Radiograph of the Chest in Polytrauma

Is the endotracheal tube well positioned? Is there a pneumothorax or even a tension pneumothorax?

Are central venous lines correctly placed? Are there rib fractures, particularly in the region overlying the spleen?

Is there a pulmonary edema, a lung contusion? Is the mediastinum widened? Beware: Patient positioning!

Is the diaphragm intact?

Is the endotracheal tube correctly positioned? Your first concern must be the endotracheal (ET) tube. Its tip should ideally be 1.5 cm above the tracheal bifurcation. If it is placed lower, movements of the patient may lead to selective intubation of a main bronchus with a consecutive reduced aeration or even collapse of the contralateral side. Volume loss ensues and eventually displaces the mediastinum to the contralateral side (Fig. 14.3). In order not to injure the vocal cords, the tube cuff should be located well inferior to them, around the level of the 5th cervical vertebral body. Are you sure the tube is inside the trachea? A lot of air in the stomach may indicate incorrect intubation of the esophagus, either presently or in the immediate past (Fig. 14.3). The anesthesiologist must be alerted to the fact at once and perform clinical examination including auscultation to check ET tube position!

I Patient A: Radiograph of the Chest

I Patient A: Radiograph of the Chest

Pneumothorax Before Chest Tube Radiology
Fig. 14.2 This is the chest radiograph of patient A. Do you see any abnormality? Use the checklist for your image analysis.

Is there a pneumothorax? The second major thing to consider is the potential complications of the vascular access. If the large internal jugular or subclavian veins are punctured, the lung apex is particularly at risk, especially if several attempts are necessary before venous access can be established. Is there evidence for a pneumothorax (Fig. 14.4a, b)? In supine portable CXRs the air in the pleural space moves anteriorly. A fine rim of decreased attenuation along the heart and diaphragm contour may be the only indication of a pneumothorax. There is another sign to look for, however.

f The deep pleural recesses are only reached and unfolded i by free air in the pleural space (Fig. 14.4c). This is the rather specific "deep sulcus sign" of a pneumothorax.

If there is a tension pneumothorax (Fig. 14.4d) that causes a mediastinal shift to the contralateral side, the ventilation of the contralateral lung and the venous backflow into the chest are impaired. Rapid relief of the increased pressure in the pleural space is crucial. Catheters, textile folds, rib margins, the medial contours of the scapulae, and skin folds (Fig. 14.4e) can simulate a pneumothorax because they may look like the outline of the visceral pleura.

f Check for crossing anatomical structures: any "pleural line" i that is crossed by pulmonary vessels on their way to the periphery cannot be the pleural outline in pneumothorax.

Are the central venous lines correctly placed? Subclavian or jugular venous lines should harmonically follow the course of the vena cava (Fig. 14.5a) and not reach the level of the tricuspid valve (Fig. 14.5b) in order to avoid catheter-induced arrhythmias. A catheter to measure the central pulmonary pressure (Swan-Ganz catheter) is advanced through the right heart into the pulmonary

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