Patient C

By now the third heavily traumatized patient (C, name unknown, female, about 45 years of age) is wheeled into the resuscitation room. She is conscious and is breathing spontaneously; several peripheral venous cannulas have been inserted and she wears a cervical collar. Joey is now in charge of the ultrasound machine.

Radiography of the chest and rib series: The CXR is felt to be within normal limits. A skin bruise on the left lateral thorax and pain in this area prompt a rib series (Fig. 14.31a). This shows a fracture of the 8th rib.

A fracture of the lower bony thorax should alert you to potential severe trauma of underlying abdominal organs and must be correlated with an ultrasound or CT examination of the abdomen.

Patient B

a Radiograph of the chest a Radiograph of the chest

8th Rib Fracture

Fig. 14.28a This is the chest radiograph that led to the immediate transfer of the patient to the trauma center. The upper mediastinum appears widened. Are you sure the patient is well positioned? b Go ahead and trace the aortic arch and its branches on the consecutive slices. Try to form a three-dimensional model of the arch in the back of your mind. Now try to rotate it.

Fig. 14.28a This is the chest radiograph that led to the immediate transfer of the patient to the trauma center. The upper mediastinum appears widened. Are you sure the patient is well positioned? b Go ahead and trace the aortic arch and its branches on the consecutive slices. Try to form a three-dimensional model of the arch in the back of your mind. Now try to rotate it.

b Chest CT

b Chest CT

Causes Mediastinal Widening

I Causes of Mediastinal Widening a Incomplete aortic rupture a Incomplete aortic rupture

Causes Mediastinal Widening

Fig. 14.29a This CT shows an incomplete rupture of the ascending aorta. The leakage of contrast into the defect of the intima and media is seen well (arrow). b In this patient a pseudoaneurysm has formed in the typical location close to the ligament of Bothalli (star). c The sagittal reconstruction of the aortic arch shows the aneurysm (star) in its relation to the spine to better advantage. d The sagittal reconstruction of the thoracic spine depicts the fracture of the adjoining vertebral body emphasizing the brutal force of the trauma.

b-d Traumatic pseudoaneurysm b-d Traumatic pseudoaneurysm

Traumatic Aortic Pseudoanuerysm

I Causes of Mediastinal Widening e Aortic dissection f Hematopericardium e Aortic dissection f Hematopericardium

Mediastinal Lipomatosis

g Mediastinal lipomatosis

Fig. 14.29e A hematoma of the wall of the descending aorta has been the sequel of a severe chest trauma in this patient. This is a precursor of a full-blown aortic dissection. f A heated exchange of arguments among friends climaxed in a knife stab directly into the heart. The pericardium is filled with blood—rapid surgical intervention is imperative. g The large vessels are surrounded by a wide fatty tissue cuff. Compare the density of the subcutaneous fat. Only CTcan diagnose mediastinal lipomatosis with certainty in an emergency setting.

I Patient B: Aortography

Ultrasound and CT of the abdomen: During the ultrasound examination, Joey takes a particularly good look at Morrison's pouch (Fig. 14.31b), where free fluid in the abdomen tends to accumulate first. Owing to its location and consistency, the spleen is the abdominal organ most at risk for blunt injury. Contusions, lacerations, and ruptures of spleen (Fig. 14.32a, b) and liver (Fig. 14.32c) as well as bleeds from larger vessels into the open abdomen (Fig. 14.32b) are readily appreciated on CT images.

Fig.14.30 A catheter that has the shape of a pigtail is located in the aortic arch. This digital subtraction angiography image (the images acquired before and after contrast administration are subtracted from each other) shows the cranial bulge of the aortic lumen close to the origin of the brachiocephalic trunk. This is a false aneurysm. The diagnosis fits very well with the conventional chest radiograph findings (see Fig. 14.28a): The trachea has been displaced to the right by the aneurysm.

f Remember that the amount of hemorrhage may be dei creased in severe shock. After circulatory stabilization, bleeds may intensify and manifest with some delay.

Free fluid in the abdomen in a trauma patient can also have other causes. Trauma may rupture the bowel or induce bursting of a full urinary bladder. Bleeds may also arise in the retroperitoneum, particularly in renal injuries, which often become symptomatic with hematuria (Fig. 14.33).

f In a patient with polytrauma, the parenchymal organs of i the upper abdomen and especially the retroperitoneum are not sufficiently examined by ultrasound. An abdominal CT is indicated in all cases of doubt and severe trauma. Ultrasound may be useful as a rapid screening tool to detect conditions that require immediate surgical attention even prior to a trip to the CT scanner, such as pericardial hematoma/tamponade, hemothorax, and large amounts of free fluid in the abdomen requiring immediate emergency laparotomy.

Joey immediately worries about splenic rupture, having seen the obvious fracture of the 8th rib on the left side. the ultrasound aspect of the space of Morrison reinforces

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