Transcript chestpage3.ppt

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The challenges associated with accurately •
diagnosing diaphragmatic rupture with MDCT
include the complex shape of the thin
diaphragmatic muscle, the horizontal in-plane
orientation of the diaphragmatic dome, and the
frequency of associated traumatic
abnormalities in the lung bases. •
Direct discontinuity of a hemidiaphragm (see Fig. •
11), which may allow herniation of intraabdominal mesenteric fat, parenchymal organs,
or viscera, is the most sensitive imaging finding of
diaphragmatic rupture. •
The “hourglass” or “collar” sign refers to the waist-like •
constriction of partially herniated viscera by the edges
of a small diaphragmatic defect.
On the right side, the same mechanism can appear as a •
focal indentation of the liver, termed the “rim” sign,
which may be subtle and easily overlooked on axial
images.
Detection of this sign requires careful analysis of axial •
images as well as the sagittal and coronal multiplanar
reformatted images.
The “dependent viscera” sign describes the close •
contact of the herniated stomach or liver with the
posterior chest wall, with no diaphragmatic leaflet
holding it up against gravity, and lack of normal
interposition of aerated lung tissue posteriorly.
Given the difficulty of reaching an accurate diagnosis, •
many patients are not diagnosed in the acute setting,
possibly as many as 40% to 50%.
A delayed diagnosis is often made days, weeks, or even •
years later, frequently with a complication of visceral
herniation.
IMAGING ALGORITHMS
When one endeavors to devise an appropriate •
imaging algorithm for the investigation of the
child who has suffered chest trauma, three
key factors have to be considered. First, the
imaging modalities used should be as quick
and as accurate as possible. Second, the result
of these tests should positively direct patient
management and help dictate treatment
Finally, the nature of the investigative tools •
should not have any negative effect on the child’s
health or, at least, that effect should be
minimized.
Whereas the natural inclination would be to •
immediately use the most accurate and sensitive
test, thereby satisfying the first criterion, one has
to carefully consider whether such a choice
affects the other criteria positively or negatively.
MDCT is more sensitive than chest •
radiography for a multitude of chest injuries.
Rib fracture, pneumothorax, hemothorax,
pulmonary contusion and laceration,
diaphragmatic rupture, and vascular injuries
are all more accurately diagnosed with MDCT
Furthermore, MDCT is quick and readily •
available in most trauma units.
The arrival of an injured child in the trauma room •
is an upsetting event for all involved. Therefore, it
is understandable that caregivers might choose a
CT scan as their first choice investigation so as to
diagnose all injuries within the shortest possible
time frame. The potential advantages seem clear;
not only is MDCT accurate, but a complete
contiguous head-through-pelvis scan may be
performed in less than a minute, without the
need for repositioning of the critically injured
patient
The dose from a single continuous total-body scan is •
less than the individual components performed
separately,
although this in itself should not be used as a reason •
to include all body segments in the CT scan.
The volumetric data set acquired with MDCT allows for •
multiplanar reconstructions, better demonstrating
both soft tissue and skeletal injuries, and potentially
foregoing the need for other radiographs, which might
require multiple projections.
Such total body scanning is advocated by •
many investigators for the adult population,
but one needs to be more cautious before •
employing a similar policy for children, taking
into consideration the second and third
criteria outlined above.
With respect to the second criterion, one needs •
to consider whether the supplemental
information provided by a CT scan, over and
above the findings on chest radiography,
substantially alter patient management.
In a study on chest trauma in an adult population •
by Trupka and colleagues, the routine addition of
a CT scan to chest radiography did not alter
patient management in 59% injuries.
A more recent adult study reported that the routine •
use of a CT scan in chest trauma resulted in a greater
number of additional diagnoses in 43%, but resulted in
a change in patientmanagement in just 17%.
Moreover, in a recent pediatric study, most •
intrathoracic findings requiring surgical management
could be identified on images of the lower chest that
are part of routine abdominopelvic CT scan
examinations, and chest CT scan findings added
relatively little to those of radiography.
Therefore, rather then •
routinely” scanning all potential chest trauma
patients, a more selective approach guided by the
nature and severity of the trauma, clinical
parameters,101 and chest radiographic findings is
more prudent.
This selective approach has been shown to
increase the incidence of clinically significant
findings demonstrated by a CT scan that actually
alter patient management.
Given the relative infrequency of serious •
cardiovascular and diaphragmatic injuries in
children, most abnormalities detected with a
CT scan that may affect patient management
relate to pneumothoraces and complications
of chest tube placement.
Although most radiographically occult •
pneumothoraces that are detected with a CT
scan do not require chest tube placement,
if left untreated, they might expand and/or •
develop into a tension pneumothorax
following the institution of positive pressure
ventilation. For this reason, a chest CT scan is
nearly always indicated in children whose
chest injury is severe enough to require
mechanical ventilation.
In our era of escalating medical costs, one also •
has to take into account the cost-effectiveness of
expensive imaging resource use
. Renton and colleagues103 reported that if CT •
scans were to replace the chest radiograph as the
primary tool for investigating pediatric chest
trauma, 200 studies would need to be performed
to detect one clinically significant finding,
incurring a hospital
cost of $39,600 and a patient cost of $180,000.
The current medico-legal climate, which •
encourages defensive medicine, likely results
in the over-use of CT scans, ignoring the fact
tha many of the injuries demonstrated do not
affect patient management or treatment.
Another potential problem with performing CT scans is
the risk of detecting “pseudodisease” and clinically
unimportant findings as a result of overinterpretation
of the CT scan images
. This may influence clinicians to perform costly and
sometimes invasive additional imaging tests and
treatments that are unnecessary, which can lead to
iatrogenic complications as well as added expense
.
In the era before the implementation of CT scans, this
pseudodisease would have simply remained unnoticed,
without adverse effect on patient outcome
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Finally, one must consider the third criterion, •
which is that of radiation carcinogenesis and
teratogenesis resulting from the indiscriminate
use of CT scans.
For a discussion of these risks and their •
significance, see the article by Donald Frush
elsewhere in this issue. The challenge in imaging
pediatric chest trauma is to incorporate all of
these complex issues in an attempt to derive an
appropriate imaging algorithm.
The authors believe that the initial imaging •
evaluation of pediatric trauma should consist
of the conventional trauma series (lateral
cervical spine in collar, AP pelvis, and chest
radiographs).
The sensitivity of the conventional •
radiographic series may be increased by
implementing a novel fullbody digital
radiograph system.
The initial radiographic findings should be •
interpreted in conjunction with a careful and
rapid triage by an experienced clinician, taking
the mechanism and force of injury into account.
This will determin the need for additional •
imaging. If cross-sectional imaging is required, a
CT scan is not the only option.
Ultrasound has been used to demonstrate •
pleural effusions, hemothorax, pneumothorax,
pulmonary contusions, pericardial tamponade,
and even sternal fractures.
Although ultrasound is frequently more time •
consuming than CT scanning, the clinical situation
may allow for it and spare the patient
unnecessary radiation.
However, the exact place of FAST ultrasound11,12 •
in the diagnostic algorithm of trauma, in
particular with regard to the qualifications of its
practitioners and the optimal technique, remains
somewhat controversial at this time.
eventually
undergo a CT scan focused on the area of
impact, because the risk of occult internal injury
is high in these patients. Unconscious patients
and those with suspicion for unstable cervical
spine fractures will generally undergo a CT scan
of the head and cervical spine. Factors that influence
the decision to perform more extensive CT
scanning include the severity of the injuries
demonstrated on the initial radiographic trauma
series, the degree of respiratory compromise,
and the presence of hemodynamic instability.
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If
a thoracic spine fracture is clinically suspected or
demonstrated on the initial radiographic survey,
a CT scan should be performed, with coronal
and sagittal reformatted images. Fractures of the
upper ribs, shoulder girdle, and sternum will often
necessitate a contrast-enhanced CT scan to look
for vascular injury. If there is persistent hemorrhagic
output from chest tubes or there is
radiographic evidence for progressive pneumomediastinum,
a CT scan is indicated to look for
bronchial and/or vascular injury. Although traumatic
aortic injury in children remains rare, the
associated high mortality dictates that a high index
of suspicion should be maintained for this condition:
unexplained hemodynamic compromise or
an abnormal mediastinum on chest radiography
would indicate the need for an emergent CT
angiogram.
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SUMMARY
Given the heterogeneous nature of pediatric chest
trauma, the optimal imaging approach is one
tailored to the specific patient. Chest radiography
remains the most important imaging modality for
initial triage. Although the role of ultrasound in the
setting of trauma is currently somewhat controversial,
it may suffice in specific circumstances. The
decision to perform a chest CT scan should be
dictated by the nature of the trauma,
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the clinical condition of the child, and the initial •
radiographic findings, taking the age-related, pretest
probabilities of serious injury into account.
In the conscious pediatric polytrauma patient who has •
a normal neurologic function, is not in respiratory
failure, has no signs of hemodynamic instability, and
who has a normal appearance of the mediastinum on
the initial radiograph, there is sufficient evidence to
support that a chest CT scan be withheld initially.
If an abdominal CT scan is done for initial evaluation, •
proper attention should be paid to injuries that are
visible in the lower thorax (including the
diaphragm). Chest CT scanning is particularly important in children
with chest trauma when hemodynamic instability or respiratory
failure requiring intubation develops, or when there is persistent
drainage of blood or air from chest tubes, suspicion for chest tube
malfunction, or a progressive pneumomediastinum
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In the unconscious polytrauma patient, the performance of a
contiguous, headthrough- pelvis MDCT may be considered
. Whenever a CT scan is performed, the principles of as low as
reasonably achievable (ALARA) and “Image Gently” should be
adhered to. Radiologists should be actively involved in trauma care.
Continued education and close communication between
radiologists and the clinical care team are essential to optimize
patient care.
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REFRENCES
1. Bliss D, Silen M. Pediatric thoracic trauma. Crit
Care Med 2002;30(Suppl 11):S409–15.
2. Cooper A, Barlow B, DiScala C, et al. Mortality and
truncal injury: the pediatric perspective. J Pediatr
Surg 1994;29(1):33–8.
3. Sartorelli KH, Vane DW. The diagnosis and
management of children with blunt injury of the
chest. Semin Pediatr Surg 2004;13(2):98–105.
4. Westra SJ, Wallace EC. Imaging evaluation of pediatric
chest trauma. Radiol Clin North Am 2005;
43(2):267–81.
•
•
•
•
•
•
•
•
•
•
•
5. Moore MA, Wallace EC, Westra SJ. The imaging of
paediatric thoracic trauma. Pediatr Radiol 2009;
39(5):485–96.
6. Furnival R. Controversies in pediatric thoracic and
abdominal trauma. Clin Pediatr Emerg Med 2001;
2(1):48–62.
7. Tovar JA. The lung and pediatric trauma. Semin
Pediatr Surg 2008;17(1):53–9.
8. Nakayama DK, Ramenofsky ML, Rowe MI. Chest
injuries in childhood. Ann Surg 1989;210(6):770–5.
9. Shah CC, Ramakrishnaiah RH, Bhutta ST, et al.
Imaging findings in 512 children following allterrain
vehicle injuries. Pediatr Radiol 2009;39(7):
677–84.
•
•
•
•
•
•
•
•
•
•
•
•
•
•
10. McEwan K, Thompson P. Ultrasound to detect haemothorax
after chest injury. Emerg Med J 2007;
24(8):581–2.
11. Patel NY, Riherd JM. Focused assessment with
sonography for trauma: methods, accuracy, and
indications. Surg Clin NorthAm2011;91(1):195–207.
12. Korner M, Krotz MM, Degenhart C, et al. Current
role of emergency US in patients with major
trauma. Radiographics 2008;28(1):225–42.
13. Jin W, Yang DM, Kim HC, et al. Diagnostic values of
sonography for assessment of sternal fractures
compared with conventional radiography and bone
scans. J Ultrasound Med 2006;25(10):1263–8
[quiz: 1269–70].
•
•
•
•
•
•
•
•
•
•
•
•
•
•
14. Lichtenstein DA, Meziere G, Lascols N, et al. Ultrasound
diagnosis of occult pneumothorax. Crit Care
Med 2005;33(6):1231–8.
15. Rocco M, Carbone I, Morelli A, et al. Diagnostic
accuracy of bedside ultrasonography in the ICU:
feasibility of detecting pulmonary effusion and
lung contusion in patients on respiratory support
after severe blunt thoracic trauma. Acta Anaesthesiol
Scand 2008;52(6):776–84.
16. Soldati G, Testa A, Sher S, et al. Occult traumatic
pneumothorax: diagnostic accuracy of lung ultrasonography
in the emergency department. Chest
2008;133(1):204–11.
•
•
•
•
•
•
•
•
•
•
•
•
•
17. Testerman GM. Surgeon-performed ultrasound in
the diagnosis and management of pericardial tamponade
in a 20-month-old blunt injured toddler.
Tenn Med 2006;99(6):37–8.
18. Singh S, Kalra MK, Moore MA, et al. Dose reduction
and compliance with pediatric CT protocols
adapted to patient size, clinical indication, and
number of prior studies. Radiology 2009;252(1):
200–8.
19. Silva AC, Lawder HJ, Hara A, et al. Innovations in
CT dose reduction strategy: application of the
adaptive statistical iterative reconstruction algorithm.
AJR Am J Roentgenol 2010;194(1):191–9.
20. Garcia VF, Gotschall CS, Eichelberger MR, et al.
Rib fractures in children: a marker of severe
trauma. J Trauma 1990;30(6):695–700.
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
21. Donnelly LF, Frush DP. Abnormalities of the chest
wall in pediatric patients. AJR Am J Roentgenol
1999;173(6):1595–601.
22. Barsness KA, Cha ES, Bensard DD, et al. The positive
predictive value of rib fractures as an indicator
of nonaccidental trauma in children. J Trauma
2003;54(6):1107–10.
23. Kleinman PK, Schlesinger AE. Mechanical factors
associated with posterior rib fractures: laboratory
and case studies. Pediatr Radiol 1997;27(1):
87–91.
24. Livingston DH, Shogan B, John P, et al. CT diagnosis
of rib fractures and the prediction of acute
respiratory failure. J Trauma 2008;64(4):905–11.
•
•
•
•
•
•
•
•
•
•
•
•
•
•
25. Cadzow SP, Armstrong KL. Rib fractures in infants:
red alert! The clinical features, investigations and
child protection outcomes. J Paediatr Child Health
2000;36(4):322–6.
26. Hall A, Johnson K. The imaging of paediatric
thoracic trauma. Paediatr Respir Rev 2002;3(3):
241–7.
27. Rozycki GS, Tremblay L, Feliciano DV, et al.
A prospective study for the detection of vascular
injury in adult and pediatric patients with cervicothoracic
seat belt signs. J Trauma 2002;52(4):
618–23 [discussion: 623–4].
•
•
•
•
•
•
•
•
•
•
•
•
28. Pawar RV, Blacksin MF. Traumatic sternal segment
dislocation in a 19-month-old. Emerg Radiol 2007;
14(6):435–7.
29. Lomoschitz FM, Eisenhuber E, Linnau KF, et al.
Imaging of chest trauma: radiological patterns of
injury and diagnostic algorithms. Eur J Radiol
2003;48(1):61–70.
30. el-Khoury GY, Whitten CG. Trauma to the upper
thoracic spine: anatomy, biomechanics, and
unique imaging features. AJR Am J Roentgenol
1993;160(1):95–102.
31. van Beek EJ, Been HD, Ponsen KK, et al. Upper
thoracic spinal fractures in trauma patients - a diagnostic
pitfall. Injury 2000;31(4):219–23.
32. Slimane MA, Becmeur F, Aubert D, et al. Tracheobronchial
ruptures from blunt thoracic trauma in
children. J Pediatr Surg 1999;34(12):1847–50.
33. Chan O, Hiorns M. Chest trauma. Eur J Radiol
1996;23(1):23–34.
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
34. Bridges KG, Welch G, Silver M, et al. CT detection
of occult pneumothorax in multiple trauma patients.
J Emerg Med 1993;11(2):179–86.
35. Holmes JF, Brant WE, Bogren HG, et al. Prevalence
and importance of pneumothoraces visualized
on abdominal computed tomographic scan
in children with blunt trauma. J Trauma 2001;
50(3):516–20.
36. Ouellet JF, Trottier V, Kmet L, et al. The OPTICC
trial: a multi-institutional study of occult pneumothoraces
in critical care. Am J Surg 2009;197(5):
581–6.
37. Grisoni ER, Volsko TA. Thoracic injuries in children.
Respir Care Clin N Am 2001;7(1):25–38.
38. Taylor GA, Kaufman RA, Sivit CJ. Active hemorrhage
in children after thoracoabdominal trauma:
clinical and CT features. AJR Am J Roentgenol
1994;162(2):401–4.
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
39. Balci AE, Kazez A, Eren S, et al. Blunt thoracic
trauma in children: review of 137 cases. Eur J Cardiothorac
Surg 2004;26(2):387–92.
40. Allen GS, Cox CS Jr, Moore FA, et al. Pulmonary
contusion: are children different? J Am Coll Surg
1997;185(3):229–33.
41. Allen GS, Cox CS Jr. Pulmonary contusion in children:
diagnosis and management. South Med J
1998;91(12):1099–106.
42. Elmali M, Baydin A, Nural MS, et al. Lung parenchymal
injury and its frequency in blunt thoracic
trauma: the diagnostic value of chest radiography
and thoracic CT. Diagn Interv Radiol 2007;13(4):
179–82.
43. Schild HH, Strunk H, Weber W, et al. Pulmonary
contusion: CT vs plain radiograms. J Comput
Assist Tomogr 1989;13(3):417–20.
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
44. Kwon A, Sorrells DL Jr, Kurkchubasche AG, et al.
Isolated computed tomography diagnosis of
pulmonary contusion does not correlate with
increased morbidity. J Pediatr Surg 2006;41(1):
78–82 [discussion: 78–82].
45. Deunk J, PoelsTC, Brink M,et al. Theclinicaloutcome
of occult pulmonary contusion on multidetector-row
computed tomography in blunt trauma patients.
J Trauma 2010;68(2):387–94.
46. Wagner RB, Jamieson PM. Pulmonary contusion.
Evaluation and classification by computed tomography.
Surg Clin North Am 1989;69(1):31–40.
47. Donnelly LF, Klosterman LA. Subpleural sparing:
a CT finding of lung contusion in children. Radiology
1997;204(2):385–7.
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
48. Peclet MH, Newman KD, Eichelberger MR, et al.
Thoracic trauma in children: an indicator of
increased mortality. J Pediatr Surg 1990;25(9):
961–5 [discussion: 965–6].
49. StathopoulosG,Chrysikopoulou E,KalogeromitrosA,
et al. Bilateral traumatic pulmonary pseudocysts:
case report and literature review. J Trauma 2002;
53(5):993–6.
50. Tsitouridis I, Tsinoglou K, Tsandiridis C, et al. Traumatic
pulmonary pseudocysts: CT findings.
J Thorac Imaging 2007;22(3):247–51.
51. Wintermark M, Schnyder P. The Macklin effect:
a frequent etiology for pneumomediastinum in
severe blunt chest trauma. Chest 2001;120(2):
543–7.
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
52. Bars N, Atlay Y, Tulay E, et al. Extensive subcutaneous
emphysema and pneumomediastinum
associated with blowout fracture of the medial
orbital wall. J Trauma 2008;64(5):1366–9.
53. Marwan K, Farmer KC, Varley C, et al. Pneumothorax,
pneumomediastinum, pneumoperitoneum,
pneumoretroperitoneum and subcutaneous emphysema
following diagnostic colonoscopy. Ann R
Coll Surg Engl 2007;89(5):W20–1.
54. Chapdelaine J, Beaunoyer M, Daigneault P, et al.
Spontaneous pneumomediastinum: are we overinvestigating?
J Pediatr Surg 2004;39(5):681–4.
•
•
•
•
•
•
•
•
•
•
•
•
55. Jackimczyk K. Blunt chest trauma. Emerg Med Clin
North Am 1993;11(1):81–96.
56. Harvey-Smith W, Bush W, Northrop C. Traumatic
bronchial rupture. AJR Am J Roentgenol 1980;
134(6):1189–93.
57. Ein SH, Friedberg J, Shandling B, et al. Traumatic
bronchial injuries in children. Pediatr Pulmonol
1986;2(1):60–4.
58. Mahboubi S, O’Hara AE. Bronchial rupture in children
following blunt chest trauma. Report of five
cases with emphasis on radiologic findings. Pediatr
Radiol 1981;10(3):133–8.
•
•
•
•
•
•
•
•
•
•
•
•
59. Hrkac Pustahija A, Vukelic Markovic M, Ivanac
G,
et al. An unusual case of bronchial rupture—
pneumomediastinum
appearing 7 days after blunt chest
trauma. Emerg Radiol 2009;16(2):163–5.
60. Ozdulger A, Cetin G, Erkmen Gulhan S, et al.
A review of 24 patients with bronchial ruptures: is
•
•
•
•
•
•
delay in diagnosis more common in children? Eur J
Cardiothorac Surg 2003;23(3):379–83.
61. Scaglione M, Romano S, Pinto A, et al. Acute
tracheobronchial injuries: impact of imaging on
diagnosis and management implications. Eur J
Radiol 2006;59(3):336–43.
62. Le Guen M, Beigelman C, Bouhemad B, et al. Chest
computed tomography with multiplanar reformatted
images for diagnosing traumatic bronchial rupture:
a case report. Crit Care 2007;11(5):R94.
63. Wan YL, Tsai KT, Yeow KM, et al. CT findings of
bronchial transection. Am J Emerg Med 1997;
15(2):176–7.
•
•
•
•
•
•
•
•
•
•
•
•
•
64. Sinclair DS. Traumatic aortic injury: an imaging
review. Emerg Radiol 2002;9(1):13–20.
65. Heckman SR, Trooskin SZ, Burd RS. Risk factors
for blunt thoracic aortic injury in children.
J Pediatr Surg 2005;40(1):98–102.
66. Spouge AR, Burrows PE, Armstrong D, et al. Traumatic
aortic rupture in the pediatric population.
Role of plain film, CT and angiography in the diagnosis.
Pediatr Radiol 1991;21(5):324–8.
67. Trachiotis GD, Sell JE, Pearson GD, et al. Traumatic
thoracic aortic rupture in the pediatric patient. Ann
Thorac Surg 1996;62(3):724–31 [discussion: 731–2].
68. Buffo-Sequeira I, Fraser DD. Widened mediastinum
in a child with severe trauma. CMAJ 2007;177(10):
1181–2.
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
69. Gschwentner M, Gruber G, Oberladstatter J, et al.
Mediastinal widening after blunt chest trauma in
a child: a very rare case of thymic bleeding in
a child and possible differential diagnosis. J Trauma
Inj Infect Crit Care 2007;63(2):E51–4.
70. Lowe LH, Bulas DI, Eichelberger MD, et al. Traumatic
aortic injuries in children: radiologic evaluation.
AJR Am J Roentgenol 1998;170(1):39–42.
71. Bertrand S, Cuny S, Petit P, et al. Traumatic rupture
of thoracic aorta in real-world motor vehicle
crashes. Traffic Inj Prev 2008;9(2):153–61.
72. Mirvis SE, Bidwell JK, Buddemeyer EU, et al. Value
of chest radiography in excluding traumatic aortic
rupture. Radiology 1987;163(2):487–93.
73. Anderson SA, Day M, Chen MK, et al. Traumatic
aortic injuries in the pediatric population.
J Pediatr Surg 2008;43(6):1077–81.
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
74. Ng CJ, Chen JC, Wang LJ, et al. Diagnostic value
of the helical CT scan for traumatic aortic injury:
correlation with mortality and early rupture.
J Emerg Med 2006;30(3):277–82.
75. Sammer M, Wang E, Blackmore CC, et al. Indeterminate
CT angiography in blunt thoracic trauma: is
CT angiography enough? AJR Am J Roentgenol
2007;189(3):603–8.
76. Pabon-Ramos WM, Williams DM, Strouse PJ.
Radiologic evaluation of blunt thoracic aortic injury
in pediatric patients. AJR Am J Roentgenol 2010;
194(5):1197–203.
•
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•
•
•
•
•
•
•
•
•
•
77. Markarian MK, MacIntyre DA, Cousins BJ, et al.
Adolescent pneumopericardium and pneumomediastinum
after motor vehicle crash and ejection.
Am J Emerg Med 2008;26(4):515.e511–2.
78. Dowd MD, Krug S. Pediatric blunt cardiac injury:
epidemiology, clinical features, and diagnosis.
Pediatric Emergency Medicine Collaborative Research
Committee: Working Group on Blunt Cardiac
Injury. J Trauma Inj Infect Crit Care 1996;
40(1):61–7.
79. Murillo CA, Owens-Stovall SK, Kim S, et al. Delayed
cardiac tamponade after blunt chest trauma in
a child. J Trauma Inj Infect Crit Care 2002;52(3):
573–5.
•
•
•
•
•
•
•
•
•
•
•
•
•
•
80. Sakka SG, Huettemann E, Giebe W, et al. Late
cardiac arrhythmias after blunt chest trauma. Intensive
Care Med 2000;26(6):792–5.
81. Palacio D, Swischuk L, Chung D, et al. Posttraumatic
ventricular pseudoaneurysm in a 7-year-old
child diagnosed with multidetector CT of the chest:
a case report. Emerg Radiol 2007;14(6):431–3.
82. Eren S, Kantarci M, Okur A. Imaging of diaphragmatic
rupture after trauma. Clin Radiol 2006;
61(6):467–77.
83. Ramos CT, Koplewitz BZ, Babyn PS, et al. What have
we learned about traumatic diaphragmatic hernias
in children? J Pediatr Surg 2000;35(4):601–4.
•
•
•
•
•
•
•
•
•
•
•
•
•
84. Sharma AK, Kothari SK, Gupta C, et al. Rupture of
the right hemidiaphragm due to blunt trauma in
children: a diagnostic dilemma. Pediatr Surg Int
2002;18(2–3):173–4.
85. Soundappan SV, Holland AJ, Cass DT, et al. Blunt
traumatic diaphragmatic injuries in children. Injury
2005;36(1):51–4.
86. Iochum S, Ludig T, Walter F, et al. Imaging of diaphragmatic
injury: a diagnostic challenge? Radiographics
2002;22(Spec No):S103–16 [discussion:
S116–8].
87. Mihos P, Potaris K, Gakidis J, et al. Traumatic
rupture of the diaphragm: experience with 65
patients. Injury 2003;34(3):169–72.
•
•
•
•
•
•
•
•
•
•
•
•
•
•
88. Nchimi A, Szapiro D, Ghaye B, et al. Helical CT of
blunt diaphragmatic rupture. AJR Am J Roentgenol
2005;184(1):24–30.
89. Bodanapally UK, Shanmuganathan K, Mirvis SE,
et al. MDCT diagnosis of penetrating diaphragm
injury. Eur Radiol 2009;19(8):1875–81.
90. Alper B, Vargun R, Kologlu MB, et al. Late presentation
of a traumatic rupture of the diaphragm with
gastric volvulus in a child: report of a case. Surg
Today 2007;37(10):874–7.
91. Shanmuganathan K, Mirvis SE. Imaging diagnosis
of nonaortic thoracic injury. Radiol Clin North Am
1999;37(3):533–51.
92. Sivit CJ, Taylor GA, Eichelberger MR. Chest injury
in children with blunt abdominal trauma: evaluation
with CT. Radiology 1989;171(3):815–8.
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
93. Ptak T, Rhea JT, Novelline RA. Radiation dose is
reduced with a single-pass whole-body multidetector
row CT trauma protocol compared with
a conventional segmented method: initial experience.
Radiology 2003;229(3):902–5.
94. Griffey RT, Ledbetter S, Khorasani R. Changes in
thoracolumbar computed tomography and radiography
utilizationamong traumapatients after deployment
of multidetector computed tomography in the
emergency department. J Trauma Inj Infect Crit
Care 2007;62(5):1153–6.
95. Kessel B, Sevi R, Jeroukhimov I, et al. Is routine
portable pelvic X-ray in stable multiple trauma
patients always justified in a high technology era?
Injury 2007;38(5):559–63.
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
96. Anderson SW, Lucey BC, Varghese JC, et al. Sixtyfour
multi-detector row computed tomography in
multitrauma patient imaging: early experience.
Curr Probl Diagn Radiol 2006;35(5):188–98.
97. Self ML, Blake AM, Whitley M, et al. The benefit of
routine thoracic, abdominal, and pelvic computed
tomography to evaluate trauma patients with
closed head injuries. Am J Surg 2003;186(6):
609–13 [discussion: 613–4].
98. Trupka A, Waydhas C, Hallfeldt KK, et al. Value of
thoraciccomputedtomography inthefirstassessment
of severely injured patients with blunt chest trauma:
results of a prospective study. J Trauma Inj Infect Crit
Care 1997;43(3):405–11 [discussion: 411–2].
99. Brink M, Deunk J, Dekker HM, et al. Added value of
routine chest MDCT after blunt trauma: evaluation
of additional findings and impact on patient
management. AJR Am J Roentgenol 2008;190(6):
1591–8.
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
100. PatelRP,Hernanz-SchulmanM,HilmesMA,etal.PediatricchestCTafter
trauma: impact onsurgical andclinical
management. Pediatr Radiol 2010;40(7):1246–53.
101. Holmes JF, Sokolove PE, Brant WE, et al. A clinical
decision rule for identifying children with thoracic
injuries after blunt torso trauma. Ann Emerg Med
2002;39(5):492–9.
102. TraubM,StevensonM,McEvoyS,etal.Theuseof chest
computed tomography versus chest X-ray in patients
with major blunt trauma. Injury 2007;38(1):43–7.
103. Renton J, Kincaid S, Ehrlich PF. Should helical CT
scanning of the thoracic cavity replace the conventional
chest x-ray as a primary assessment tool in
pediatric trauma? An efficacy and cost analysis.
J Pediatr Surg 2003;38(5):793–7.
104. Jindal A, Velmahos GC, Rofougaran R. Computed
tomography for evaluation of mild to moderate pediatric
trauma: arewe overusing it?World J Surg 2002;
26(1):13–6.
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
105. Markel TA, Kumar R, Koontz NA, et al. The utility of
computed tomography as a screening tool for the
evaluation of pediatric blunt chest trauma. J Trauma
2009;67(1):23–8.
106. Deyle S, Wagner A, Benneker LM, et al. Could fullbody
digital X-ray (LODOX-Statscan) screening in
trauma challenge conventional radiography?
J Trauma 2009;66(2):418–22.
107. Mirvis SE, Shanmuganathan K. The 2008 RadioGraphics monograph issue: emergency imaging
in adults. Radiographics 2008;28(6):1539–40.
108. Strauss KJ, Goske MJ, Kaste SC, et al. Image
gently: ten steps you can take to optimize image
quality and lower dose for pediatric patients. AJR
Am J Roentgenol 2010;194:868–73.
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Isolation or with polytrauma •
Minor to life- threatening •
1-Diagnostically accurate
2-cost-effective
3-provide for efficient treatment decisions
4-using the lowest-;possible radiation dose
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Imaging modality
Chest-x-ray:relatively low-dose •
Us:not use ionizing radiation: •
CT scan(MDCT):rapid acquistion-accurate •
anatomic detail- multiplanar-3-dim information-----disadv: high dose
EPIDEMIOLOGY AND PATHOLPHYSIOLOGY
1-14 Y/O TRAUMA
Death;15-25%brain--------chest trauma 6%
Serious chest trauma with poly regien 20
folds
Silent cocomitant chest injury in the patient
with known head; cervical spine and
abdomen
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MORTALITY
Isolated-------5%
With one body part--------25-29%
With more than two parts-------33-40%
With brain trauma--------40-70%
Poly trauma with chest trauma death
nonthoracic 66-75%
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A ge-based classification
0-4
5-9
10-17
m/f-------2’6-3
Blunt >6 times
14%---------blunt trauma
97% -------penetrating
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adult:rib fx; flial ch;aortic injury;and diaph •
rupture is common
Children:pulmonary contusion;pneumothorax; •
Intrathoracic injury without bony injury •
Differing pattern of injury; •
Anatomic and physiologic differences •
beetwen adult and children
IMAGING TECHNIQUE
RADIOGRAPHY
Upright PA----lateral
US
CT scan
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X-ray
Upright frontal and lateral
Supine
attention technical factors;
Poper collimation---adequate exposure
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3;5-7MHZsector
10-12;5MHZlinear
Aterior approach for occult pneumothorax
hemopericardium
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