Algorithm of radiation diagnostics for chest injuries. Research methods of the chest. Bone trauma on x-rays. Rib fractures

Methods of radiation examination of the chest organs: ü ü ü ü ü Fluoroscopy; X-ray; Longitudinal tomography; Bronchography; CT scan; Magnetic resonance imaging; Angiopulmonography; Radionuclide research; Ultrasound examination of the heart and pleural cavities.

Fluoroscopy Objectives: to determine the degree of displacement of shadows during the patient's breathing; ü to assess changes in the transparency of the pulmonary background during inhalation and exhalation, which makes it possible to judge the elasticity of the lung tissue; ü dynamic control over the pathological process and the level of fluid in the pleural cavity; ü for the purpose of puncture biopsy of formations in the chest cavity. ü

Radiography Projections: Ø Straight posterior Ø Lateral left Ø Lateral right Ø Oblique Ø Straight anterior Ø Sight

Radiography A picture of the lungs in a direct anterior projection Purpose of the study: to study the state of the lungs in case of suspicion of any disease or damage to them. Laying for the picture: the picture is taken in the patient's standing position (or sitting, depending on the condition) at a special vertical stand; the patient is pressed tightly with his chest to the cassette, slightly bent forward.

Radiography X-ray image of the lungs in the lateral projection It is performed in the left or right projections. The patient is installed so that he is pressed against the cassette with the examined side. Hands are raised up and crossed over the head.

Longitudinal tomography Objectives: 1. To determine the nature, exact localization and prevalence of the pathological process in the pulmonary parenchyma; 2. To study the condition of the tracheobronchial tree, including, in most cases, and segmental bronchi; 3. To clarify the nature of the defeat of the lymph nodes of the roots and mediastinum in various pathological conditions.

Bronchography The technique of X-ray examination of the contrasted large and medium bronchi along their entire length after preliminary anesthesia

Bronchography Plan for studying a bronchogram: For each bronchus, take into account: a) position, b) shape, c) width of the lumen, d) nature of filling, e) angle of origin and nature of branching, f) contours, g) localization and nature of deviations from the normal picture ... With regard to the bronchi, which are not filled with a contrast agent, take into account the position, shape and outline of their stump, the state of the lung tissue surrounding the bronchus.

X-ray computed tomography Features of CT images: ú Absence of superposition; ú Lateral orientation of the layer; ú High contrast resolution ú Determination of absorption coefficient; ú Various types of image processing.

Magnetic resonance imaging A method based on the paramagnetic properties of tissues. Indications: - volumetric processes in the mediastinum; -assessment of the condition of the lymph nodes; -pathological changes in large vessels; -determination of the invasion of lung tumors into the mediastinum, large vessels and pericardium. Restrictions: -calcifications; -assessment of the pulmonary parenchyma.

Pulmonary angiography is a method of X-ray examination of pulmonary vessels after their contrasting with water-soluble iodine-containing non-ionic RCS. Varieties of methods: üAngiopulmonography; üSelective angiography of one lung or its lobe (segment); üAngiography of bronchial arteries; üThoracic aortography.

Radionuclide examination Indications: ú Suspicion of pulmonary embolism; ú suspicion of a pulmonary infarction; ú Areas with reduced or no blood flow are identified in the form of zones with low-intensity radiation.

Ultrasound examination Indications: ü for studying the heart and large vessels; ü to assess fluid structures, primarily pleural effusion; ü for puncture drainage of encapsulated formations in the pleural cavity Ultrasound examination is not the method of choice in assessing the amount of fluid in the pleural cavity (!), but only allows you to accurately localize it and give its characteristics. Ultrasound beam does not penetrate air-filled alveoli

Normal anatomy of the lungs The lungs are a paired parenchymal organ covered with a visceral pleura. Allocate: 3 lobes in the right lung; 2 lobes in the left lung.

The functional unit of the lungs is ACINUS ü The size of the acinus is up to 1.5 mm. ü Includes alveolar sacs, terminal bronchiole, arteriole, 2 venous branches, lymphatic vessels and nerves. ü A group of acini is a lobule.

Non-parenchymal component 1. Bronchial branches 2. Pulmonary veins 3. Lymphatic vessels 4. Nerves 5. Connecting layers between the lobules, around the bronchi and blood vessels 6. Visceral pleura

X-ray picture of the chest organs This is the summation of shadows: - soft tissues of the chest wall - bone skeleton - lungs - mediastinum - diaphragm

Soft tissues Muscles - The pectoralis major muscle at the level of 4 m / ribs goes obliquely upward and outward and extends beyond the edge of the pulmonary field - The sternocleidomastoid muscle, gives a decrease in the transparency of the pulmonary field in the medial region above the clavicle and passes into the supraclavicular skin fold - Milk glands and shadows of the nipples, give darkening of the pulmonary fields at the level of 4-7 ribs in women and in men

Bony skeleton Ribs limit the pulmonary fields Above - the lower edge of the posterior part 2 ribs From the sides - the shadows of the intersecting costal arches In the projection of the pulmonary fields, 11 pairs of the posterior parts of the ribs are visible, going upwards, then downwards and outwards. The front line runs from the outside and from the top to the inside and down. The cartilaginous part of the rib is visible when it is calcified

Bone skeleton Shadow of the clavicle Projected onto the upper portions of the pulmonary fields. If the patient is correctly positioned, the inner ends are symmetrically spaced from the shadow of the handle of the sternum and the spine and are located at the level of the 3rd intervertebral space.

Bone skeleton Shadow of the sternum Not visible in frontal projection or partially of the facets of the handle of the sternum from the median shadow. The shadows of the shoulder blades When properly laid, their greater mass is projected outside the pulmonary fields.

Diaphragm Restricts the pulmonary fields from below In the central part it stands high, to the periphery it descends steeply downward and forms costo-diaphragmatic angles. Right dome - anterior section 6 ribs Left dome - 6 intercostal space and depends on the state of the abdominal organs

Segmental structure of the lungs The right main interlobar groove begins behind the level of 2-3 thoracic vertebra and is projected in the region of the first intercostal space above the shadow of the head of the right root, goes obliquely outward and downward towards the posterior parts of the ribs and reaches 5 ribs on the lateral outer contour of the chest, descends anteriorly along the anterior end of 4 ribs to the diaphragm (crosses almost in the middle). From the main oblique interlobar groove to the right at the level of the 5th rib, the middle groove begins at the outer contour of the chest, goes strictly horizontally to the median shadow, crossing the anterior end of the 4th rib along the midclavicular line and reaches the middle of the shadow of the arterial part of the root.

Segmental structure of the lungs The posterior border of the left oblique interlobar sulcus is higher, projected towards the end of the 1st rib, goes outwards more obliquely downward and, crossing the anterior end of the 6th rib, approaches the area of ​​the left cardiophrenic angle.

Additional lobes The proportion of the azygos vein (lobus venae azygos) Occurs in 3 - 5% of cases, with an abnormal location of the azygos vein. If the pleura of the lobe of the azygos vein is compacted, then it is clearly visible on the direct radiograph on the right in the medial section of the upper lobe. The lingual lobe is analogous to the middle lobe of the right lung.

Additional lobes There are also other additional lobes: Ø pericardial Ø posterior lobe Additional lobes are ventilated by zonal or segmental bronchi, the number of which is not increased. T. O. with additional interlobar grooves, the amount of lung tissue, bronchi and blood vessels remains normal.

The shadow of the lungs on the roentgenogram is called the pulmonary fields.The image is made up of the normal pulmonary background and the normal pulmonary pattern It is important to remember that the pulmonary fields on the roentgenogram are smaller than the true size of the lung, some of them are blocked by the diaphragm, subphrenic organs and the mediastinum.

Pulmonary background This is the degree of film blackening within the pulmonary fields. Displays the density of the lung tissue, its air and blood filling.

Pulmonary drawing Substrate - vessels of the pulmonary circulation. At a young age, the rest of the elements of the lung stroma are not normally visible. After 30 years, paired strips of thickened bronchial walls appear, the number of which increases with age. This is the age norm. Long linear shadows of the vessels emanate from the root of the lung, are fan-shaped, become thinner and disappear before reaching the periphery 2 -2. 5 cm ü Short linear or trabecular shadows - small vascular network ü Looped formations - projection overlay of trabecular shadows ü Small intense focal shadows are vessels in a transverse (tangential) section. ü

The roots of the lungs The anatomical substrate is the pulmonary artery and large bronchi. The image of a normal root is characterized by the presence of structure, that is, the ability to distinguish between its individual elements.

Characteristics of the root 1. 2. 3. 4. Position of the root at the level of 2-4 intercostal space; Dimensions diameter = 2.5 cm (1: 1 pulmonary artery: intermediate bronchus); The outer contour of the pulmonary artery is convex, retracted; Structure - bronchus, artery, vein.

The root of the right lung The base of the head is the upper lobe bronchus. The body is the trunk of the pulmonary artery, the intermediate bronchus. The tail is the broncho-vascular legs at the level of the 4th intercostal space.

The root of the left lung. It is located above the right one by 1.5-1 cm. The shadow of the mediastinum is superimposed on it. The head is the left pulmonary artery and bronchovascular legs. Tail - vessels going to the pyramid.

Mediastinum Occupies an asymmetric position: 2/3 - in the left chest cavity, 1/3 - in the right. Right contour: § right atrial arch; § the ascending part of the aorta; § point of intersection - atriovasal angle.

Mediastinum Left contour: 1 arch - the descending part of the aortic arch, the upper contour is located below 1. 5 -2 cm from the sternoclavicular joint; 2 arch - the trunk of the pulmonary artery; 3 arc - left atrial appendage; 4 arc - left ventricle.

Algorithm for studying the X-ray of the chest organs. cells 1. Assessment of quality 2. 3. 4. Determination of the correctness of the patient's position. X-ray anatomical orientation (shape and size of the chest, topography of the chest cavity organs). Study of soft tissues and bone skeleton (symmetry, shape, structure)

Algorithm for studying the X-ray of the chest organs Comparison of the transparency of the right and left lungs. 6. Analysis of the pulmonary pattern. 7. Assessment of the roots of the lungs. 8. Position of the diaphragm. 9. The state of the costophrenic sinuses. 10. Study of the mediastinal organs. 5.

The work used illustrations and materials of the Moscow Humanitarian Medical and Dental Faculty, as well as materials found on the Internet.


Classification of closed injuries and chest injuries: Closed injuries. I. No damage to internal organs. 1. No bone damage. 2. With damage to the bones (without paradoxical or paradoxical movements of the chest). II. With damage to internal organs. 1. No bone damage. 2.With damage to the bones (without paradoxical or 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.With an injury to the anterior mediastinum: a) without damage to organs; b) with damage to the heart; c) with damage to large vessels. 3.With an injury to the posterior part of the 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 require 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 interventions; 2) patients with severe injuries in need of resuscitation measures without surgical intervention; 3) patients with moderate injuries 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 position of the patient. 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 complications such as bronchial fistulas, hidden cavities, etc., they 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.


Rice. 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 radiography of the ribs in the lateral projection.


Rice. 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. Laying for X-ray 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. Rice. 10. Fitting for radiography of the sternum in the anterior oblique projection without turning the patient Fig. 11. Placement for lateral sternum radiography 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 when struck, comminuted fractures occur. 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 slightly below.


CLASSIFICATION OF RIBS FRACTURES According to the etiology, fractures are divided into: traumatic and pathological fractures. Traumatic fractures appear due to the fact that a short but powerful 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 the soft tissues of the 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 shifted 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 damage, fractures of the ribs are divided into: - isolated fractures of the ribs without attaching other injuries to the skeleton, - fractures of the ribs, which are combined with injuries of the chest organs and fractures of other parts of the skeleton, - minor fractures of the ribs, which 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 Y-shaped Hole Marginal Tooth-shaped comminuted -Compression-Impacted 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 moment 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 displacement of the bone in a segment with two long bones (forearm, lower leg) is also called axial displacement. 8. Classification of fractures by clinical condition: - Stable - Unstable With stable fractures, a transverse fracture line is observed. With unstable fractures (oblique, helical), secondary displacement appears (due to increasing post-traumatic muscle retraction).


Symptoms of rib fractures 1. The victim complains of severe pain in the area of ​​the broken rib; 2. Pain in the area of ​​the injured rib increases with body movements and breathing; 3. The victim has chest pain 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 ​​the 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 are broken in the anterior and lateral parts of the chest 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's general condition worsens, breathing becomes shallow, the heart rate becomes more frequent; 11. In the area of ​​the patient's broken ribs, subcutaneous hemorrhages and tissue edema may be observed; 12. In some patients, in the area of ​​rib 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 rib fracture, the victim may experience hemoptysis;




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. The appearance of acute pain when coughing. 4. The victim tries to take a bent position to weaken the muscle tension, which provokes pain. 5. Relief of pain in the sitting position. 6. Formation of edema in the area of ​​the fracture. 7. Under the skin, capillary ruptures are visible, a hematoma is formed. 8. Such an injury 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 lower angle extend from the chest. 5. The shoulder is lowered, pressed to the body and rotated inward. 6. The subclavicular fossa is smoothed. In the region of the clavicle, swelling is visible due to the protruding central fragment. 7. Palpation reveals a violation of the continuity 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 ​​application of the traumatic force, usually at the level of damage to the ribs. With a widespread injury (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 appear, 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 upper parts of the 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 ​​a 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 X-ray 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: By origin 1. Traumatic. 2. Spontaneous. primary (or idiopathic) secondary (symptomatic) recurrent 3. Artificial According to 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 to 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 pressed 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 height of inspiration, 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 an 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 of the dome of the diaphragm downward from the side of the lesion.


Emphysema of the soft tissues of the breasts A frequent and reliable sign of lung rupture 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, radiographically 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; cardiopalmus; lowering blood pressure. 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. When listening, the cessation or sudden weakness of the breathing sounds is noticeable. Patients complain of a feeling of heaviness in the chest, lack of air and the inability to take a full full breath.




Methods of X-ray studies of the lungs. Radiation examination of the lungs plays an important role in modern clinical practice. X-ray examinations are mainly performed.

The primary method of radiation examination of the lungs is chest x-ray. Chest X-ray, of course, is indicated for clinical suspicion of lung disease, chest trauma and polytrauma, in patients with an unclear cause of fever, and cancer.

Radiography is survey and sighting. General images, as a rule, should be performed in two projections - direct and lateral (with the examined side to the cassette). On plain chest radiographs, both the anterior and posterior ribs, clavicle, scapula, spine and sternum will always be visible, regardless of the projection of the image (Fig. 3.1 and 3.2). This is what distinguishes the plain radiograph from the tomogram.

Tomography. This technique is the next step in X-ray examination (Fig. 3.3). Longitudinal direct tomography is used more often. The mid-cut is made at half the thickness of the chest; the middle of the anteroposterior diameter (from back to sternum) in an adult is 9-12 cm.

The anterior slice is 2 cm closer from the median to the front, and the posterior slice is 2 cm posterior to the median. On the median tomogram, the shadows of either the anterior or posterior ribs will not be detected, on the anterior tomogram, the anterior sections of the ribs are well visualized, and on the posterior tomogram, on the contrary, the posterior sections of the ribs. Usually, by these basic features, the topographic sections of the lungs can be most easily identified. Longitudinal tomography is used for:

- detailing the topography, shape, size, structure of pathological formations of the larynx, trachea and bronchi, roots of the lungs, pulmonary vessels, lymph nodes, pleura and mediastinum;

- studying the structure of pathological formation in the pulmonary parenchyma (presence and peculiarity of destruction, calcification);

- clarification of the connection of the pathological formation with the root of the lung, with the vessels of the mediastinum, the chest wall;

- detection of a pathological process with insufficiently informative radiographs;

- evaluating the effectiveness of treatment.

CT. Computed tomography provides diagnostic information unattainable by other methods (Figure 3.4).

CT is used for:

- identification of pathological changes hidden by pleural exudate;

- assessment of small focal disseminations and diffuse interstitial lung lesions;

- differentiation of solid and fluid formations in the lungs;

- detection of focal lesions up to 15 mm in size;

- identification of larger foci of lesion with an unfavorable location for diagnosis or a weak increase in density;

- visualization of pathological formations of the mediastinum;

- assessment of intrathoracic lymph nodes. With CT, the lymph nodes of the roots of the lungs are visualized, starting at 10 mm (with conventional tomography - at least 20 mm). If the size is less than 1 cm, they are regarded as normal; from 1 to 1.5 cm - as suspicious; larger ones - as definitely pathological;

- solving the same issues as with conventional tomography and with its uninformativeness;

- in case of possible surgical or radiation treatment.

Fluoroscopy. Transillumination of the chest organs as a primary study is not carried out. Its advantage is in real-time image acquisition, assessment of the movement of chest structures, multi-axis examination, which provides adequate spatial orientation and the choice of the optimal projection for sighting images. In addition, under the control of fluoroscopy, punctures and other manipulations are performed on the organs of the chest. Fluoroscopy is performed using an EOC.

Fluorography. As a screening method for lung imaging, fluorography is supplemented with full-format radiography in unclear cases, in the absence of positive dynamics for 10-14 days or in all cases of identified pathological changes and with negative data that diverge from the clinical picture. In children, fluorography is not used because of the higher radiation exposure than with radiography.

Bronchography. The contrast study method of the bronchial tree is called bronchography. The contrast agent for bronchography is most often iodolipol - an organic compound of iodine and vegetable oil with an iodine content of up to 40% (iodolipol). The introduction of a contrast agent into the tracheobronchial tree is performed in different ways. The most widespread methods are those using catheters - transnasal catheterization of the bronchi under local anesthesia and bronchography subanesthesia. After the introduction of a contrast agent into the tracheobronchial tree, serial images are taken taking into account the sequence of contrasting of the bronchial system.

As a result of the development of fiber-optic bronchoscopy, the diagnostic value of bronchography has declined. For most patients, the need for bronchography arises only in cases where bronchoscopy does not give satisfactory results.

Angiopulmonography is a technique for contrast study of the vessels of the pulmonary circulation. Selective pulmonary angiography is used more often, which consists in the introduction of a radiopaque catheter into the cubital vein, followed by its passage through the right heart cavities, selectively to the left or right trunk of the pulmonary artery. The next stage of the study is the introduction of 15-20 ml of a 70% aqueous solution of a contrast agent under pressure and taking serial images. The indications for this method are diseases of the pulmonary vessels: embolism, arteriovenous aneurysms, varicose veins, etc.

Radionuclide studies of the respiratory system. Methods of radionuclide diagnostics are aimed at studying three main physiological processes that form the basis of external respiration: alveolar ventilation, alveolar-capillary diffusion and capillary blood flow (perfusion) of the pulmonary artery system. Currently, practical medicine does not have more informative methods for registering regional blood flow and ventilation in the lungs.

To carry out this kind of research, two main types of RFP are used: radioactive gases and radioactive particles.

Regional ventilation. Radioactive gas 133 Xе is used (T½ biol. - 1 min, T½ physical. - 5.27 days, -, β-radiation). The study of alveolar ventilation and capillary blood flow using 133 Xe is carried out using multi-detector scintillation devices or a gamma camera.

Radiospirography (radio-pneumography)

With intratracheal administration of 133 Xe, it spreads through various zones of the lungs, according to the level of ventilation of these zones. Pathological processes in the lungs, which lead to local or diffuse ventilation impairment, reduce the amount of gas entering the affected areas. This is recorded using radio diagnostic equipment. External registration of xenon-radiation makes it possible to obtain a graphical record of the level of ventilation and blood flow in any given area of ​​the lung.

The patient inhales 133 Xe, at the onset of a plateau, he takes a deep breath and exhale (as much as possible). Immediately after washing out, the 2nd stage is carried out: an isotonic solution of NaCl is injected intravenously with 133 Xe dissolved in it, which diffuses into the alveoli and is exhaled.

    To assess regional ventilation, the following indicators are determined:

- vital capacity of the lungs (VC), in%;

- total lung capacity (OEL); v %,

- residual lung volume (RO);

Is the half-life of the indicator.

    To assess arterial blood flow, determine:

- amplitude height;

- indicator half-time.

Intrapulmonary dynamics of 133 Xe depends on the degree of participation of the alveoli in external respiration and on the permeability of the alveolar-capillary membrane.

The height of the amplitude is directly proportional to the amount of radionuclide and, consequently, to the mass of blood.

At present, Tekhnegaz is more often used to study the ventilation function of the lungs, which is a nanoparticle (5-30 nm in diameter and 3 nm thick) consisting of 99m Tc surrounded by a carbon shell, which are placed in an inert gas argon. "Technegaz" is injected into the lungs by inhalation (Fig. 3.5.).

Perfusion lung scintigraphy. It is used to study pulmonary blood flow, usually to diagnose pulmonary embolism. Used RFP - 99m Tc - a macroaggregate of human serum. The principle of the method is to temporarily block a small part of the pulmonary capillaries. A few hours after injection, the protein particles are destroyed by blood enzymes and macrophages. Violations of capillary blood flow are accompanied by changes in the normal accumulation of RP in the lungs.

PET is the best way to detect the prevalence of lung cancer. The study is carried out with RP - 18-fluorodeoxyglucose. The application of the method is constrained by its high cost.

Magnetic resonance imaging in the diagnosis of respiratory diseases

The use of MRI is mainly limited to visualization of pathological formations of the mediastinum and roots of the lungs, lesions of the chest wall, the identification and characterization of diseases of large vessels of the chest cavity, especially the aorta. The clinical significance of MRI of the pulmonary parenchyma is small.

Ultrasound examination in the diagnosis of respiratory diseases. This method is of limited value in the diagnosis of most diseases of the chest organs (with the exception of diseases of the cardiovascular system). With its help, you can get information about the formations in contact with the chest or enclosed in it, about the pleural cavity (fluid and dense formations) and the diaphragm (about movement and shape), as well as about formations located in certain parts of the mediastinum (for example, about thymus gland).

The existing methods of examining the chest allow the doctor to diagnose in time and prescribe the appropriate treatment.

X-ray examination the chest in the frontal plane is usually done to everyone suffering from respiratory diseases, but sometimes it is supplemented with a lateral image. A chest X-ray provides a good picture of the contours of the heart and major blood vessels, helping to identify diseases of the lungs, adjacent organs, and the chest wall, including the ribs. This test can diagnose pneumonia, lung tumors, collapsed lungs with pneumothorax, pleural fluid and emphysema. Although a chest x-ray is rarely helpful in determining the exact cause of an illness, it allows the doctor to determine what additional tests are needed to clarify the diagnosis.

Computed tomography (CT) chest provides more accurate data. In a CT scan, a series of X-rays are taken and analyzed by a computer. Sometimes, during CT, a contrast agent is injected intravenously or by mouth, which helps to clarify the structure of some structures in the chest.

Magnetic resonance imaging (MRI) also provides detailed images, which is especially valuable when a physician suspects a blood vessel disorder in the chest, such as an aortic aneurysm. Unlike CT, MRI does not use X-rays - the device records the magnetic characteristics of atoms.

Ultrasound examination (ultrasound) creates an image of internal organs on the monitor due to the reflection of ultrasonic waves from them. This test is often used to find fluid in the pleural space (the space between the two layers of the pleura). Ultrasound can be used as a control when inserting a needle to suction fluid.

Radionuclide research lungs with the use of trace amounts of short-lived radionuclides allows you to analyze gas exchange and blood flow in the lungs. The research consists of two stages. In the first, a person inhales a gas containing a radionuclide marker. Ultrasound allows you to see how the gas is distributed in the airways and alveoli. In the second stage, the radionuclide substance is injected into a vein. With the help of an ultrasound, the doctor determines how this substance is distributed in the blood vessels of the lungs. This test can detect blood clots in the lungs (pulmonary embolism). Radionuclide research is also used during the preoperative examination of patients with a malignant lung tumor.

Angiography makes it possible to accurately assess the blood supply in the lungs. A contrast agent is injected into the blood vessel, which is visible on x-rays. In this way, images of the arteries and veins of the lungs are obtained. Angiography is most commonly used when pulmonary embolism is suspected. This study is considered a reference for the diagnosis or exclusion of pulmonary embolism.

Puncture of the pleural cavity

When puncturing the pleural cavity with a syringe, a pleural effusion, a pathological fluid that has accumulated in the pleural cavity, is aspirated and sent for analysis. Puncture of the pleural cavity is performed in two cases: when it is necessary to reduce shortness of breath caused by squeezing of the lungs with accumulated fluid or air, or if you need to take fluid for a diagnostic study.

During the puncture, the patient sits comfortably, leaning forward and resting his hands on the armrests. A small area of ​​skin (most often on the side of the chest) is disinfected and anesthetized with a local anesthetic. The doctor then inserts a needle between the two ribs and draws a small amount of fluid into the syringe. Sometimes ultrasound is used to control the insertion of the needle. The collected fluid is sent for analysis to determine its chemical composition and check for bacteria or malignant cells.

If a large volume of fluid has accumulated and causes shortness of breath, the fluid is suctioned off, allowing the lung to expand and making breathing easier. During a puncture, substances can be injected into the pleural cavity that prevent excessive accumulation of fluid.

After the procedure, a chest X-ray is taken to see the part of the lungs that was previously obscured by fluid and to make sure that the puncture is not causing any complications.

The risk of complications during and after pleural puncture is negligible. Sometimes the patient may feel a little pain as the lungs fill with air, expand, and the pleural sheets rub against each other. There may also be short-term dizziness and shortness of breath, collapse of the lungs, internal bleeding into the pleural cavity or external bleeding, fainting, inflammation, puncture of the spleen or liver, and (very rarely) accidental entry of air bubbles into the bloodstream (air embolism).

Puncture biopsy of the pleura

If the puncture of the pleural cavity does not allow to find out the cause of the pleural effusion, or a microscopic examination of the tumor tissue is necessary, the doctor performs a puncture biopsy. First, local anesthesia is done, as with a puncture of the pleural cavity. Then, using a larger needle, the doctor removes a small piece of the pleura. In the laboratory, it is examined for signs of cancer or tuberculosis. In 85-90% of cases, pleural biopsy can accurately diagnose these diseases. Possible complications are the same as with a puncture of the pleural cavity.

Bronchoscopy

Bronchoscopy is a direct visual examination of the larynx and airways using a fiber-optic instrument (bronchoscope). The bronchoscope has a light source at the end that allows the doctor to view the bronchi.

Bronchoscopy is used for diagnostic and therapeutic purposes. With the help of a bronchoscope, you can remove mucus, blood, pus and foreign bodies, inject drugs into certain areas of the lungs, and look for the source of bleeding.

If the doctor suspects a malignant lung tumor, bronchoscopy provides an opportunity to examine the airways and take tissue samples from any suspicious areas. With the help of a bronchoscope, you can take sputum for analysis and examine it for the presence of microorganisms that cause pneumonia. They are difficult to obtain and identify in other ways. Bronchoscopy is especially necessary when examining AIDS patients and patients with other immune disorders. It helps assess the condition of the larynx and airways after burns or inhalation of smoke.

A person should not eat or drink at least 4 hours before the start of the procedure. A sedative to reduce anxiety and atropine are often prescribed to reduce the risk of laryngeal spasm and slow heart rate that may occur during the study. The throat and nasal passage are numbed with an anesthetic aerosol, and then a flexible bronchoscope is passed through the nostril into the airway.

Bronchoalveolar lavage is a procedure that is performed to take material for analysis from small airways that are not accessible during bronchoscopy. After inserting the bronchoscope into the small bronchus, the doctor injects a saline solution through the tube. Then the liquid, together with cells and bacteria, is sucked back into the bronchoscope. Examination of the material under a microscope helps in the diagnosis of infections and malignant tumors. Inoculating this fluid is the best way to identify microorganisms. Bronchoalveolar lavage is also used to treat pulmonary alveolar proteinosis and other conditions.

Transbronchial lung biopsy allows you to get a piece of lung tissue through the bronchial wall. The doctor removes a piece of tissue from the suspicious area by passing the biopsy instrument through a channel in the bronchoscope and then through the wall of the small airways into the suspicious area of ​​the lungs. For more accurate localization, sometimes they resort to X-ray control. This can reduce the risk of accidental damage and collapse of the lungs when air enters the pleural space (pneumothorax). Although transbronchial lung biopsy carries a risk of complications, it provides additional diagnostic information and often helps avoid surgery.

After bronchoscopy, the person is monitored for several hours. If a biopsy has been taken, a chest X-ray is taken to make sure there are no complications.

Thoracoscopy

Thoracoscopy is a visual examination of the surface of the lungs and pleural cavity through a special instrument (thoracoscope). The thoracoscope is also used to remove fluid from the pleural space.

The procedure is usually performed under general anesthesia. The surgeon makes three small incisions in the chest wall and guides the thoracoscope into the pleural space, causing air to enter and the lung to collapse. This allows the doctor to examine the surface of the lungs and pleura, as well as take tissue samples for microscopic examination and inject drugs through the thoracoscope that prevent the accumulation of fluid in the pleural cavity. After removing the thoracoscope, a chest tube is inserted to remove the air that entered the pleural space during the examination. As a result, the collapsed lung expands again.

After such an intervention, the same complications are possible as with puncture of the pleural cavity and puncture biopsy of the pleura. Thoracoscopy requires hospitalization.

Mediastinoscopy

Mediastinoscopy is a direct visual examination of the chest area between two lungs (mediastinum) through a special instrument (mediastinoscope). The mediastinum contains the heart, trachea, esophagus, thymus gland (thymus), and lymph nodes. Mediastinoscopy is almost always used to determine the cause of swollen lymph nodes or to assess how much a lung tumor has spread before chest surgery (thoracotomy).

Mediastinoscopy is performed in the operating room under general anesthesia. A small incision is made above the sternum, then an instrument is inserted into the chest, which allows the doctor to see all the organs of the mediastinum and, if necessary, take tissue samples for diagnostic examination.

Thoracotomy

Thoracotomy is an operation in which an incision is made in the chest wall. A thoracotomy allows a doctor to see internal organs, take pieces of tissue for laboratory testing, and perform medical interventions for diseases of the lungs, heart, or large arteries.

Thoracotomy is the most accurate method for diagnosing lung diseases, however, it is a serious operation, therefore, it is resorted to when other diagnostic methods - pleural puncture, bronchoscopy or mediastinoscopy - do not provide sufficient information. In more than 90% of patients, it allows diagnosing lung disease, because during the operation it is possible to see and examine the affected area and take a large amount of tissue for analysis.

Thoracotomy requires general anesthesia and is performed in the operating room. An incision is made in the chest wall, the pleural cavity is opened, the lungs are examined, and samples of lung tissue are taken for microscopic examination. If tissue is to be taken from both lungs, an incision in the sternum is often necessary. If necessary, remove a segment of the lung, a lobe, or the entire lung.

At the end of the operation, a drainage tube is inserted into the pleural cavity, which is removed after 24-48 hours.

Suction

Suction is performed when it is necessary to obtain mucus and cells from the trachea and large bronchi for microscopic examination or to determine the presence of pathogenic microbes in sputum, as well as to remove it from the respiratory tract.

One end of a long flexible plastic tube is attached to a suction pump, the other is passed through the nostril or mouth into the trachea. When the tube is in the desired position, begin suction in short bursts lasting from 2 to 5 seconds. For people with an artificial opening in the trachea (tracheostomy), a tube is inserted directly into the trachea.

The spirometer consists of a tip, a tube and a recording device. The person takes a deep breath, and then exhales vigorously and as quickly as possible through the tube. The recorder measures the volume of air that is inhaled or exhaled over a specified period of time with each breathing cycle.

Radiation diagnostics for trauma

Radiation diagnostics plays an important role in the initial examination of patients with trauma and in determining the EMF tactics. The main method of radiation diagnostics used at this stage is radiography. However, many trauma centers are increasingly using other techniques * 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 obtained and to reduce the examination time, and the development of endopascular methods of treatment has created an alternative to traditional surgical interventions for certain vascular injuries.

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 the results of the study to other specialists.
  • The ability to monitor basic physiological indicators, 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 research may be unsafe. The only test that can be done is a bedside ultrasound scan to detect fluid in 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.).

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