Thoracic Trauma Imaging

Overview
In many patients with thoracic trauma injury, urgent exploratory thoracotomy or laparotomy may take precedence over imaging, whereas in others, diagnosis and treatment are frequently combined with tube thoracostomy or pericardiocentesis. Imaging studies are an essential part of thoracic trauma care once the patient is stabilized. Imaging has little if any role in the initial treatment of a critically ill and hemodynamically unstable patient. The first priority in cases of thoracic trauma is the provision of effective therapeutic measures to minimize trauma-related deaths and morbidity. Imaging is not indicated until the airway, breathing, and circulation (ABC) have been secured and stabilized. The initial approach to chest trauma is clinical evaluation, which starts with a thorough examination of the chest after the airway is controlled. Severe internal injury may be present without external tenderness. A chest radiograph is obtained for every patient who has significant trauma. The diagnosis is generally obvious with standard chest radiography or CT, but more subtle signs require careful analysis of CT images and examination with MRI in some situations. Prolonged observation in a monitored setting is usually not required for patients with suspected myocardial contusion. Patients with a normal electrocardiogram (ECG) and a normal echocardiogram are usually discharged home after 12 hours of monitoring. Cardiac complications are rare in cases of cardiac contusion, particularly in the young. Echocardiography is useful for detecting wall-motion abnormalities and pericardial effusions. In combination with abnormal creatine kinaseMB levels, this may be predictive of complications. Radionuclide angiographic results also may be predictive of complication. Thallium scanning may depict areas of decreased perfusion but are not useful in differentiating an acute lesion from a preexisting lesion. Ultrasonography, CT, and magnetic resonance imaging (MRI) may all demonstrate pericardial effusions and hemopericardium, but they are rarely indicated in a patient with acute traumatic tamponade. The roles of CT, MRI, and transesophageal ultrasonography in the evaluation of aortic injuries have not been clearly defined, although multisection CT scanning is increasingly used for diagnosis. Radiography Chest radiography (see the images below) is indicated in virtually every trauma patient; a series of radiographs are generally obtained to assess the progress and complications of the trauma. They are also used to look for malpositioned lines and tubes; in the stress and confusion of an emergency department inadequate and inappropriate placement of lines and tubes is common *1,2,3

A chest radiograph is usually performed initially in the acute setting. Findings on a chest radiograph include pneumothorax (which is difficult to see on a supine image), pneumomediastinum, airspace shadowing (resulting from pulmonary contusion), and pleural hematoma. CT is better for assessing most of these lesions.

Repeat chest radiographs are obtained after any invasive intervention, such as intubation or placement of the central venous pressure catheter or chest tube. Iatrogenic lung trauma may occur after lung biopsy, thoracentesis, cauterization, and other procedures. Mechanical ventilation predisposes the patient to barotrauma and pneumothorax. Lung injuries may result from the inhalation of toxic and inert substances, as well as in association with blast or radiation. Portable AP radiographs have several limitations when the images are obtained in an emergency situation with the patient in a supine position. Expiratory artifacts and the magnification effect of a short beam distance may make the mediastinum appear widened. Injuries involving the diaphragm are often missed, and preexisting diaphragmatic eventrations or an elevated hemidiaphragm may mimic diaphragmatic injuries. Radiographic findings associated with aortic transection are nonspecific. They may be seen in a variety of other mediastinal or chest wall injuries, including nonaortic vascular injuries, fractures of the sternum, vertebral fractures, and esophageal rupture. Predictions regarding the presence of mediastinal hemorrhage on supine portable chest radiographs in the setting of trauma are inaccurate. Plain imaging findings of thoracic spinal fractures are often subtle and are difficult to identify because of the limited quality of many trauma radiographs. Computed tomography Advancements in CT imaging have changed the management of blunt lung trauma and permitted the detection of blood in bronchi and interstitial air or blood with greater accuracy.[6, 7] Many centers now screen patients with chest trauma for aortic injuries by using contrast-enhanced CT. CT scans (see the images below) also demonstrate injuries to the lung, pleura, mediastinum, and chest wall better than plain radiographs do. Many serious thoracic injuries may be overlooked on initial chest radiographs; these include tracheobronchial tears, diaphragmatic rupture, esophageal tears, thoracic spine injuries, chest wall and seat-belt injuries, lung contusion, cardiac injuries, pneumothorax, hemothorax, and chest tube complications. *4,5,6 CT images demonstrate fractures of the vertebral bodies with great accuracy and readily show the relationship of fractured fragments and displaced disk material to the cord. Sagittal and coronal reconstructions may provide further exquisite detail. Because of a dramatic reduction in motion and beam-hardening artifacts and significant improvement of spatial resolution, especially along the z-axis, helical and multisection CT scanning allows better demonstration of the most subtle signs of thoracic trauma, such as a focal indentation of the liver or a right-sided collar sign. In addition, helical and multisection CT is a useful tools in the evaluation of patients with multiple traumatic injuries. Patients with severe trauma are often difficult to scan with CT because of resuscitative equipment. CT is an excellent modality, but patients are required to receive contrast agents and be transported from the protected resuscitation area to the radiology suite. Therefore, CT scanning is difficult to perform in hemodynamically unstable patients. Magnetic resonance imaging MRI has many advantages over CT in the evaluation of patients with suspected dorsal spine injuries. It provides excellent detail of intervertebral disks, spinal ligaments, paravertebral soft tissues, and other spinal contents (eg, cord and nerve roots). MRI is particularly useful in evaluating patients with spinal cord injury without radiographic abnormality (SCIWORA) syndrome. MRIs show cord edema

or hematoma, which may account for any neurologic deficit the patient may have. MRI is an important diagnostic and prognostic tool in patients with thoracolumbar compressiontype fractures. MRI with breath-hold acquisition permits good visualization of diaphragmatic abnormalities, but this technique cannot be performed in emergency situations. MRI offers a major advantage in exploring the cord, disks, and ligaments and in looking for a hematoma. Nevertheless, the indication is carefully weighed in patients with multiple trauma because of monitoring difficulties during the examination, which may be long. MRI is expensive and is not universally available in emergency departments. Also, MRI often cannot be used in patients with ferromagnetic foreign bodies or some types of prosthetic cardiac valves, as well as in those with claustrophobia. MRI should be performed only in patients when MRI-compatible resuscitation equipment is readily available. Echocardiography, ultrasonography, and angiography Conventional echocardiography has long been used to image the heart, the pericardial space, and the ascending aorta. Transesophageal ultrasonography is an excellent modality for visualizing the aortic arch and the descending aorta and may be used at the patient's bedside. Because ultrasonography is unique in being portable, rapid, and noninvasive, it is particularly suited to the trauma setting and offers immediate feedback that may be incorporated into the management plan for the patient. Ultrasonography is operator dependent and may cause some aortic injuries to be missed. Conventional or digital subtraction angiography (see the images below) remains the criterion standard for depicting traumatic aortic rupture and aortic pseudoaneurysm. Angiography is invasive and may cause small aortic tears to be missed. Iodinated contrast media are nephrotoxic and pose a risk of anaphylaxis *7,8 uclear medicine study Thallium and multigated acquisition isotope scans are useful for assessing myocardial damage. Similarly, technetium-99m diphosphonate may be used to assess fracture sites when radiographs are negative and patients are symptomatic. Injury scoring The abbreviated injury scale (AIS) and the injury severity score (ISS) are accurate methods for quantifying trauma severity and have many potential applications. The ability to predict morbidity and mortality from trauma by using injury severity scoring is an obvious application. Such scores may be used to inform patients and their families if they desire to know the prognosis and apply the knowledge to end-of-life decision making and resource allocations. However, there is always uncertainty in predicting trauma mortality and morbidity in an individual patient. Decisions for individual patients should never be made solely on the basis of a statistically derived ISS. A variety of anatomic and physiologic trauma scores are used alone or in combination to score the severity of injuries.[8] The AIS is an anatomic scoring system first introduced in 1969. Since then, it has been revised several times with regard to survival so that it now provides a reasonably accurate means of ranking the severity of injury. A scaling committee of the Association for the Advancement of Automotive Medicine (AAAM) monitors the AIS. The AIS is used to score traumatic injuries in terms of the anatomic location and severity of the injury. Each traumatic injury is assigned a 7-digit number, with

the last number representing the severity of the injury to be used in tabulating the ISS. AIS numbers may be found in the AIS Dictionary, distributed by the AAAM. The ISS is an anatomic scoring system but only recognizes the highest AIS in each of the 6 body regions: head, face, chest, abdomen, extremities, and external. The ISS is used to assess survivability; its results are often compared with various benchmarks (eg, ISS versus length of stay and ISS versus mortality). Only the highest AIS score in each body region is used. The scores for the 3 most severely injured body regions are squared and added to produce the ISS. Injuries are scored on a scale of 1-6, with 1 being minor, 5 being severe, and 6 being lethal. This score represents the threat to life associated with an injury and is not meant to represent a comprehensive measure of severity. The AIS is not an injury scale in that the difference between an AIS score of 1 and a score of 2 is not the same as that between 4 and 5. The AIS scale and the organ injury scales of the American Association for the Surgery of Trauma have many similarities. AIS scores for injury are as follows:

Minor Moderate Severe Serious Critical Not survivable