Radiation diagnostics of the chest organs using the radiation technique. Radiation algorithm for bruises, concussion and compression of the chest X-ray methods of lung studies

17.05.2020

IN last years significant number of injured chest enters the hospital in a state of alcoholic or drug intoxication. Impairment of consciousness in victims with severe intoxication can create the illusion of a more serious condition.

Symptoms of a chest injury

Analyzing the severity of the victim's condition, one must pay attention to mental status... By aggravating, the victim can create a suspicion of a more serious condition in the absence of such, and vice versa, a state of euphoria can give the impression of a satisfactory state in the presence of internal injuries. To confirm or exclude alcoholic or drug intoxication, it is necessary to conduct a study of blood, urine for the content of alcohol or other substances that can affect the state of consciousness.

Forced horizontal position, weakness, dizziness, pallor, weakness may indicate or hypovolemia. Forced semi-sitting and sitting position, increased pain when moving to a horizontal position, lack of air indicate a probable penetrating injury and hemopneumothorax. Facial cyanosis, tension, swelling of the cervical veins, weak pulse, tachycardia in the presence of wounds in the projection of the heart speak of a possible hemopericardium and developing hemotamponade. Severe pallor, moist skin, weakness, tachycardia indicate hypotension due to internal bleeding.

Weakening of breathing on auscultation indicates the presence of air or blood in the pleural cavity. The boxed sound with percussion indicates pneumothorax, the shortening of the percussion sound indicates free fluid. The greater the volume of pathological contents in the pleural cavity, the more the lung is compressed, the more the damaged half of the chest lags behind during breathing.

Dyspnea at rest (respiratory rate\u003e 22-25 per minute) with chest injury is a sign of developing respiratory failure, which is more often associated with tension pneumothorax.

Coughing when the chest is injured is a sign of blood entering the tracheobronchial tree. In the absence of other diseases in which hemoptysis is possible, the presence of blood in the sputum of these victims is an obvious sign of lung injury.

Tissue emphysema is an important diagnostic sign of penetrating injury. Most often it is localized around the chest wound. The more massive the emphysema, the more likely it is to damage the lung or bronchi. In a number of observations with an obliterated pleural cavity after exudative and inflammatory diseases, after severe closed injury or surgery, tissue emphysema may be the only sign of a penetrating injury.

In some patients, the diagnosis of penetrating injury is made when air enters through the wound.

A distinction should be made between single and bilateral, single and multiple chest wounds. The presence of one wound on each side is referred to as a bilateral chest injury. Having more than one wound on one side is a multiple, unilateral wound.

Localization of wounds is of great importance in assessing injury. So, wounds localized from the parasternal line to the right and to the anterior axillary line to the left are potentially dangerous for the heart, and this zone is designated as cardiac. Wounds localized below the line starting in the sixth intercostal space along the midclavicular line connecting with the angle of the scapula are potentially dangerous from the point of view of injury to the diaphragm, and the zone is designated as diaphragmatic. Therefore, for wounds localized in the diaphragmatic zone, one should look for clinical ultrasound symptoms of thoracoabdominal injury, and in case of injury in the cardiac zone, exclude the presence of hemopericardium.

Thus, at the stage of examination of the victim, direct or indirect signs of a penetrating injury to the chest can be identified, which, together with an assessment of the severity of physiological disorders, can influence the choice of surgical tactics.

Diagnosis of chest injury

Examination of stable patients takes place mainly in the admission department. For patients admitted to the operating room without examination, diagnostic tests are performed on the operating table. Obligatory diagnostic methods are a survey radiography of the chest, chest and abdomen, electrocardiography and the study of hemoglobin, hematocrit, erythrocyte count in the blood.

Plain radiography in patients with stable hemodynamic parameters should be performed in a stationary X-ray room in a standing position in two projections: frontal and lateral. Evaluate pulmonary fields, median shadow, diaphragm shadow, exclude bone pathology... In the presence of foreign bodies breast polypositional study allows you to accurately localize them.

When using fluoroscopy, the pulsation of the heart is assessed. Detection of total shading of the pulmonary field or total collapse of the lung is an indication for transferring the patient to the operating room. If it is impossible to study in upright position survey radiography is performed in a direct projection lying down and in a direct lateroposition with the wounded side up. This research method allows you to identify, including small volume.

Ultrasound in the diagnosis of chest trauma

Ultrasound of the chest and abdomen is necessary in the diagnosis of hemothorax and hemopericardium and associated (thoracoabdominal) injuries. The study is carried out according to the FAST and EFAST method (Davis, 2005). To increase the sensitivity of ultrasound in the diagnosis of hemothorax up to 100 ml, it is necessary to carry out ultrasound both in the supine position and in the sitting position, since the frequency of detection of small hemothorax significantly increases during polypositional examination. The volume of fluid in the pleural cavity is assessed by the degree of divergence of the sheets of the parietal and visceral pleura, determined at the level of the costophrenic sinus along the posterior axillary and scapular lines.

There is a correlation between the volume of hemothorax and the degree of dissociation of the pleural sheets. The absence of signs of hydrothorax in a primary ultrasound scan in a victim with a chest wound performed shortly after the injury is an indication for re-examination within an hour, if surgery is not started within this time period. The main obstacle to performing an ultrasound scan is widespread tissue emphysema.

In addition to detecting free fluid in the pleural cavity, ultrasound can detect intrapulmonary changes resulting from a lung injury.

Hemopericardium is an indication for emergency transfer of the victim to the operating room. With ultrasound of the pericardium, one should take into account the possibility that, normally, serous fluid with a volume of up to 60-80 ml can be contained in its cavity, which corresponds to 1-4 mm of separation of the pericardial sheets. Another factor contributing to the overdiagnosis of hemopericardium is the dissociation of the pericardial layers, and hemopericardium and associated (thoracoabdominal) injuries.

Computed tomography in the diagnosis of chest trauma

CT among all the listed radiation methods is the most accurate diagnostic method. It is used to localize foreign bodies and clarify injuries along the wound channel in hemodynamically stable

patients with gunshot and stab wounds to the chest. The use of CT allows us to assess the volume of hemo- and pneumothorax, to determine the depth of the wound channel in the lung and, as a result, to avoid thoracotomy and perform videothoracoscopy in a significant number of victims. The advantages of CT are speed, the ability to obtain objective quantitative indicators. The sensitivity of spiral CT in detecting hemo- and pneumothorax is 100%.

Thus, the use of radiation diagnostic methods makes it possible to identify hemopneumothorax and, depending on the research method, to estimate its volume. The use of CT allows you to accurately assess the severity of injuries along the wound channel. Taking into account the state of the victim's hemodynamics, the results of radiation diagnostics and the time elapsed from the moment of injury to admission, a decision is made on the method of surgical treatment.

The article was prepared and edited by: surgeon

For citation:Kotlyarov P.M. Radiation methods in the diagnosis of respiratory diseases // BC. 2001. No. 5. P. 197

Russian Scientific Center for X-ray Radiology, Ministry of Health of the Russian Federation

D diagnosis of many diseases of the bronchopulmonary system is based on radiography, X-ray computed tomography (RKT), ultrasound examination (Ultrasound), magnetic resonance imaging (MRI) of the chest. Methods of medical imaging (radiation diagnostics), despite the different methods of obtaining an image, reflect the macrostructure and anatomical and topographic features of the respiratory system. The combined analysis of their data makes it possible to increase the sensitivity and specificity of each of them, to move from probabilistic to nosological diagnosis. We analyzed the data obtained in the study of more than 4000 patients with pneumonia of various etiologies, chronic obstructive pulmonary disease (COPD), tuberculosis, and lung cancer. Radiography and CT are the most commonly used medical imaging methods for respiratory pathology. The frequency of using longitudinal tomo- and zonography, angiopulmonography with the introduction of CT into clinical practice has decreased.

Radiography and longitudinal tomography

Traditional chest x-ray remains the mainstay of primary chest examination. This is due to the low radiation dose on the patient and the low cost of the study compared to other methods with a fairly high information content. Devices for radiography are being improved, devices with digital image processing have reduced the dose of radiation by an order of magnitude, increasing the quality of the image, which has become possible to undergo computer processing, to store it in memory. The need for X-ray film and archives has disappeared. Now it is possible to transfer images over cable networks, processing on the monitor. It should be noted the high quality of digital X-ray equipment from leading domestic manufacturers, which is not inferior to foreign counterparts in its technical characteristics. Thus, digital receivers of NIPK “Electron”, installed on the X-ray diagnostic and fluorographic systems produced by this company, provide a resolution comparable to that of an X-ray film: 2.5-2.8 pairs of lines per mm. Plain radiography is performed for all patients with suspected respiratory pathology.

Longitudinal tomography of the lungs- the method of layer-by-layer examination - is used in traditional radiology in 10-15% of patients to clarify the data of plain radiography on the macrostructure of the zone of pathological changes in the lung tissue, roots of the lungs, mediastinum, and today, given the lack of devices for CT in practical health care, this is the main method "Fine" assessment in bronchopulmonary pathology in the absence of a RKT apparatus.

X-ray computed tomography

Due to its high resolution, RKT has significantly supplanted longitudinal tomography. Thin sections of the chest organs, computer processing of information, performing the study in a short time (10-20 seconds) eliminate artifacts associated with breathing, transmission pulsation, etc., and the possibility of contrast enhancement can significantly improve the quality of the CT image on the latter generations. Volumetric reconstruction gives an idea of \u200b\u200bthe bronchopulmonary system in the mode virtual reality... A relative disadvantage of X-ray CT is the high cost of the study compared to conventional X-ray methods. This limits the widespread use of X-ray CT. Studies carried out at the Russian Scientific Center for Radiology and Radiation have shown that the damaging effect of radiation exposure with X-ray CT is significantly lower than with conventional longitudinal tomography. The absolute indications for chest CT are:

Spontaneous pneumothorax of unknown etiology;

Tumors of the pleura, pleural layers;

Clarification of the nature and prevalence of focal lung pathology;

Study of the state of the lymph nodes in the mediastinum, the roots of the lungs;

Volumetric formations in the mediastinum;

Absence of pathological changes in the lungs, mediastinum with conventional radiography, in the presence of clinical and laboratory data for such;

Study of the fine macrostructure of the lungs in chronic processes.

Magnetic resonance imaging

MRI has been considered by a number of authors as an alternative to CT in the study of the bronchopulmonary system. It should be noted that the method has made significant progress in improving the quality of visualization of the lung and lymphoid tissue by improving the technique and reducing the time required to obtain an image. The advantages of MRI include a clear differentiation of vascular and tissue structures, fluid, the ability to clarify the properties of tumors in the process of contrast enhancement, their growth into vessels, adjacent organs, and the absence of radiation exposure to the patient. Data on visualization of pathological changes in lymphoid tissue are encouraging. However, such disadvantages of the method as the lack of visualization of the broncho-alveolar tissue, the duration of the study (from 40 minutes or more), claustrophobia in 30-50% of patients, higher than that of CT, the cost hinder the use of MRI in pulmonological practice. Absolute indications for MRI are suspicion of vascular genesis of pathological changes in the lungs, changes in the mediastinum, fluid containing focal changes (cysts of various origins, pleural tumors, pleurisy of unknown origin).

Lung fluoroscopy

Lung fluoroscopy is used for differential diagnosis fluid in the pleural cavity and old pleural layers, studying the respiratory function of the lungs with suspicion of a small tumor of the bronchus, when performing targeted X-ray images to assess the fine internal macrostructure of the focus, especially with its parietal localization. The disadvantage of this method is a significant radiation load on the patient, which depends on a number of factors (type of device, experience of the radiologist, the severity of the patient's condition) and can reach 10-15 R per skin. To reduce the radiation exposure to the patient and staff, it is necessary to use X-ray diagnostic devices equipped with digital amplifiers of the X-ray image. URI-612 X-ray image intensifiers manufactured by NIPK Electron are used to equip new X-ray diagnostic systems and to modernize those already in operation. The absolute indication for fluoroscopy is the study of ventilation in case of suspicion of a small tumor of the bronchus according to plain radiography. Fluoroscopy is superseded by ultrasound scanning to determine fluid, and X-ray CT is used to study the fine structure.

Ultrasound procedure

Ultrasound of the lungs and mediastinal organs has become a part of everyday practice. The indications for using the method are determined by X-ray data. The absolute are: the presence of fluid in the pleural cavity; located parietally, above the diaphragm, education in the lungs, mediastinum; the need to clarify the state of the lymph nodes along the major vessels of the mediastinum, supraclavicular and axillary.

Organ ultrasound abdominal cavity, small pelvis, thyroid and mammary glands greatly facilitates understanding of the nature of focal changes in the lungs and mediastinal lymph nodes. In lung cancer, sonography is the method of choice in clarifying the spread of the tumor to the pleural sheets, chest wall. Ultrasound is the gold standard in the diagnosis of cystic changes, minimally invasive treatment of cysts of the pericardium, mediastinum and other localization. The method should be more widely used in pediatrics to monitor pneumonia.

Bronchography

The tactics and technique of performing bronchography have radically changed with the introduction of bronchoscopy. Transnasal catheterization of one of the main bronchi with the introduction of oil contrast agents is a thing of the past. It is optimal to combine bronchoscopy with bronchography through a fibroscope with the introduction of 20 ml of 76% urografin, verografin or other water-soluble contrast agent. In this case, a contrast agent is targeted injected into the lobar or segmental bronchus of the zone of interest. The low viscosity of water-soluble substances ensures their penetration down to the bronchioles. Contrast substances are absorbed through the bronchial mucosa, disappearing from its lumen within 5-10 seconds. This time is enough to perform an X-ray and visualize the macrostructure of the bronchi of the studied area. The combined analysis of visual and other information obtained in the process of bronchoscopy with bronchography increases the sensitivity, accuracy and specificity of the techniques.

Radionuclide methods

Radionuclide methods for studying the macrostructure of the lungs in connection with the introduction into clinical practice of CT began to be used more selectively. The indication for the use of technetium scintigraphy is a suspicion of pulmonary embolism. Scintigraphy with gallium is one of the ways to clarify the nature of a focal lesion in the lungs: an increased accumulation of a radionuclide in the focus in combination with the data of traditional radiography, X-ray CT with high degree probabilities may indicate malignancy of the formation. The use of radionuclide studies in pulmonology is currently limited due to the high cost of isotopes, the difficulty of obtaining them, and the narrowing of indications for their use.

Thus, medical imaging has a wide range of techniques for identifying, localizing, clarifying the nature of the pathological focus, the dynamics of its development. The algorithm for examining a particular patient should be determined by the diagnostician after analyzing the data of conventional radiography and clinical and laboratory data.

Diagnostic algorithms

Chest X-ray analysis reveals a number of X-ray syndromes. According to our data, the nosology of changes in 75% of cases can be determined by comparison with the clinical and laboratory picture of the disease and the data of previous X-ray or fluorography. Thus, pneumonia, tuberculosis, lung cancer, other pathological processes. In 25% of cases, to approximate a nosological diagnosis, conventional tomography, ultrasound, CT and even fluoroscopy are used. Establishing nosology does not always allow you to abandon RKT, since with lung cancer, pleural tumors, mediastinal tumors, the question arises about the prevalence of the process.

We propose an algorithm for radiation examination of patients, depending on the identified X-ray syndromes. Syndrome as an example pulmonary infiltration (most often encountered in practice), consider the possibilities of a combined analysis of the clinical and laboratory picture and the data of radiation examination.

Young age, acute onset, inflammatory blood picture, physical examination data plus the presence of infiltrative changes in the lungs make it possible to diagnose acute pneumonia with an accuracy of 90-95% and, as a rule, do not require other radiation methods for further examination (Fig. 1). Infiltration of lung tissue with an erased clinical picture, the absence of a pleural reaction raises the question of lung cancer and other pathological processes. In these situations, to clarify the internal macrostructure, assess the condition of the lymph nodes of the roots, mediastinum, it is necessary to perform CT. X-ray CT data clarify the macrostructure of changes: localization, internal structure of the zone of pathological changes, the presence or absence of other changes. Nosological interpretation of X-ray CT and X-ray data is possible in 60-70% of patients, in the rest, a diagnostic probabilistic series of nosologies is displayed.

Figure: 1. Chest X-ray: infiltrate of a heterogeneous structure with indistinct contours, clinic of acute pneumonia.

Figure: 2. The same patient after recovery: carnification of a part of the lobe, as an outcome of acute abscess pneumonia.

Further progress towards the diagnosis is possible by means of dynamic monitoring - periodic repetition of radiation examination and comparison of data with previous ones (Fig. 2). For infiltrative processes in the lungs inflammatory etiology (acute bacterial, fungal pneumonia, infiltrative tuberculosis) characterized by different dynamics in the treatment process, which is important diagnostic criterion to establish the etiology of the process. The ratio of the frequency of pneumonia bacterial origin with fungal and tuberculosis is 10-20: 1. Therefore, naturally, both clinicians and diagnosticians are initially focused on the treatment of bacterial pneumonia. In most cases, it is difficult for a diagnostician at the stage of primary examination to judge the exact nosology by the X-ray picture, but he may be alerted by a number of non-standard facts (high intensity of darkening, the presence of old tuberculous changes in the lungs, localization of the infiltrate in the upper lobe). In this case, in the final conclusion after the diagnosis of acute pneumonia, there should be a suspicion of an infiltrative form of tuberculosis. In another situation, when on primary radiographs there is a massive infiltrate with damage to the lobe or the entire lung, massive effusion and foci of decay, a pronounced root reaction, Friedlander's pneumonia is beyond doubt.

Repeated X-ray examination in patients with acute pneumonia is carried out depending on the clinical course of the disease. Improvement of clinical and laboratory parameters under the influence of treatment, rapid recovery give reason to postpone control radiography until the patient is discharged. On the contrary, the deterioration of the clinical and laboratory picture, the absence of the effect of the therapy being carried out strongly require a control X-ray examination (Fig. 3, 4). In this case, several options for the development of events are possible:

Figure: 3. Lateral radiograph: infiltrative changes in the root zone of the right lung, clinical manifestations of malaise.

Figure: 4. RCT of the same patient: infiltrative changes in the lung without positive dynamics after treatment for pneumonia, with verification of a pneumonia-like form of bronchioloalveolar cancer.

Negative X-ray dynamics

Lack of dynamics

Weakly positive or slightly negative dynamics.

Negative dynamics, as a rule, is expressed in an increase in infiltrative changes, the appearance of decay, pleurisy often grows, a reaction of the roots of the lungs, the appearance of inflammatory foci in the opposite lung is possible. This X-ray picture indicates the inadequacy of therapy, the weakening of the patient's defense mechanisms. To clarify the volume of the lesion, early diagnosis of possible pleural empyema, to clarify the nature of the effusion (the appearance of inclusions of increased echogenicity, gas bubbles, turbidity of the liquid, the formation of leaks in the lung tissue - an unfavorable diagnostic sign), an ultrasound of the chest is necessary. RCT is the method of choice for determining the prevalence of infiltration, clarifying the zone of decay of lung tissue. RCT is of no small importance in determining possible cause severe course of pneumonia: for the first time reveals various anomalies in the development of the lung (cystic changes, hypoplasia of the lobe, etc.), which were not previously recognized. Subsequent diagnostic monitoring of this group of patients depends on the course of the disease.

In a situation with a weakly negative dynamics of the X-ray picture, one should think about the fungal genesis of pneumonia or the tuberculous etiology of the process. It also shows an X-ray examination of the lungs: the identification of old tuberculous changes (calcifications in the infiltrate, upper lobes of the lungs, lymph nodes of the roots) will give some confidence in the tuberculous nature of the lesion. The absence of the above changes does not allow excluding the fungal genesis of the disease.

A weakly positive dynamics in most cases makes one suspect a lung tumor with impaired ventilation of the lobe (segment) and the development of secondary pneumonia. Often, with control radiography against the background of a decrease in the intensity of the infiltrate, a tumor node is detected, with or without decay zones. In the absence of obvious signs of a tumor, one should resort to bronchoscopy, lung CT. RCT can reveal the actual nodule, the presence of metastatic lesions of the lungs, pleura, lymph nodes.

The syndrome of formation (formations) in the lung is the most important from the point of view of nosological interpretation. It is necessary to resolve the issue of benignity or malignancy, as well as the tuberculous nature of education (exclude tuberculosis). For a diagnostician, this is not just a problem, since in most cases clinical and laboratory data for the disease are either absent, or the changes are of a general nature. The task is facilitated if there is anamnesis, X-ray or fluorograms of previous years, typical radiological semiotics of benign or malignant tumor (Fig. 5), tuberculomas, etc. However, this does not exclude the use of additional research methods - CT, ultrasound, MRI, scintigraphy. RCT of the lungs is necessary to search for foci that are invisible on a conventional radiograph, which can change the interpretation of the diagnosis or suggest that the process is malignant with screening in the lung tissue, pleura, regional lymph nodes; to clarify the fine internal macrostructure of the focus - small cavities of decay, calcifications, uneven contours, connection with the lung tissue. Traditional X-ray and tomography, due to the lower resolution, capture only pronounced changes measuring 1-2 cm or more.

Fig. 5. Typical picture of peripheral lung cancer on RK-tomogram.

Before concluding, I would like to dwell on the role and place of preventive fluorographic studies in the population in identifying lung diseases. The method did not justify itself in early diagnosis lung cancer - the costs are huge and the results in detecting stage I-II tumors are minimal. However, the method is effective in recognizing respiratory tuberculosis and today it should be used in population groups in regions that are unfavorable for tuberculosis infection.

Thus, the combined analysis of X-ray and X-ray CT data for focal lesions in the lungs mutually complement each other both in terms of interpreting the nature of the lesion and its prevalence, if it is malignant. It should be emphasized that if the X-ray macrostructural signs of malignancy have been studied and worked out for a long time, then the X-ray CT signs still need to be understood. This is relevant in the light of the constantly improving technique, the emergence of “spiral” X-ray CT, which gives a high resolution, a more subtle picture of focal changes, revealing foci 2-3 mm in size. In this situation, the question arose about their nosological assessment when there is a focus suspicious of lung cancer. When performing high-resolution screening CT in smoking patients, in 30-40% of them small focal pulmonary subpleural compaction is revealed, the nosological interpretation of which is impossible without RT-monitoring. X-ray CT monitoring of “small” changes in lung tissue will become a global problem in the near future.

The list of references can be found on the website http: //www. Site

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This article will discuss the most important aspects of the diagnosis of thoracic injury through X-ray examination. Thus, routine X-rays can diagnose changes such as fractures of the sternum, collarbones, ribs and spine; damage to the lung parenchyma; accumulation of fluid in the chest cavity; pneumothorax; emphysema of the soft tissues of the chest wall; hemorrhages in the pericardial cavity and in the mediastinum.

Bone trauma on x-rays. Rib fractures

On conventional radiography, rib fractures can often be missed, especially if the displacement of bone fragments is minimal, and the fracture is localized closer to the lateral side of the chest. In doubtful cases, it is necessary to take an aiming shot in an oblique projection - with a roller under the side of interest. Often rib fractures are combined with extrapleural hematomas that look like a local crescent-shaped shadow, partially compressing the lung. Rib fractures are considered multiple, when at least three ribs are damaged on one side - in this case, instability of the chest is possible - which is an indication for extra-bone fixation of broken ribs (plates).

Radiographs show multiple fractures of the ribs on the left (broken ribs are marked with red arrows). A small extrapleural hematoma is also visible (indicated by green arrows). The blue arrow marks the shadow of the tubular drainage in the chest cavity (installed for the purpose of aspiration of fluid and gas). Free gas in the chest cavity is marked with red asterisks

Bone trauma. Fractures of the sternum and vertebrae

Fractures of the sternum are diagnosed on the basis of images in the lateral projection: the typical site of the fracture is the angle of the sternum. Difficulties in the diagnosis of fractures may arise in the absence of displacement of the fragments - in this case, CT is necessary. Fractures of the vertebrae are poorly visible on images of the lungs, as a result of which radiography of the BHC in patients with trauma should be supplemented with images of the spine.

Hemothorax

On radiographs, the hemothorax looks like a shadow with an oblique upper border (however, it is impossible to reliably assert the nature of the fluid from X-rays). After puncture of the pleural cavity and aspiration of blood, the volume of hemothorax decreases significantly, the shadow becomes smaller in size and intensity. Evaluation of the volume of fluid in hemothorax on X-ray images is essential. So, in the standing position of the patient, you can notice the fluid in the chest already starting from a volume of 0.2 liters, in the lying position - from 0.5 liters. Smaller lying volumes are hardly visible - so, only a decrease in the transparency of the pulmonary field on the affected side can be detected.

Damage to the trachea, large bronchi

Ruptures of the wall of the trachea or large bronchi are a relatively rare injury that requires the application of a large traumatic force. In isolation, such injuries almost never occur, and are accompanied by fractures of the upper ribs, sternum, spine, mediastinal hemorrhage, hemothorax, hemopericardium, etc. The most common place of rupture is tracheal bifurcation and 2-3 cm higher. The size of the defect is different - from several mm to complete rupture with a divergence of the tracheal walls. In this case, air escapes into the mediastinum and into the tissue of the neck and chest wall (with a rupture of the bronchus to the point of entry into the lung) with the development of pneumomediastinum and subcutaneous emphysema, as well as into the pleural cavity - with compression of the lung (with a rupture after the place of entry into the lung). Differential diagnosis with a ruptured esophagus requires oral contrast radiography (using a water-soluble contrast agent).

Pleural injury, pneumothorax

Depending on the communication with the external environment, pneumothorax can be:

- Open to the outside (through a defect in the chest wall);
- Open inwards (through a defect in the visceral pleura);
- Open both outside and inside;
- Valve;
- Closed (with pressure above, below, or equal to atmospheric).

Pneumothorax on radiographs: 1 - compressed lung, 2 - shadow of tubular drainage, 3 - subcutaneous emphysema (gas in soft tissues), 4 - free gas in the chest cavity (pneumothorax), 5 - fluid level in the chest cavity (horizontal)

Contusion foci in the lung parenchyma are detected in those places that directly border on dense anatomical structures (chest skeleton, diaphragm, heart). When a force is applied to a section of the lung, blood vessels and membranes are damaged, blood extravasation, and then edema (interstitial and alveolar).

Radiation diagnostics for trauma

Radiation diagnostics plays an important role in the initial examination of patients with trauma and in determining EMF tactics. The main method of radiation diagnostics used at this stage is radiography. However, many trauma centers are increasingly using other methods * such as helical CT, angiography and RT to make a definitive diagnosis and rule out injuries. Improvement of methods of radiation diagnostics made it possible to increase the accuracy of the information received and reduce the examination time, and the development of endopascular treatment methods has created an alternative surgical interventions with some vascular damage.

The choice of the method of radiation diagnostics is individual and depends on a number of factors, which are listed below.

Availability of equipment for carrying out a particular study and its proximity to the place of provision of EM P.
The quality and speed of obtaining information using the available equipment.
Availability of specialists in radiation diagnostics and experience in their emergency research.
Availability of specialists who can analyze the information received.
The ability to timely transfer research results to other specialists.
The ability to monitor basic physiological parameters, maintain vital functions, including resuscitation, in case of a sudden deterioration in the patient's condition during transportation to the study site or during the study itself.

The main factor that determines the possibility of conducting a study and its duration is the stability of the patient's hemodynamics. In case of severe shock and ineffectiveness of the first stage of EMF, any examinations may be unsafe. The only test that can be done is a bedside ultrasound to detect fluid in the body cavities. If a patient is admitted in a state of shock but has been treated effectively, bedside chest, pelvic, and spinal x-rays can be performed, while transporting him to other departments for CT or MRI is dangerous. With initially stable hemodynamics in the absence of deterioration of the patient's condition at the first stage of EMF, if necessary, CT or MRI can be performed. Optimal use of imaging techniques requires close collaboration and interaction between trauma surgeons, nurses and research staff. A specialist in radiation diagnostics can and should help the surgeon-traumatologist select the necessary examinations and determine their sequence in order to fully answer the questions that arise in a particular clinical situation.

RADIATION DIAGNOSTICS FOR CHEST INJURY

X-ray of the chest in the posterior direct projection allows you to accurately diagnose pneumothorax, including tension, pneumomediastinum, pneumopericardium, Bruise, -a; m. Mechanical damage to the body without violating the integrity of the outer integument, accompanied by rupture of small vessels and hemorrhage, violation of the integrity of the subcutaneous tissue, muscle fibers, and sometimes internal. organs (liver, spleen, etc.).

"data-tipmaxwidth \u003d" 500 "data-tiptheme \u003d" tipthemeflatdarklight "data-tipdelayclose \u003d" 1000 "data-tipeventout \u003d" mouseout "data-tipmouseleave \u003d" false "class \u003d" jqeasytooltip jqeasytooltip4 "id \u003d" jqeasytooltip4 "title \u003d" (! LANG: Hemothorax">гемоторакс , повреждения костей грудной клетки и синдром Мендельсона. Среди недостатков метода следует отметить необходимость выполнения больным команд и его неподвижности во время исследования, низкое качество рентгенограмм при проведении прикроватного исследования и отсутствие контрастирования. При рентгенографии грудной клетки затруднена диагностика повреждений сердца и средостения, разрыва легкого, малого пневмоторакса, незначительных повреждений !} thoracic spine. Chest X-ray does not reveal about half of the lesions in the left dome and most of the lesions in the right diaphragm dome.

Classification of closed injuries and chest injuries: Closed damage... I no damage internal organs... 1. No bone damage. 2. With damage to the bones (without paradoxical or with paradoxical movements of the chest). II. With damage to internal organs. 1. No bone damage. 2.With damage to the bones (without paradoxical or with paradoxical movements of the chest)

Wounds I. Non-penetrating wounds (blind and through). 1. Without damage to internal organs: a) without damage to bones; b) with damage to bones. 2. With damage to internal organs: a) without hemothorax, with small and medium hemothorax; b) with a large hemothorax. II. Penetrating wounds (through, blind). 1.With pleura and lung injury (without hemothorax, with small, medium and large hemothorax): a) without open pneumothorax; b) with open pneumothorax; c) with valvular pneumothorax... 2.Wounded anterior section mediastinum: a) without organ damage; b) with damage to the heart; c) with damage to large vessels. 3.With injury to the posterior mediastinum: a) without damage to organs; b) with damage to the trachea; c) with damage to the esophagus; d) with damage to the aorta; e) with damage to the mediastinal organs in various combinations.

The X-ray method is one of the most informative methods for diagnosing damage to the chest and chest cavity organs. With dynamic X-ray examination, it is usually possible to objectively assess the course of the pathological process, timely recognize complications and determine the effectiveness of therapy. Almost all patients with chest trauma need primary and repeated X-ray examinations, which are usually carried out repeatedly. From a practical point of view, it is advisable to divide patients with chest trauma into three groups: 1) patients with severe injuries who are indicated for urgent surgical intervention; 2) patients with severe injuries who need resuscitation without surgical interventions; 3) patients with injuries of moderate severity and minor injuries, who do not need urgent operations and resuscitation. The victims of the first group are examined directly in the operating room on the X-ray operating table. X-ray examination of patients of the second group is carried out in the intensive care unit on a gurney, stretcher or in bed. X-ray examination of the chest is performed in two mutually perpendicular projections, using attachments and devices that allow a polypositional study without changing the patient's position. In addition to plain radiography and fluoroscopy, in the process of examining the victims, special methods of X-ray examination are used. If there is a suspicion of damage to large bronchi and such complications as bronchial fistulas, hidden cavities, etc., often resort to broncho- and fistulography. Pulmonary angiography, aortography, and radionuclide studies (gamma scintigraphy) can be used to identify damage to the aorta, as well as to assess the pulmonary circulation. Valuable information about the condition of the organs of the chest cavity can be obtained using computed tomography.

Fig. 1. Placement for X-ray of the upper and middle ribs in a direct posterior projection Fig. 2 Placement for an X-ray of the lower ribs in a direct posterior projection. 3. Placement for radiography of the ribs in a direct anterior projection Fig. 4. Laying for X-ray of the ribs in the lateral projection.

Fig. 5. Placement for radiography of the right ribs in the anterior oblique projection Fig. 6. Placement for radiography of the left ribs in the anterior oblique projection Fig. 7. Placement for radiography of the left ribs in the posterior oblique projection Fig. 8. Placement for radiography of the ribs during breathing with fixation of the chest with an elastic belt.

PACKAGING FOR BREAST X-RAY Fig. 9. Laying for radiography of the sternum in the anterior oblique projection with the patient turning to the left side. Fig. 10. Laying for radiography of the sternum in the anterior oblique projection without turning the patient Fig. 11. Placement for lateral sternum x-ray in a horizontal position on the side

Fig Stacking for radiography of the apexes of the lungs in frontal and frontal projections. PACKS FOR LUNG X-RAYS

Rib fractures Rib fractures in severe closed chest trauma, rib injuries are observed in 92%. The nature of the damage largely depends on the mechanism of injury: when the chest is compressed in the anteroposterior, direct and oblique directions, transverse and oblique fractures often occur, and comminuted fractures during impact. Injuries to the lower ribs usually occur with concomitant injuries to the chest and upper abdomen. This often damages the liver and spleen. With single oblique or transverse fractures, damage to the lungs and pleura may be absent, while multiple, especially comminuted, rib fractures are usually accompanied by damage to the lungs and pleura. X-ray diagnosis of rib fractures is based mainly on determining the fracture line and displacement of the fragments. An indirect symptom of rib damage is the presence of a pair of pleural hematoma, which has a semi-oval shape and is located along the inner surface of the ribs, at the level of their damage or somewhat lower.

CLASSIFICATION OF RIBS FRACTURES By etiology, fractures are divided into: traumatic and pathological fractures. Traumatic fractures appear due to the fact that a short but powerful enough force acts on the bone. Pathological fractures are the action of various diseases that affect the bone, destroying it. The turning point in this case happens by chance, you don't even notice it. 1. According to the mechanism of injury, rib fractures are divided into: a straight rib breaks where a traumatizing force is directly applied, which also damages soft tissue chest. indirect, when the fractured rib is pressed inward, an angular displacement of the fragments occurs. If an external force acts on the rib closer to the spine, then it causes a shear-type fracture: the central fragment remains in place, and the peripheral mobile and long fragment is displaced to the nutria. avulsion fractures of the ribs (from IX and below) are characterized by a large displacement of the fragment torn off the rib. 2. Classification of fractures depending on damage to the skin: 1. Open fractures: - Primary open - Secondary open 2. Closed fractures: - Incomplete - Complete

3. By the nature of the damage, rib fractures are divided into: - isolated rib fractures without the addition of other skeletal injuries, - rib fractures that are combined with injuries of the chest organs and fractures of other parts of the skeleton, - minor rib fractures that are combined with injuries of other parts of the body. 4. By the nature of the fracture, fractures are distinguished: Transverse Oblique Longitudinal Helical T-shaped U-shaped Hole Marginal Tooth-shaped comminuted -Compression-Impacted 5. By localization of the bone defect, fractures are distinguished: - Diaphyseal - Metaphyseal - Epiphyseal In relation to the joint, fractures are divided: extra-articular and intra-articular, distinguishing diaphyseal and metaphyseal (extra-articular) from epiphyseal (intra-articular) fractures on long tubular bones

6. Types of displacement, depending on the displacement factor: Primary (occurs at the time of fracture under the influence of traumatic force). Secondary (occurs under the influence of muscle contraction after a fracture). 7. Depending on the spatial orientation of the fragments, displacements are distinguished: - along the length - along the width or lateral, when the fragments are displaced away from the longitudinal axis of the limb; Axially or angular, when the fragments become at an angle to each other -Around the periphery, when the distal fragment retreats, i.e. rotates around the longitudinal axis of the limb; Angular displacements of the bone in a segment with two long bones (forearm, lower leg) are also called axial displacement. 8. Classification of fractures by clinical condition: - Stable - Unstable In stable fractures, a transverse fracture line is observed. With unstable fractures (oblique, helical), secondary displacement appears (due to increasing post-traumatic muscle retraction).

Rib fracture symptoms 1. The victim complains of severe pain in the area of \u200b\u200ba broken rib; 2. Pain in the area of \u200b\u200bthe injured rib increases with movements of the trunk and breathing; 3. The victim experiences pain in the chest when coughing; 4. The patient assumes a forced sitting position, as in this case the pain decreases; 5. When examining the patient, you can see that his breathing is shallow and on the side of the lesion there is a lag of the injured part of the chest in breathing; 6. On palpation in the area of \u200b\u200bthe broken rib, sharp pain and pathological mobility of the rib fragments are determined; 7. Crepitation of bone fragments is determined, which can produce a kind of "crunch"; 8. With multiple fractures of the ribs in the victim, you can notice a visible deformation of the chest; 9. If the patient's ribs in the anterior and lateral parts of the chest are broken as a result of trauma, then in this case the clinical picture is more pronounced and the symptoms of respiratory failure come to the fore; 10. With multiple fractures of the ribs, the victim has a worsening general condition, breathing becomes shallow, heart rate increases; 11. In the area of \u200b\u200bthe patient's broken ribs, subcutaneous hemorrhages and tissue edema may be observed; 12. In some patients, in the area of \u200b\u200brib fracture, subcutaneous emphysema is observed and on palpation air crepitus is determined, which differs from bone crepitus by the sound of "slight creaking" 13. If a lung injury occurs as a result of a fractured rib, then hemoptysis may occur;

A fracture of the sternum is manifested by the following symptoms: 1. Pain at the site of injury, pain symptoms intensify when breathing. 2. Shallow, heavy breathing, to relieve pain in the sternum. 3. Appearance acute pain when coughing. 4. The victim tries to take a bent position to loosen muscle tension, which provokes pain. 5. Relief of pain in the sitting position. 6. Formation of edema in the area of \u200b\u200bthe fracture. 7. Under the skin ruptures of capillaries are visible, a hematoma is formed. 8. Such trauma is often accompanied by multiple rib fractures, which blur the clinical picture and are the primary symptom for diagnosis. 9. Fracture of the sternum with displacement is visually manifested by indentation into the inside of the chest. 10. It is possible to feel the fragments of the sternum on palpation and notice their movement during breathing. 11. Severe displacement in fracture is a diagnostic symptom in heart contusion. As a rule, right ventricular dysfunction is short-term and does not require long-term cardiac monitoring. 12. Severe displacement from a fractured sternum, combined with fractured ribs, can damage the lungs and pleura, leading to filling of the chest with blood or air.

Fracture of the key Classification: fractures of the middle third fractures of the distal third fractures of the medial third Cynical picture: 1. Sharp pain at the fracture site, the patient takes a characteristic forced position, supports the arm on the side of the injury. 2. The head is turned and tilted towards the injury. 3. The shoulder girdle is lowered and displaced anteriorly. 4. The medial edge of the scapula and its inferior angle extend from the chest. 5. The shoulder is lowered, pressed to the body and rotated inward. 6. The poklyuchichny fossa is smoothed. In the area of \u200b\u200bthe clavicle, swelling is visible due to the protruding central fragment. 7. Palpation reveals discontinuity of the bone, it is possible (but not desirable!) To determine the pathological mobility and crepitus. 8. Fractures of the clavicle are very often accompanied by displacement of fragments. 9. The central fragment under the action of the sternocleidomastoid muscle is displaced upward and backward. 10. Peripheral - downward, anteriorly and medially.

Fracture of the scapula Depending on the location of the injury, the following types of fracture of the scapula are distinguished: axes; glenoid cavity; neck; coracoid process; acromial process; top and bottom corners; longitudinal, transverse, multi-fragment fractures; perforated (with a bullet wound).

Lung damage Lung contusion: cloud-like shadows of a focal-infiltrative nature appear in the lungs, the size, number and location of which depend on the mechanism and severity of the injury. With a relatively localized impact, accompanied by damage to the ribs, a single infiltrate with a diameter of 23 to 56 cm is most often detected on radiographs, located in the area of \u200b\u200bapplication of the traumatic force, usually at the level of rib damage. With a widespread trauma (fall from a height, car accident) of moderate severity, as a rule, several infiltrative shadows with a diameter of 0.53 cm are detected, located mostly in the peripheral parts of the lungs. In severe, unfavorable prognostic cases, massive intense shadows occur, capturing most of the lobe or the entire lung, and at the same time, small foci-infiltrative shadows, scattered over the entire surface of the lungs. A feature of pathological shadows in case of injury is the mismatch of their boundaries with the boundaries of the lobes and segments.

With predominantly peribronchial and perivascular hemorrhages, radiographs show symptoms characteristic of acute, predominantly interstitial pneumonia. There is an increase and loss of clarity of the image of the pulmonary pattern, compaction of the walls of the bronchi and infiltration of the interstitial tissue. Pathological changes are localized both in the lower and in upper divisions lungs, mainly on the side of the injury. Sometimes shadows of a focal-infiltrative nature are simultaneously revealed. Chest X-ray 1 hour after closed injury. Localized contusion of the right lung in the area of \u200b\u200ba comminuted fracture of the 8th rib. On the right along the scapular line, there is a rounded shadow of an infiltrative nature.

Anterior frontal chest radiograph 11 hours after severe closed chest injury. Widespread contusion of the right lung. Decrease in pneumatization of the entire right lung due to merging shadows of a focal-infiltrative nature. Fractures of the posterior parts of the 8-10 ribs.

A chest X-ray in a direct posterior projection was performed 2 days after a severe closed chest injury. Multiple rib fractures. Bruised and ruptured lungs. On the left, in the middle pulmonary field, there is an intense shadow of a rounded shape with clear bumpy contours.

Classification of pneumothorax: Origin 1. Traumatic. 2. Spontaneous. primary (or idiopathic) secondary (symptomatic) recurrent 3. Artificial By the volume of air contained in the pleural cavity and the degree of lung collapse: 1. Limited (partial, partial). 2. Full (total). By distribution: 1. One-sided. 2.Bilateral. By the presence of complications: 1. Complicated (pleurisy, bleeding, mediastinal and subcutaneous emphysema). 2. Uncomplicated. By communication with the external environment: 1. Closed. 2. Open. 3. Tense (valve).

The clinical picture of pneumothorax The clinical picture depends on the mechanism of the disease, the degree of lung collapse and the cause that caused it. The disease begins acutely after physical exertion, a coughing fit, or for no apparent reason with a sharp stabbing pain in the chest, radiating to the neck, upper limb, sometimes in the upper abdomen, aggravated by breathing, coughing or chest movements, difficulty breathing, dry cough. The patient breathes frequently and shallowly, there is severe shortness of breath, feels “lack of air”. Pallor or cyanosis (cyanosis) of the skin, in particular the face, appears. With an open pneumothorax, the patient lies on the side of the injury, pressing the wound tightly. When examining the wound, the noise of air suction is heard. Foamy blood may come out of the wound. The movements of the chest are asymmetrical.

Radiographically, pneumothorax is manifested: 1) anteroposterior projection - a thin line of the visceral pleura (about 1 mm); 2) displacement of the shadow of the mediastinum; 3) a small accumulation of fluid in the costophrenic sinus; 4) laterogram (a snapshot in the lateral position) - a strip of enlightenment paracostally with compressed lungs collapsed to the mediastinum; 5) some professional radiographers recommend chest x-ray if there is suspicion of air accumulation in the pleural cavity at the inspiratory height, as well as in the final part of the expiration; 6) deepening of the costophrenic sinus from the side of the lesion (a sign of a "deep groove"). 41 Pneumothorax On the X-ray picture, a tense pneumothorax is determined by the following symptoms: absence of pulmonary pattern against the background of a dark shadow of half of the chest; displacement of the mediastinum in the direction opposite to the pathology; lowering the dome of the diaphragm down from the side of the lesion.

Emphysema of the soft tissues of the breasts A frequent and reliable sign of a ruptured lung with a closed chest injury. An X-ray examination of the soft tissues of the breast reveals a characteristic "feathery" pattern: against the background of longitudinal and rounded enlightenments, individual groups of muscle fibers are clearly visible. A frontal projection chest X-ray was taken 24 hours after a severe closed chest injury. Rupture of the right lung. Right-sided pneumothorax. Intermuscular and subcutaneous emphysema. Drainage tube in the pleural cavity.

Mediastinal emphysema In the presence of pneumothorax, mediastinal emphysema may develop as a result of damage to the mediastinal and costal pleura. When the lung ruptures, air can penetrate into the connective tissue interlobular septa and then through the root of the lung into the tissue of the mediastinum. Gas in the mediastinum can appear as a result of damage to the trachea, bronchi, esophagus, as well as surgical interventions. X-ray: the presence of gas in the mediastinum. Gas is defined in the form of ribbon-like bands of enlightenment, located parallel to the sternum. Against the background of these stripes, the displaced leaves of the mediastinal pleura, as well as the contours of the mediastinal organs, are often clearly visible.

Hemothorax Hemothorax classification: By etiology: 1. Traumatic 2. Pathological 3. Iatrogenic Taking into account the amount of intrapleural bleeding, hemothorax can be: small - blood loss up to 500 ml, accumulation of blood in the sinus; medium - volume up to 1.5 liters, blood level to the lower edge of the IV rib; subtotal - blood loss up to 2 liters, blood level to the lower edge of the II rib; total - the volume of blood loss over 2 liters, radiologically characterized by total darkening of the pleural cavity on the side of the lesion. By the duration of bleeding: With ongoing bleeding. With stopped bleeding. According to the presence of clots in the pleural cavity: Coagulated. Uncoagulated.

Clinical presentation of hemothorax Minor hemothorax may not be accompanied by special complaints in patients. With percussion, there is a shortening of the sound on the Damoiseau line. When listening - weakness of respiratory movements in the posterior lower parts of the lung. With severe hemothorax, there are signs of acute internal hemorrhage: pale skin; the appearance of cold sweating; heart palpitations; lowering blood pressure. The symptoms of acute respiratory failure are gradually increasing. During percussion examination, a dull sound is observed in the middle and lower regions of the lung. Cessation or sudden weakness of breathing sounds is noticeable when listening. Patients complain of a feeling of heaviness in the chest, lack of air and the inability to take a full full breath.