Chest Trauma Images: Factors to Consider - Assignment Example

? Evaluation of Chest Trauma Images; Factors to Consider Introduction Chest trauma is a common occurrence in the medical setting. Trauma to the chest is a medical emergency, since the chest houses vital organs including lungs and heart. Whether it is in the form of blunt trauma or penetrating trauma, chest trauma is a very serious condition and should not be taken lightly (Demetriades 2002, p. 43). In order to gauge the extent of chest trauma, radiological investigations ranging from chest X rays, CT scans and MRI scans are normally conducted. Radiological investigations are important, since they indicate the extent of injury; hence, they guide the health care provider as he prepares for interventions. Sometimes, chest trauma may cause minimal damage only fracturing a few or no ribs. Another possibility is that the trauma may be penetrating rupturing the diaphragm and spleen below or even the heart and lungs above. From these radiological images of the chest, the health professional gets a clearer picture on what to do or on how to go next. If the first radiological image used does not give a definitive diagnosis, then the healthcare professional is able to employ another method that will lead to a more accurate diagnosis. When evaluating trauma images of the chest, there are many factors that the healthcare professionals need to have in mind, and from this, they are able to manage the condition better or request for more imaging tests. It is important to have these factors in mind since they determine the progression of management. This paper analyses these factors that the health professional needs to have in mind. In order to explain these factors well, I will first give brief insight into chest trauma and the possible implications. Chest Trauma Trauma has been rated as one of the highest causes of death, hospitalization and disability in people between 1 year and 40 years (Miller 2006, p213). Statistics also reveal that of all trauma cases, chest trauma accounts for 25%. Regardless of this, averagely 27% of chest trauma deaths are preventable (Miller 2006, p214). Normally, death from chest trauma occurs within the first 4 hours from hypoventilation and hypoxia and internal bleeding. Uncorrected hypoxia, uncontrolled bleeding and delay in surgical intervention are the major cause of accelerated death in chest trauma cases. Moreover, about 85% of patients who experience life threatening injuries to the chest, timely simple interventions can be done to enhance chances of survival (Miller 2006, p. 214). As a result of this, it is important to come up with timely management measures. The earliest intervention in trauma is to manage the patient using the ATLS (Advanced Traumatic Life Support) protocol. This protocol requires that the healthcare team manages the team using the basic ABC’s and maintaining the patient’s fluid homeostasis. The bleeding will need to be controlled; any wounds will need to be cleaned and the patient’s condition will need to be kept stable. Once this has been done, diagnostic images are taken to ascertain the extent of injury and possible complications. The patient will then be managed according to their condition. The time taken for each intervention is determined by the condition itself. For instance, penetrating trauma to the chest requires more urgent attention than blunt trauma due to the risk of internal bleeding. Trauma to the chest can be in the form of blunt forces or penetrating forces. Blunt forces can be in the form of decelerating or compression forces. This occurs in road traffic accidents, domestic violence, natural disasters and accidental falls. Penetrating injuries are from stabs or deep cuts. Whatever the type, the initial management requires the rapid assessment of the patient through ATLS protocols. The ATLS protocol is an in initiative that is meant to resuscitate the trauma patient within the first hour after injury before further management. It comprises of primary surveillance, secondary surveillance and definite management. Primary surveillance manages all immediate life threatening conditions by maintaining normal cardio-pulmonary functions. Imaging is part of definite management, after the patient’s condition is stable. Trauma to the chest causes a variety of conditions namely; rib fractures, flail chest, sterna fractures, trachea-bronchial disruptions, space occupying injuries (pneumothorax, haemothorax), direct cardiac injury, cardiac contusions, thoracic aorta disruptions etc. Therefore, diagnosis of chest trauma seeks to determine what organ has been affected, and, hence, timely measures are directed towards making the particular organ function normally (Demetriades 2002, p. 42). The measures need to be timely in the sense that these measures should be done within the first hour of trauma so as to avoid organ damage and failure. Factors to Consider When Evaluating Chest Trauma Images 1) Different chest imaging detect various chest lesions in varying accuracy and efficacy Chest imaging is the most widely used diagnostic tool in chest trauma (Shanmuganathan & Matsumoto 2006, p226). There are many imaging methods, and each of these has its own suitability and accuracy. There are many forms of imaging that are available; computed Tomography (CT), Magnetic Resonance Imaging (MRI), ultra-sonography, radiography, nuclear imaging, angiography and echocardiography (Miller 2006, p. 215). Radiography Chest radiography is performed in the acute setting and from it; the health professional is able to detect many conditions. On a chest radiograph, the following findings are possible; pneumothorax, pneumomediatinum, pleural hematoma and airspace shadowing which normally results from pulmonary contusions. Chesty Xrays are preferred to CT scans in the trauma setting since they are cheap and available in most healthcare settings. It is not all medical centers that have CT scans, which leaves X rays as viable options. The trauma patient specialist needs to be aware of the aforementioned lesions that an X ray is able to detect and the accuracy of this detection. The specialist will also need to understand that various views of Chest X rays lead to various findings and interpretations. Computed Tomography CT Scans are able to discern lesions not well discerned by chest radiographs (Omert, Yeaney & Protetch 2007, p662). CT scans are able to detect blunt lung trauma and are even able to detect blood in bronchi or even air with noteworthy accuracy. Chest radiographs can overlook some important details in chest trauma. Some of these are; diaphragmatic ruptures, pneumothorax, haemothorax, lung contusions, thoracic spine injuries, cardiac injuries and tracheobronchial tears. However, the CT discerns these lesions clearly and fully. Magnetic Resonance Imaging The advantage of MRI is that it is able to evaluate patients who have spinal injuries. It is able to elicit intricate details about vertebral discs, paravertebral tissues, spinal ligaments and even nerve roots. MRI is even able to show cord hematoma or oedema. Despite these facts, MRI is not available in many clinical setups as it is expensive (Livingstone 2004, p. 508). Echocardiography, Ultra-sonography and Angiography Conventional echocardiography has an advantage over the aforementioned methods as it is able to image the heart and the pericardial space. It is also able to visualize the ascending aorta. Ultra-sonography is a rapid and non invasive procedure that is also used to visualize the heart and adjoining structures. Transoesophageal ultra-sonography has the advantage of being able to image the aortic arch and even the descending aorta. Digital subtraction angiography is able to image aortic rupture or even aortic pseudoaneurysm. However, angiography is invasive. Besides, contrast media used are nephrotoxic (Shanmuganathan & Matsumoto 2006, p224); Factors to consider when evaluating trauma images 2) Initial clinical assessment of trauma patient determines the prognosis When evaluating trauma images, clinical assessment of the patient must be put into consideration since through it, the health professional is able to know what to expect (Shanmuganathan & Matsumoto, p227). Trauma to the chest may affect the following structures; the airways, the lungs, the aorta and associated vessels, the diaphragm, the heart and the ribs. The earliest assessment is meant to check which of these structures are affected and from this, the health professional orders the relevant images to gauge the extent of damage. On the other hand a penetrating stab most likely perforates structures in the upper mediastinum instead of fracturing the ribs (Livingstone 2004, p. 509). Therefore, the initial assessment needs to be thorough. As a result of this, the doctor who receives the patient first needs to conduct a thorough history so as to gauge the mechanism of injury. By taking a thorough history and conducting a thorough examination, the health professional is able to establish the high index of suspicion in the condition. The X-rays they request for are based on these findings. From this, it becomes easier to assess trauma images. Clinical examination is also important in the sense that the health professional is able to detect any other conditions in the patient that need to be managed together with the trauma condition. In case a person is stabbed with a knife, it is possible that the diaphragm is injured, hence when images are taken, the health professional will be checking whether the diaphragm was affected or not. As the health professional evaluates the images, it is also necessary to look for any associated injuries to the face, head and any injuries to the upper and lower airway. This is able to offer more clues to the healthcare professional in case the findings were vague in the original assessment. This may further prompt the health professional to run more tests in order to find the diagnosis in case the present findings are not conclusive. 3) The organ injured determines the diagnosis and management When assessing the images, one factor that should be kept in mind is that, various organs are injured during trauma, and injury to any of these organs has its ramifications. However, sometimes blunt trauma may not cause any injury to organs. Various rib fractures have various implications When there are suspected rib fractures, there is need to examine the underlying lung. As a result of this, it is important to check the images clearly for contusion, laceration or pleural effusion. Multiple rib fractures are likely to cause a flail chest. A flail chest occurs when sections of the rib cage are detached from it which affects normal movements of the chest. Hence, if the radiographs show that the fractures are many, the health professional needs to come up with prompt measures of ensuring that the thoracic cage becomes potent and functional (Freedland, Wilson & Bender 1990, p. 1460). When imaging indicates that the fractures span the first to the fourth rib, it becomes necessary for the health professional to look for all the associated injuries since most mediastinal structures are located below these ribs. 4) Fluid level in chest images may be fluid or blood This is another factor to consider. Fluid levels indicated in chest images may either be fluid or blood. Having this in mind helps the health care provider not to rush the diagnosis. Pleural effusion refers to water, air, pus or blood within the pleural cavity. Air within the pleural cavity is referred to as pneumothorax. In trauma, the pneumothorax may be partial or total (tension). Tension pneumothoarax causes cardiovascular impairment since there is insufficient blood reaching the extremities. This requires emergency treatment to remove the trapped air by use of a chest tube to drain the air into an underwater drainage (Demetriades 2002, p42). However, in cases of partial pneumothorax, the case is not an emergency and it may resolve by itself. All these are normally indicated by chest images. With this in mind, the health professional is able to know what measures to put in place so as to avoid any emergency cases. For instance, knowing that tension pneumothorax is a medical emergency, the health professional should and must place a chest tube to the patient so that normal cardiovascular activities resume. It is also common knowledge that multiple rib fractures in trauma patients harbor subclinical pneumothorax. It is important to put this in mind because ignoring it may be dangerous since the condition is likely to worsen in case it is not managed early. A haemothorax can be detected as a fluid level at the inferior junction of the thoracic cage. It is important to note that as much as 40% of blood volume can be in a single pneumothorax (Demetriades 2002, P43). A haemothorax is caused by blunt injury to the chest cage. This may cause injuries to various blood vessels in the mediastinum. Having this in mind, prompt management needs to be put in place when a haemothorax is detected. The best management measure when a haemothorax id detected is placing a chest tube with underwater seal drainage. At the same time, the injured areas need to be sutured to avoid more damage and bleeding. 5) A widened mediastinum in a Chest X ray is associated with aortic injury On chest radiographs, a widened mediastinum is an indication that aortic injury has occurred. However, a widened mediastinum may be caused by very many conditions that are not trauma related ( Dubinsky 1997, p241). These include; retrosternal goiter, thymoma, teratoma, lymphoma, tortuous thoracic vessels, pulmonary tuberculosis, pulmonary anthrax, mediastinal abscess, sarcoidosis, Hodgkin’s disease, among other causes.Based on this, more tests are conducted, to ascertain the cause. For instance, ultra-sonography and conventional angiography are able to detect aortic injuries well as compared to chest radiograph. Therefore, if CT scans and radiographs are able to indicate that aortic arch injury is a possibility, further tests would be important in ascertaining the nature and extent of aortic arch injury. In order to ensure that this is possible, the method selected for the next imaging needs to be ultra-sonography or angiography. Statistics have revealed that about 90% of patients who have a ruptured aortic arch die before they reach hospital. The chest radiograph will have the earliest impression of injury, and it is up to the health provider to select the right method in gauging the extent of aortic arch injury. Presence of a pneumothorax may signal the presence of a diaphragmatic rupture . 6) Haemothorax may be from a splenic rupture When haemothorax is elicited in chest imaging, another important factor to consider is that splenic ruptures may be the cause of haemothorax. Normally, haemothorax is as a result of ruptured blood vessels in the thoracic cage (Dubinsky 1997, p241). However, the health professional will have to rule out splenic ruptures. Rupture of the spleen is a very serious medical condition and if serious, the victim dies in a matter of hours. Conclusion Chest trauma accounts for almost 25% of all trauma cases. Trauma cases are becoming more and more common in the medical set up, hence, health care professionals need to be aware of some important factors concerning chest trauma when managing these conditions. Failure to know these factors may cause them to mismanage the patients or it may cause them to have difficulties in managing the cases. There are various imaging techniques but the commonest are chest radiography, CT scans and MRI scans. Ultra-sonography and angiography are used for clarity and in some specific situations. Bibliography Ahmed Z, Mohyuddin Z. 'Management of flail chest injury: internal fixation versus endotracheal intubation and ventilation.' J Thorac Cardiovasc Surg 1995; 110: 1676 Clark GC, Schecter WP, Trunkey DD. 'Variables affecting outcome in blunt chest trauma: Flail chest vs. pulmonary contusion.' J trauma 1990; 30: 93 Craven KD, Oppenheimer L, Wood LD. 'Effects of contusion and flail chest on pulmonary perfusion and oxygen exchange.' 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