Is there pulmonary edema Are there lung contusions

Perihilar symmetric patchy opacities and ill-defined blood vessels indicate pulmonary edema if (very important!) the radiograph is performed with sufficient inspiration (Fig. 14.7). Causes may include an overly aggressive fluid resuscitation during the initial emergency care. In elderly patients a cardiac decompensation can also be induced by the trauma itself.

If—particularly in the presence of rib fractures—circumscribed consolidations are detectable in the lung of a freshly traumatized person, lung contusions are the most likely cause (Fig. 14.6). They consist of pulmonary hemorrhages that tend to clear within a few days. The injuries to the lung can, however, also lead to tears of the pulmonary parenchyma, so-called lung lacerations (Fig. 14.6). Opacities in dependent lung areas may also be due to atelectasis or aspiration.

Is the mediastinum widened? The mediastinum is always wider in the recumbent than in the upright patient. The diaphragm pushes upward, especially in the fatter individual, and compresses the mediastinum. In addition the venous backflow is increased, which also adds to the mediastinal volume. Any rotation of the patient around the longitudinal axis also makes the mediastinum appear wider. For that reason it is crucial that the patient is positioned straight for the radiograph; this is not always trivial in an emergency room or intensive care setting. Assessing the relative position of the spinous processes between the medial edges of the two clavicles (ideally centered)

I Central Venous Catheter a

Venous Catheter Azygous
Fig. 14.5 a A central venous catheter has been introduced via the left jugular vein and has then deviated into the azygos vein, where its tip appears to have a very high density. It is, however, imaged orthogonally or "down the barrel."

b On this radiograph you can follow the central venous catheter through the right atrium into the apex of the heart (see window). Does anything else strike you?

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I Serial Rib

Fractures

Bronchus Fracture

Fig. 14.6 This patient suffered from serial rib fractures (ribs 3-6 on the left). A pneumothorax has already been taken care of with an intrathoracic chest tube in drainage. The lung in the vicinity of the fracture is considerably increased in density: The alveoli are filled with blood, which is why the bronchi are beautifully visible as black stripes, so-called "positive air broncho-grams" in a patient with a lung contusion. Within this zone there is a circumscribed area of increased lucency (see also the inset)—this is a pulmonary tear. The pulmonary hemorrhage clears within a few days. The pulmonary tear may take months to heal.

I Pulmonary Edema

Pulmonary Alveolar Edema

Fig. 14.7 Severe alveolar edema is characterized by positive air broncho-grams and perihilar symmetrical opacities. The distribution of the consolidations resembles the outline of a butterfly in flight (or even a less popular creature), which is why perihilar alveolar lung edema is often labeled as "butterfly edema" or "batwing edema." This patient underwent vigorous fluid resuscitation and defibrillation (you can see the large transparent electrode of the defibrillator superimposed on the right chest) and developed pulmonary edema in this context.

Fig. 14.7 Severe alveolar edema is characterized by positive air broncho-grams and perihilar symmetrical opacities. The distribution of the consolidations resembles the outline of a butterfly in flight (or even a less popular creature), which is why perihilar alveolar lung edema is often labeled as "butterfly edema" or "batwing edema." This patient underwent vigorous fluid resuscitation and defibrillation (you can see the large transparent electrode of the defibrillator superimposed on the right chest) and developed pulmonary edema in this context.

I Pneumomediastinum

Pulmonary Contusion Butterfly

Fig. 14.8 This view of the upper mediastinum shows some fine, dark stripes parallel to the trachea and the large mediastinal vessels, for example, the brachiocephalic trunk. There must be air in the mediastinum. Have a close look!

Pulmonary Contusion Butterfly

Fig. 14.9a The hemidiaphragm on the left is obliterated. Parts of the colon and the stomach have prolapsed into the chest. b CT confirms the finding. The stomach is located high in the left hemithorax.

helps to determine the degree of rotation of the patient around the body axis. If the rotation is taken into consideration and the mediastinum still appears to be abnormally wide, a contrast-enhanced CT of the chest should be done—particularly in those patients with high-speed motor vehicle accident (MVA) trauma or some other deceleration trauma. This is to exclude any treatable injuries to the large vessels, especially traumatic aortic dissection or aneurysm formation. Blood in the mediastinum seen on CT can be an indirect hint. If there is a pneumomedia-stinum (Fig. 14.8), a tracheal or bronchial tear should be considered.

Fig. 14.9a The hemidiaphragm on the left is obliterated. Parts of the colon and the stomach have prolapsed into the chest. b CT confirms the finding. The stomach is located high in the left hemithorax.

Is the diaphragm intact? If the outline of the diaphragm is invisible or if there are bowel loops seen inside the thorax (Fig. 14.9a), a CT (Fig. 14.9b) should be done to assess the presence of a rupture and look for associated injuries. Most diaphragmatic ruptures occur on the left side because on the right the diaphragm is protected by the sturdy liver.

Giufeng calls the diagnoses out loud for the taker of the minutes to jot down: "Tube malpositioned in the right main bronchus, severe tension pneumothorax on the right, serial rib fractures on the right (4th-8th ribs); volume loss of the left lung; mediastinal shift to the left." The defibrillation electrode is still fixed to the chest.

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