penetrating chest trauma. With the advent of multidetector CT, imaging of cardiac injury has increased and accurate identification of these rare but potentially lethal injuries has become paramount for improving survival. Selection of the most appropriate modality for evaluation and recognition of the imaging findings in cardiac injuries in the acute trauma setting is important to expedite treatment and improve survival.

Sternal fracture in the emergency department: diagnostic value of multidetector CT with sagittal and coronal reconstruction images

BACKGROUND

Multidetector CT (MDCT) is being increasingly used for patients with traumatic injuries in the emergency room. This is the first study to evaluate the diagnostic performance of MDCT for sternal fracture.

PATIENTS AND METHODS

For 87 patients who had motor vehicle accidents, we evaluated the diagnostic performance of MDCT for the sternal fractures. For 31 patients who underwent both MDCT and lateral radiography for the sternum, we compared the diagnostic performance of two examinations for the evaluation of sternal fracture.

RESULTS

Thirty-two patients had sternal fractures and all the sternal fractures (sensitivity=100%) were detected on MDCT, especially on the sagittal reconstruction images. However, the axial and coronal images detected 65% and 59% of all sternal fractures, respectively. For 31 patients who underwent both MDCT and lateral radiography for the sternum, MDCT showed superior diagnostic performance compared to that of radiography (accuracy=97% and 77%, respectively, P=.02). For the one case that showed false positivity for sternal fracture on MDCT due to respiratory artifact, the lateral radiography enabled making the correct diagnosis.

CONCLUSION

Sternal fracture is frequently seen in patients who have blunt trauma injury secondary to motor vehicle accidents. MDCT, particularly sagittal images detect all of the sternal fractures, is superior to lateral radiography for diagnosis of sternal fracture. In the limited case that CT has severe motion artifact, additional radiography could help the diagnosis of sternal fracture.

Multidetector CT findings of skeletal chest injuries secondary to cardiopulmonary resuscitation

INTRODUCTION

Rib and sternal fractures are frequent complications of cardiopulmonary resuscitation (CPR) in adults. This is the first study to evaluate the MDCT findings of chest injuries secondary to CPR, by comparing with the findings of radiography.

METHODS

For 40 patients who underwent MDCT after CPR for a non-traumatic cause of cardiac arrest, we evaluated the MDCT findings of the CPR associated traumatic chest injuries and compared the diagnostic performance of chest radiography and MDCT for the evaluation of chest injuries.

RESULTS

MDCT revealed that 26 patients (65%) had rib fractures and 12 patients (30%) had sternal fractures. However, radiography detected only 10 patients who had rib fractures. In 25 of the 26 cases, multiple ribs were fractured (ranging up to 13 rib fractures), and the rib fractures were bilateral in 18 of these cases. The majority of rib fractures were located in the anterior part of the thoracic cage. Six of the patients had fracture-related complications (pneumothorax=1, subclavian vein injury=1, chest wall hematoma=4). The sternal fractures predominantly occurred in the middle and lower third of the sternal body (five each for the middle and lower third of the sternal body).

CONCLUSION

Rib and sternal fractures are frequent complications in patients who underwent CPR. MDCT is useful for the evaluation of chest injuries secondary to CPR as compared with that of radiography and also for the evaluation of the fracture-related complications.

CT imaging of blunt chest trauma

BACKGROUND: Thoracic injury overall is the third most common cause of trauma following injury to the head and extremities. Thoracic trauma has a high morbidity and mortality, accounting for approximately 25% of trauma-related deaths, second only to head trauma. More than 70% of cases of blunt thoracic trauma are due to motor vehicle collisions, with the remainder caused by falls or blows from blunt objects. METHODS: The mechanisms of injury, spectrum of abnormalities and radiological findings encountered in blunt thoracic trauma are categorised into injuries of the pleural space (pneumothorax, hemothorax), the lungs (pulmonary contusion, laceration and herniation), the airways (tracheobronchial lacerations, Macklin effect), the oesophagus, the heart, the aorta, the diaphragm and the chest wall (rib, scapular, sternal fractures and sternoclavicular dislocations). The possible coexistence of multiple types of injury in a single patient is stressed, and therefore systematic exclusion after thorough investigation of all types of injury is warranted. RESULTS: The superiority of CT over chest radiography in diagnosing chest trauma is well documented. Moreover, with the advent of MDCT the imaging time for trauma patients has been significantly reduced to several seconds, allowing more time for appropriate post-diagnosis care. CONCLUSION: High-quality multiplanar and volumetric reformatted CT images greatly improve the detection of injuries and enhance the understanding of mechanisms of trauma-related abnormalities.

[Principles of reanimation in managing thoracic injuries]

<zakljucak> Bez obzira na tezinu povreda grudnog kosa vecini povredjenih moze se pomoci ako se povrede prepoznaju na vreme i ako se, pre svega, na vreme preduzmu reanimacijske mere i pruzi odgovarajuca prva pomoc. Primenom reanimacijskih mera stvaraju se uslovi za ocuvanje vitalnih funkcija povredjenih i primenu ostalih vidova lecenja. Tako shvacen koncept zbrinjavanja povreda grudnog kosa predstavlja kontinuiran i dinamican proces u toku koga se stalno preplicu inicijalni pregled, procena stanja povredjenog, primena reanimacijskih mera i hirursko lecenje, uz stalnu procenu efekta reanimacije i preduzetog lecenja.

Blunt traumatic injuries of the lung parenchyma, pleura, thoracic wall, and intrathoracic airways: multidetector computer tomography imaging findings

This pictorial review discusses multi-detector computed tomography (MDCT) cases of non-vascular traumatic chest injuries, with a brief clinical and epidemiological background of each of the pathology. The purpose of this review is to familiarize the reader with common and rare imaging patterns of chest trauma and substantiate the advantages of MDCT as a screening and comprehensive technique for the evaluation of these patients. Images from a level 1 trauma center were reviewed to illustrate these pathologies. Pulmonary laceration, pulmonary hernia, and their different degrees of severity are illustrated as examples of parenchymal traumatic lesions. Pleural space abnormalities (pneumothorax and hemothorax) and associated complications are shown. Diaphragmatic rupture, fracture of the sternum, sternoclavicular dislocation, fracture of the scapula, rib fracture, and flail chest are shown as manifestations of blunt trauma to the chest wall. Finally, direct and indirect imaging findings of intrathoracic airway rupture and post-traumatic foreign bodies are depicted. The advantage of high quality reconstructions, volume rendered images, and maximal intensity projection for the detection of severe complex traumatic injuries is stressed. The limitations of the initial chest radiography and the benefits of MDCT authenticate this imaging technique as the best modality in the diagnosis of chest trauma.

Imaging hemidiaphragmatic injury

The supine chest radiograph is the initial and most commonly performed imaging study to evaluate the thorax after trauma. Whenever the chest radiograph is equivocal or suspicious for acute diaphragmatic injury (DI), computed tomography (CT) is usually the next study of choice since it is both generally available and often used to examine other body regions in the patient after trauma. CT is usually diagnostic, particularly if supplemented by multiplanar reformation (MPR) obtained using thin-slice axial scanning and overlapping images for reformations. Magnetic resonance imaging (MRI) is potentially useful to assess the diaphragm if CT findings are indeterminate and the patient is stable enough to have the procedure. Simple T1-weighted spin-echo images in the sagittal and coronal orientation are usually sufficient to establish or exclude DI. This article reviews imaging modalities and strategies for diagnosing DI from blunt trauma.

Diaphragmatic rupture: a frequently missed injury in blunt thoracoabdominal trauma patients

In the US and Western Europe, trauma is the fourth most common cause of death and the leading cause of death in the population less than 45 years of age [Mullinix and Foley, J Comput Assist Tomogr 28(Suppl 1):S20-S27, 2004]. Diaphragmatic injuries occur in 0.8 to 8% of patients after blunt trauma (Gray H, The muscles of the thorax. Anatomy of the human body. Lea & Febiger, Philadelphia, 1918) and may be a predictor of severity of injury in the blunt trauma patient [Worthy et al., Radiology 194(3):885-888, 1995]. The clinical diagnosis of diaphragmatic rupture (DR) is difficult and is missed in anywhere from 7 to 66% of patients [Cantwell, Radiology 238(2):752-753, 2006]. The accurate diagnosis and prognosis of this pathology depend on a complete knowledge of the clinical and radiological presentation. Computed tomography is the imaging modality of choice in the assessment of patients with clinical or radiographic findings suggestive of DR.