CORE Case 3 Workshop

1. Petra Lewis MD Professor of Radiology and OBGYN Geisel School of Medicine at Dartmouth CORE Case 3 Workshop

2. Learning objectives • Learn the common findings of traumatic aortic injury on CXR and CT • Know some of the alternative imaging options in TAI • Understand the concept of ruptured diaphragm • Understand how supine pneumothoraces can appear different from upright • Recognize a pneumomediastinum • Know the normal positions of common lines and tube • Be able to recognize common abnormal line and tube positions • Know how to approach imaging in patients with suspected rib fractures.

3. What questions/difficulties did you have arising from the case

4. Traumatic aortic injury

5. Aortic Injury • Common clinical question: CXR often first examination • What are the signs?

7. Traumatic aortic injury

8. Traumatic aortic injury

11. Traumatic aortic injury

12. Traumatic aortic injury

13. What other ways do we have of evaluating a traumatic aortic injury?

17. Supine pneumothorax

18. So you know about how to detect a pneumothorax. But what if the patient is supine?

22. Day 1 Day 2

25. What are the cause of a pneumomediastinum?

30. Lines and tubes

31. ETT Picc Central lines PA catheters Chest tubes PTX Effusion

32. NG tube Dobhoff

41. Suspected rib fractures

42. What study will you order? • 24 year old man, kicked by a horse on left side with diffuse LUQ tenderness. • 65 year old woman who tripped over at home yesterday, right lower chest pain on deep inspiration, and focal tenderness to palpation over right lateral 10th rib. No dyspnea • 62 year old woman with a history of breast cancer and spontaneous onset of right lower rib pain, worsened by inspiration. Focally tender to palpation • 18 year old man hit by a baseball in his left chest with shortness of breath and pleuritic chest pain. Focally tender to palpation.

43. Appendix

44. Learning objectives for CORE 3 • Know the indications, limitations and typical views obtained of a screening radiographic trauma series in major trauma. • Have a concept of the indications for and advantages of using of CT for suspected chest/abdomen/pelvis trauma. • Recognize the common radiographic and CT imaging findings seen in traumatic aortic injury • Know alternative imaging options to evaluate the aorta in patients with contrast allergies or renal insufficiency. • Understand the difference between aortic aneurysm, aortic dissection, and aortic lacerations (traumatic aortic injury) • Understand the concept and typical appearance of pulmonary contusive injuries. • Be able to recognize a tension pneumothorax on a radiograph. • Be able to recognize the ‘deep sulcus” sign of pneumothorax on supine radiographs and its significance. • Know the correct positioning of chest tubes and how to evaluate chest tube placement on chest radiographs. • Recognize the difference between skin folds and a true pneumothorax on chest radiographs. • Be able to determine correct and incorrect positioning of endotracheal tubes. • Be able to determine the correct and incorrect positioning of NG tubes and feeding tubes. • Understand the indications for imaging in suspected rib fractures. • Recognize a pneumomediastum on chest radiographs • Be able to provide a differential diagnosis of possible etiologies for a pneumomediastinum. • See the common radiographic presentations of traumatic rupture of the diaphragm