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Trauma in the elderly (>65 years) is an increasingly common presentation to the ED. A fall from standing height is the most common mechanism after which such patients present, and rib fracture is the most common non-spinal fracture. Thoracic injury in patients aged over 65 is associated with significant morbidity and mortality. There are currently no universally applied guidelines for assessment, investigation and management of such patients. In this expert practice review, we discuss the evidence base and options for clinical management in this vulnerable patient group.

Lung herniation is a rare pathology seen after trauma. A case of acquired lung hernia is presented after blunt thoracic trauma that was repaired primarily. Surgical management and decision-making for this process are discussed.

The treatment of asymptomatic non-occult pneumothoraces (ANOPTX) secondary to blunt chest trauma (BCT) has not been well delineated. We sought to analyze our experience with ANOPTX in pediatric trauma patients and determine if a chest tube (CT) is mandatory.A retrospective chart review of patients17 years old with ANOPTX from BCT who presented to a level 1 trauma children's hospital, between January 2000 and June 2015 was performed. Demographics, vitals, trauma scores, imaging, interventions, hospital expenses and outcomes were analyzed.Of the 77 patients who had ANOPTX, 48 (62.3%) were managed with observation only, while 29 (37.7%) underwent CT placement. The median length of stay for patients who had CT placement was 7 days (IQR, 4, 12) and 2 days (IQR, 1, 4) in those observed (p 0.01). All patients who were observed had complete resolution of the pneumothorax without recurrence or the need for CT placement. Patients who had CT placement had more imaging performed and more hospital expenditure compared to those who were observed.CT is not mandatory in all pediatric patients with ANOPTX from BCT and observation has been found to be safe and cost effective.

Introduction Interpretation of pelvic radiography is an important component of the primary survey and is commonly performed by emergency physicians. Radiologists bring unique skills to trauma care, including choice of imaging modality and image interpretation. It is not clear if this limited resource is most efficiently used in the resuscitation room. No studies have compared radiologists and trauma clinicians in their ability to interpret pelvic radiographs following trauma. Objective To determine the sensitivity and specificity of trauma experienced and trauma inexperienced emergency physicians in detecting pelvic fractures compared with radiologists, the latter subgroup combined report being used as the gold standard. Setting and methods Prospective cohort study conducted in two large teaching hospitals in central London. All participants reviewed 144 consecutive pelvic radiographs performed each as part of a ‘trauma series’ and known to have undergone concomitant pelvic CT imaging. Results No statistically significant difference was found between radiologists and emergency physicians from a trauma centre in pelvic radiograph interpretation. Radiologist reporting was associated with an improved specificity compared with emergency physicians working in a non-trauma hospital (p=0.049). The study population missed 30% of fractures on plain radiography against the gold standard of CT. Discussion The ability to interpret trauma series pelvic radiographs is comparable between emergency physicians and radiologists. If this were also true of trauma chest radiographs, then the most valuable use of the radiologist may not be the resuscitation room but in rapid reporting of more complex imaging techniques. However, plain radiography is insensitive for pelvic fracture detection compared with CT, even in expert hands.

To assess the prevalence and morphologic characterization of pulmonary nodules in children on a chest computed tomography (CT). Two hundred and fifty-nine trauma chest CTs in children aged 0–18 years were retrospectively reviewed by two radiologists, each with more than 10 years of experience. Images were acquired on a 64-row CT. Pulmonary lobes with trauma affections such as contusion or haemorrhage were excluded. All pulmonary nodules were evaluated for distance from the pleural surface, location, calcification and size on axial slices. A total of 1,190/1,295 (92 %) pulmonary lobes without traumatic injury were included in this study. In 86 of 259 (33 %) patients, 131 pulmonary nodules were detected. Number of nodules per patient ranged from 1 to 4. Calcifications were seen in 19 % (25) of all nodules. Diameters ranged from 1 to 5 mm. 59 % (77) were located in the lower lobes, 9 % (12) in the middle lobe and 32 % (42) in the upper lobes. 84 % of the non-calcified nodules >2 mm showed a slightly angular or triangular (mostly pleural nodes) shape. Pulmonary nodules smaller than 5 mm can be detected frequently in children without malignant disease and are predominantly located in the lower lobes. • Pulmonary nodules in children with trauma CTs were retrospectively analysed • Pulmonary nodules seen on CT are frequent in children without malignant disease • Nodules in this group are more frequent in the lower lobes • No age dependency for the number of pulmonary nodules in children was observed

Tracheobronchial injury is an uncommon event associated with blunt chest trauma. The clinical signs and symptoms as well as plain radiographic findings are usually nonspecific, so a high index of suspicion is required for early detection and optimal management. This report describes a severely traumatized patient whose tracheal inury was suspected when a spherical endotracheal tube cuff was noted on a portable trauma chest radiograph.

The purpose of this study was to corroborate the relation between the estimated absorbed fetal dose derived from directly measured uterine doses early in the first trimester and the volume CT dose index (CTDI(vol)) for 16- and 64-MDCT of the maternal chest, abdomen, and pelvis.Estimated absorbed fetal dose was measured with a metal oxide semiconductor field effect transistor (MOSFET) dosimeter placed in the expected uterine location in an anthropomorphic phantom of a woman and scanned with 16- and 64-MDCT units of one vendor and a 64-MDCT unit of another vendor. A trauma chest, abdomen, and pelvis protocol and an abdomen and pelvis protocol were used. Absorbed uterine dose was measured directly from the MOSFET detector. The CTDI(vol) for each protocol was recorded from the scanner console. Correlation between mean uterine dose and CTDI(vol) was tested with a goodness of fit model.The absorbed uterine dose ranged from 9.25 to 37.7 mGy. Absorbed fetal dose in the early first trimester correlated with CTDI(vol) in a linear regression equation. For the 16-MDCT scanner, at 130 kVp, the fetal dose was 2.091 x CTDI(vol) - 9.489. For the 64-MDCT scanner from the same vendor, at 120 kVp, the fetal dose was 1.113 x CTDI(vol) + 1.773. For the 64-MDCT scanner from the other vendor, at 120 kVp, the fetal dose was 1.378 x CTDI(vol) - 1.014. The goodness of fit results (R(2)) for the equations were 0.97, 0.98, and 0.99.Estimated absorbed fetal dose during the first trimester of pregnancy is linearly associated with CTDI(vol) regardless of beam energy, detector configuration, and scanner manufacturer.

Subcutaneous emphysema describes the presence of gas in subcutaneous tissue. It has several known causes, among them anaerobic infections, traumatic disruption of mucosal surfaces, and alveolar rupture. Diagnosis is characterized by the presence of crepitation on palpation over the affected area and radiographic evidence of gas in the subcutaneous tissues. The pathogenesis relates to the tracking of gas along fascial planes into the subcutaneous space of the neck, chest, or extremities. Therapy of subcutaneous emphysema itself is generally supportive and involves the treatment of the underlying condition, as subcutaneous emphysema is usually self-limited and benign. However, the appearance of subcutaneous emphysema often warrants a search for more serious underlying pathology such as pneumothorax, pneumomediastinum, or tracheobronchial or esophageal disruption.

The postpneumonectomy syndrome is a rare complication of pneumonectomy that is typically seen several years after surgery. The classical presentation is in patients who have undergone right-sided pneumonectomies during childhood or early adult life. However, it can occur in patients at any age and can also be seen in patients who have undergone left-sided procedures. This syndrome develops as a result of severe anatomical changes that occur in the chest after pneumonectomy. Signs and symptoms include progressive dyspnea, wheezing, and recurrent episodes of pneumonia. Symptoms typically develop months to years after pneumonectomy. Pulmonary function tests, chest computed tomography, and bronchoscopy are helpful in confirming the diagnosis. Treatment is surgical, with excellent outcomes. Surgical correction of these anatomical changes results in resolution of symptoms, and good long-term survival.

A 46-year-old woman was brought to the emergency department after having been found stabbed at home. A 25 cm long knife was stuck on the anterior left chest, over the cardiac area approximately between the sternum and the midclavicular line on the fifth intercostal space. Two further deep wounds were on the left chest 3–4 cm above the knife along the midclavicular line and on the …

Routine radiographic chest screening—as employed upon entry and release from the Royal Navy—is intended to identify pathology which may be clinically covert. Occasionally, asymptomatic lesions of wholly benign appearance are identified. In these circumstances, clinicians may feel obliged to undertake a series of increasingly complex investigations, even exploratory surgery, in order to confirm the diagnosis. This course of events may also follow chest radiographs taken for unrelated reasons—eg exclusion of skeletal injury following trauma.Mediastinal cysts (eg Bronchogenic and Enteric) may present as asymptomatic mediastinal masses with benign features. Two such cases are reported in which a prominent mediastinal mass was revealed at routine or post trauma chest radiography and a brief review of bronchogenic and enteric cysts is presented.

In a case of transient right bundle branch block due to nonpenetrating chest trauma, this abnormal electrocardiographic finding was the sole manifestation of cardiac contusion. There is a high frequency of occult cardiac contusion and routine electrocardiography is recommended in the evaluation of nonpenetrating chest trauma.