Medical Image of the Week: Post-Traumatic Diaphragmatic Rupture

Figure 1. A: Admission portable chest radiograph, demonstrates elevation of the right hemidiaphragm of uncertain chronicity (large arrow, also shown in B and C). B: Study after 20 min, shows a moderate hemothorax (*). Mildly displaced fractures are evident, involving at least the3^rd and 5^th right ribs (small arrows). C: Follow up exam. A right chest tube (thin arrow in c) has been inserted, and the hemothorax is drained. Immediately after, a CT chest abdomen and pelvis is performed.

Figure 2. A-C: A large anterolateral diaphragmatic defect is diagnosed, as shown in the coronal images, from anterior to posterior (A-C), with displacement of the liver (L) and loops of bowel (B) into the chest. Note the discontinuity of the diaphragm (arrows in A, B and D). A small liver laceration is noted in the gallbladder bed (arrows in C). D:  Image, near the midline, showing atelectasis (A) in the posterior right lung base. Additional injuries (not shown), included, right ribs 2-11 fractures, gallbladder fossa liver, right adrenal hemorrhage, mesenteric root contusion and multiple pelvic fractures.

A 67-year-old woman was admitted after being struck by a vehicle, at high speed. She has a diaphragmatic rupture (Figures 1 and 2).

Diaphragmatic injuries occur in approximately 0.8%–8% of blunt trauma patients, largely from motor vehicle accidents (1). The mechanism of injury includes distortion of the chest wall with resulting shearing forces, or direct frontal impact with acute increased intraabdominal pressure (2).

Rupture of the left diaphragm is more common, presumably due to a protective mechanism by the liver, but also in part due to underdiagnoses (3). Most ruptures are large, posterolateral, between the lumbar and intercostal attachments (4).  Associated liver injuries are seen mostly with right diaphragmatic injuries (93 % vs. 24% with left injuries). Multiorgan abdominal injury and pelvic fractures are common (2).

In cases of associated hemothorax, pulmonary laceration/contusion, atelectasis, and phrenic nerve palsy, a diaphragmatic injury, may be masked on chest radiographs. Also, the positive pressure of ventilatory support may delay herniation of abdominal contents through the ruptured diaphragm (5).

Up to 12% to 66% cases of diaphragmatic rupture cases, are missed on chest radiograph. Suggestive findings include elevation of the hemidiaphragm, distortion or obliteration of the outline of the hemidiaphragm, and contralateral shift of the mediastinum (6,7).

On CT visualization of a diaphragmatic defect has most sensitivity and specificity for diaphragmatic injury (73% and 90%) respectively) (8). Intrathoracic herniation of abdominal contents has a sensitivity of 55% and a specificity of 100% (8). The “collar sign”, a waist-like constriction of the herniating hollow viscus at the site of the diaphragmatic tear, is usually seen sagittal and coronal multiplanar reformatted images (2,8). The “dependent viscera sign” (1), consists of bowel or solid organs fallen to a dependent position against the posterior ribs, due to lack of supported by the intact diaphragm. This may be an early sign of diaphragmatic tear on axial images, before visceral herniation is clearly seen on multiplanar reformatted images.

Diana Palacio MD, Veronica Arteaga MD, Berndt Schmidt MD

Department of Medical Imaging

The University of Arizona-Banner Medical Center

Tucson, AZ USA

References

1. Bergin D, Ennis R, Keogh C, et al. The "dependent viscera" sign in CT diagnosis of blunt traumatic diaphragmatic rupture. AJR Am J Roentgenol. 2001;177:1137-40. [CrossRef] [PubMed]
2. Shanmuganathan K, Killeen K, Mirvis SE, et al. Imaging of diaphragmatic injuries. J Thorac Imaging. 2000;15:104-11. [CrossRef] [PubMed]
3. Killeen KL, Mirvis SE, Shanmuganathan K. Helical CT of diaphragmatic rupture caused by blunt trauma. AJR Am J Roentgenol.1999;173:1611-6. [CrossRef] [PubMed]
4. Boulanger BR, Milzman DP, Rosati C, et al. A comparison of right and left blunt traumatic diaphragmatic rupture. J Trauma. 1993;35:255-60. [CrossRef] [PubMed]
5. Kuhlman JE, Pozniak MA, Collins J, Knisely BL. Radiographic and CT findings of blunt chest trauma: aortic injuries and looking beyond them. RadioGraphics. 1998;18:1085-1106. [CrossRef] [PubMed]
6. Iochum S, Ludig T, Walter F, et al. Imaging of Diaphragmatic Injury: A Diagnostic Challenge RadioGraphics 2002; 22:suppl. 1,S103-16. [CrossRef] [PubMed]
7. Gelman R, Mirvis SE, Gens D. Diaphragmatic rupture due to blunt trauma: sensitivity of plain chest radiographs. AJR Am J Roentgenol. 1991;156:51-7. [CrossRef] [PubMed]
8. Murray JG, Caoili E, Gruden JF, et al. Acute rupture of the diaphragm due to blunt trauma: diagnostic sensitivity and specificity of CT. AJR Am J Roentgenol. 1996;166:10. [CrossRef] [PubMed]

Cite as: Palacio D, Arteaga V, Schmidt B. Medical image of the week: post-trumatic diaphragmatic rupture. Southwest J Pulm Crit Care. 2018;16(3):143-5. doi: https://doi.org/10.13175/swjpcc030-18 PDF 

Medical Image of the Week: Stomach Rupture

Figure 1. Cross table view of patient showing massively dilated abdomen.

Figure 2. Chest x-ray showing air under diaphragm (arrow).

A 61-year-old man was transferred from another hospital for further care. He had a history of oxygen-dependent chronic obstructive pulmonary disease in addition to congestive heart failure, hypertension and diabetes mellitus. He had been seen earlier in the day at his primary care physician’s office for a routine visit. Although he was asymptomatic, emergency medical services (EMS) were called because of significant hypoxemia detected by pulse oximetry. EMS noted that the patient said he “feels OK”. However, a decision was made to intubate the patient. Multiple failed intubation attempts failed and he suffered a cardiopulmonary arrest. He was successfully resuscitated and underwent a cricotracheotomy with an uncuffed endotracheal tube. When transferred his mouth was taped shut and his nose clamped. His abdomen was markedly distended and tympanic (Figure 1). A supine chest x-ray showed air under the diaphragm. Abdominal exploration showed a ruptured stomach which was repaired. He made an uneventful recovery.

The difficult airway outside the operating room can be problematic. While preparation for airway control are made, preoxygenation should be performed (1). The patient should be placed in the “sniffing” position and mask ventilation performed. Appropriate positioning - with the tragus of the ear elevated parallel to the sternum - may require special preparation in obese patients. When adequate preoxygenation is accomplished endotracheal intubation can be attempted. However, when endotracheal intubation fails and/or mask ventilation is inadequate a variety of advanced intubation techniques can be considered including a laryngeal mask airway, fiberoptic intubation, cricothyroidotomy, or transtracheal jet ventilation (1).

Confirmation of proper endotracheal tube placement should be completed in all patients (2). Physical examination methods such as auscultation of chest and epigastrium, visualization of thoracic movement, and fogging in the tube are not sufficiently reliable to confirm endotracheal tube placement. During intubation, direct visualization of the endotracheal tube passing through the vocal cords into the trachea, especially with the use of a videolaryngoscope, constitutes firm evidence of correct tube placement. Use of an end-tidal carbon dioxide detector (i.e., continuous waveform capnography, colorimetric and non-waveform capnography) to evaluate and confirm endotracheal tube position should be performed.  For patients in cardiac arrest and for those with markedly decreased perfusion other methods of confirmation such as an esophageal detector device, ultrasound, or bronchoscopy should be used.

Robert A. Raschke, MD

University of Arizona College of Medicine Phoenix

Phoenix, AZ USA

References

1. Langeron O, Amour J, Vivien B, Aubrun F. Clinical review: management of difficult airways. Crit Care. 2006;10(6):243. [CrossRef] [PubMed]
2. American College of Emergency Physicians. Verification of endotracheal tube placement. January 2016. Available at: https://www.acep.org/Clinical---Practice-Management/Verification-of-Endotracheal-Tube-Placement/#sm.00004sk8v7vduedxxs618zbgnij0n (accessed 1/24/18).

Cite as: Raschke RA. Medical image of the week: stomach rupture. Southwest J Pulm Crit Care. 2018;16(1):53-4. doi: https://doi.org/10.13175/swjpcc008-18 PDF 

Medical Image of the Week: Coccidioidomycosis Pneumothorax

Figure 1. Right-sided pneumothorax (A) with subsequent placement of pigtail catheter and re-expansion of right lung (B).  CT shows bilateral multifocal airspace consolidation with nodules and cavitary interstitial disease (C).

Figure 2. PAP stain (A) and GMS stain (B) demonstrating Coccidioidomycosis from BAL (magnification, 400x).

A 36-year-old man with AIDS and disseminated coccidioidomycosis presented with severe right chest pain, shortness of breath, and a right-sided pneumothorax on CXR. A pigtail catheter was placed with near resolution of the pneumothorax. A bronchoscopy with bronchoalveolar lavage revealed spherules on cytology as well as coccidioidomycosis on culture. No other pathogens were identified. The pigtail catheter was removed three days later with resolution of the pneumothorax.

Rupture of subpleural coccidioidomycosis cavity into the pleural space resulting in pyopneumothorax and/or bronchopleural fistula is rare with reported rates of 1.4 – 2.6% for cavitary lesions (1).  Despite antiretroviral therapy and an undetectable viral load, disease was unresponsive to fluconazole.  Therapy was subsequently initiated with amphotericin B lipid complex, which resulted in significant improvement of his disease.

Ishna Poojary MD,  Christopher Geffre MD PhD,  Tirdad Zangeneh DO MA and Janet Campion MD

University of Arizona Medical Center

Tucson, AZ

Reference

1. Tiu CT, Cook J, Pineros DF, Rankin LF, Lin YS, Ghitan M, Brichkov I, Shaw JP, Chapnick EK. Pneumothorax in a young man in Brooklyn, New York. Clin Inf Dis. 2011;53(12);1296-7. [CrossRef] [PubMed] 

Reference as: Poojary I, Geffre C, Zangeneh T, Campion J. Medical image of the week: coccidioidomycosis pneumothorax. Southwest J Pulm Crit Care. 2013;7(4):251-2. doi: http://dx.doi.org/10.13175/swjpcc140-13 PDF