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light. I'm sorry, I'm starting a bit late, but I just wanted to show you some trauma cases that we have experienced here in the UK, many of which would be entirely compatible with the trauma that is experienced in Ukraine. So I'm going to start off with a simple, straightforward chest X ray. First of all, can people tell me, are they able to open the link that I've posted? And perhaps if if the moderator, uh, could keep on posting that link as people join, that would be very helpful. Yeah, you can see the link. That's great. Super. OK, so I'm going to go to the very first case, which is trauma number 001. If you want to put them in numerical order, you just press over the name tab and you can get them in numerical order like that. Okay, Say, just open study. And this patient is a young guy who has, um, presented with a road traffic accident. He was run over by a large vehicle, and you can see that there's a chest X ray and the chest X ray shows. Uh, et tube. Does anyone want to tell me what they think about that e t tube position. Any thoughts? There's nothing in the chat. Uh, not far enough. In fact, it's probably too far. Okay, so the Korean A is just here. And what needs to happen is it needs to be withdrawn. Maybe about a centimeter and a half. Okay. It's it's quite important, actually, that, uh, you get, um, patient, uh, to have the ET tube within five centimeters of the carina, but no nearer than 2.5 centimeters. And that's because when the nursing staff move the patient's head, uh, during, uh, cleaning the patient, uh, you can get, um, intubation of one of the bronch I Anyway, it's, uh it's slightly too low. Could do with coming back a wee bit. Um, now, can you also notice that the left costophrenic sulcus is here and the right costophrenic sulcus is here. And so this is in a super inpatient. The deep costophrenic sulcus, okay. And the deep costophrenic sulcus is, of course, a sign of a pneumothorax, and you can actually see the pneumothorax appear. The pneumothorax is so large in this patient that, uh, it's visible both at the base and also at the apex. You'll notice also that there are streaks of gas going up into the neck and into the supraclavicular fossa and a very large gas collection surrounding the heart within the pericardial sac. So this patient has got a pneumothorax. They've got pneumopericardium. They've got a new memory to start him, they've got an ET tube which needs to be pulled back approximately 1.5 centimeters. And you'll also notice that there is a marked a pacification of both lungs. Now, in a young person, um, who don't usually get pulmonary edema, You should be thinking that this is likely to be, uh, something like, um neurogenic pulmonary edema or over resuscitation. Okay, so there are various causes for this, and you just need to, uh, think about the possible causes. Unfortunately, this patient died before they could have a CT scan, Uh, because of the extent of their injuries. Okay, I'm now going to go on to number seven, and this is a patient who has chest trauma 31 year old male, and I use this case in the Royal College of Radiologists. Chest trauma. Uh, symposium. So this is a CT scan of somebody who has had chest trauma. Okay. And the first thing I want to show you is that when we do a CT scan on anyone, we always do what's called a scout, and the scout is to map the patient's body part so that later on, it could be mapped to the CT scan. Slice itself. Okay. And so what we've got here is we've got a super inpatient who has been intubated. You can see the ET tube here, and you can see those the leaflet of the left Hemi diaphragm. But then there's another interface just here. And then we've got the stomach bubble here. Now, this is quite difficult to explain, and so I will explain it in a bit more detail. When I go through the CT scan, can everyone see that we've got a pacification of the left lung? What do you think that might be in the context of major trauma? Yeah, blood. Absolutely. Right. So this is confusion in the left up below. And so the other thing to note is that the CPI angle is lower on the left than it is on the right, And that in a supine patient tells me that it is highly likely that this patient has got a pneumothorax. Okay, so let's go on to the CT, and I'm going to put the CT side by side. So using this software, you can put, uh, two or three frames side by side. I'm gonna put three together, and it's giving me the axial and the corona, Okay? And it quite, quite nicely shows me these grids here. So the grid shows that the axial slice is at the level just below the carina through this consolidated lung. And if I want to change the windows, I do so by going over to the sun symbol here and doing lung or pressing key five on your keyboard. Okay, so this demonstrates to me that there's lots of confusion in the lung. I can see the pneumothorax, but in the supine patient, in theory, the pneumothorax should look bigger as you go down to the base of the hemithorax. And as we go down to the base, the Hemi thorax, Sure enough, the pneumothorax gets bigger. And if we look on the sagittal section, we can see here that the pneumothorax is much bigger anteriorly than it is uh, anteriorly at the base than it is at the apex, and that's because the patient is sitting in a super imposition. But also you just need to look at the die from here. So the anterior portion of the diaphragm, which is this portion here, instead of being convex upwards, is concave, concave upwards. And that tells me that the patient has got a tension, pneumothorax and attention. Pneumothorax is a situation that exists in which the patient will die unless you do something about it, because the intrathoracic pressure far exceeds the intra abdominal pressure. And so, if that's the case, it causes depression and e version of the diaphragm, which you can see here now. The reason why patient's with attention hemothorax will die is because the blood that normally goes back to the right side of the heart the venous blood is aided in its journey by the negative intrathoracic pressure that occurs between inspiration and expiration. So if that is removed by virtue of the fact that you've got massively raised intrathoracic pressure, you're going to have no venous return to the heart, and therefore you get circulated collapse. And that's what causes a cardiac arrest impatience with the tension pneumothorax. Okay, so, uh, so that's that's an important consideration when you're looking at noon Authorities. You want to know? To what extent is the pneumothorax going to cause trouble for the patient? Okay, so the next one I want to go through is number eight. So if you go to number eight and this actually gives you a little report, and I'm going to open it and it's a tension hemothorax, post trauma and you can see here that the patient has got, uh, increased a classification of the left hemithorax. Now, this is following major trauma. Okay, so what, Uh, what things go through your mind when you see anyone who's got a pacification of the Hemi thorax? Any thoughts? Yeah. Hemothorax. Massive pleural effusion. Yeah, absolutely right. And so if you look at a previous film before the trauma, it's likely that it's going to be normal. Okay, um, if you don't have a history of trauma and you see this a pacification of the heavy thorax, you may think that this is due to a malignant pleural effusion or a pneumonectomy or other causes. And it's important to look at previous films in that regard, but this patient has had a massive hemothorax. Now, what would be the wrong thing to do in the case of a massive hemothorax? What would be the wrong thing to do? Would it be the right thing to do to put a chest raining? Which, which of you would put a chest rain in? Yeah, that's absolutely right. Now, for some reason, I've lost my, um I've lost my screen. Apologies about this. Can you see my shirt screen? Not right now. No. No. Okay. No problem. I think something's happened. Let me try again. Um, can people see what you were showing through that link? If they just go on the link I could do. Yeah. Um, that's it. I think we're back in business. Um, sorry about that. It's not showing. It's not showing you. Yeah, don't worry. I'll get this. I'll get this right. I'm not in my normal place. I'm actually on holiday, so I'm improvising somewhat. How's that? That's great. Yeah. Sorry about that. Um, yes. So if you put a chest drain into somebody who's got an enormous amount of blood in the heavy thorax, the problem is that you release the pressure in the Hemi thorax, and that just allows the bleeding vessel to carry on bleeding. So actually, having blood in the Hemi thorax provides a tamponade effect to the the bleeding vessel. So putting a chest drain in this situation could actually be counterproductive. Okay? And it could increase the amount of blood that's lost, and I'll just show you why that might be so if you go on to the axial images and you can see that this is a female patient, she's actually young, and she fell down the stairs and she fractured her rib. Okay. And you can just see that rib fracture there. Now, if you want to see the rib on bone windows, put it on to number two and you can see the rib fracture bit easy, either. And it's on slice 78. See that posterior rib fracture? And if you look a bit lower down, she's got rib fracture here also, so she's got several contiguous rib fractures. There's one there as well, and if I go back onto the medicine all windows, you can see that there's a very large fluid collection in the heavy thorax and the lung has collapsed, and the reason why the lung is dense on the left but not on the right is because the lung has completely collapsed and has expelled all the gas within it. And because we've given contrast, the contrast is still going in the blood vessels in the lung. And so the lung appears much denser because the blood vessels are closer together because of the collapse. And the fluid in the Hemi thorax is clearly due to blood because of the history and because of the presence of the rib fractures. Now can everyone see posteriorly by this rib fracture? Here there is an increased density lump of what looks like blood clot. Now that's called a sentinel clot, and a sentinel clot tells a radio radiologist where the bleeding is coming from. So I've just I've just put sentinel in the chat just to explain what this is. So whenever you see a stent in a clot, it tells you that the bleeding is likely to be coming from around here, and in fact, this patient had a bleeding intercostal artery. So during the fall, the fractured rib lacerated the artery and in lacerating the artery. It produced this hemothorax. And there's the blood clot. Okay, so So this is, um, a tension he mo thorax. Now, the reason I know it's tension is for exactly the same reason as the tension pneumothorax explanation I gave earlier, and I'm going to show you what I mean. So if we then go to the Corona, all slices. So I'm dragging the thumbnail over to the left hand pain. Can you see that there is depression of the diaphragm on the left hand side so that left left Hemi diaphragm should mirror the right Hemi diaphragm. But it's pushed well down because of the increased intrathoracic pressure caused by the hemothorax. So if you then put a chest drain into the safe triangle, which is here, you're going to release the pressure. And then the bleeding vessel from the rib fracture is going to use out more blood. Okay, so the wrong thing to do is to put a chest rain in this situation, what you need to do is you need to seek help from an interventional radiologist who can put a catheter down the aorta and a small catheter into one of the intercostal vessels and embolize the bleeding vessel. Or if you don't have access to an interventional radiologist, you can get a general or a thoracic surgeon produce. Just do a small thoracotomy where we think the bleeding point is just here and they can tie off the vessel. So that's really, really quite important to remember now. I just wanted to go over attention hemothorax in some detail because I think it is quite important. And I'm just going to, um, swapped display. They can't, uh, so a tension pneumothorax is a clinical diagnosis where you get increased intrathoracic pressure in the pleura that exceeds the atmospheric pressure. So it's not just the loss of the negative pull pressure. It's because the pressure in the thorax exceeds the intraabdominal pressure. And therefore you get flattening Andy version of the diaphragm. Okay, and that's the more specific sign. Here's another example where we've got the version of the diaphragm. It was a case that I was involved in in 1996 and note that the chest drain is present on the right, and on the left, there's lots of medicine will shift. And so even though the chest drain is in on the left that chest drain, maybe blocked by blood. We've got attention hemopneumothorax, which is causing depression of the diaphragm and deviation of the me to start them over to the right. Now, how do I know it's attention? Hemopneumothorax and not a pneumothorax? So I'm quite confident there's blood and gas in the or acts, not just not just blood or gas. Any thoughts? If this was a pure pneumothorax, this would be much blacker than the other lung field. But because it's gray and because the patient is supine, there must be a layering of hemothorax below the pneumothorax. Don't forget, the patient's in a supine position, and so this is a hemopneumothorax. There's the diaphragm, which is averted and depressed, and attention pneumothorax on a chest X ray. This patient was on the intensive care unit, and they've just recently had a right internal jugular line placed. They've got an ET tube in situ, and you can see here. There's the left hemidiaphragm, and the left Hemi diaphragm is much higher than the right hemidiaphragm, which can't be seen because it's so depressed. It's off the scale. Note also that we've got a meter tunnel shift and we've got collapse of the right lung. And this is a tension pneumothorax and the treatment for attention. Pneumothorax is different from attention. Hemothorax and clinicians should really be draining this with a fine ball cannula pretty quickly. And so what we do is we put the smallest needle we can get, usually a green needle between the 2nd and 3rd ribs anteriorly. So that's the second intercostal space in the midclavicular line. The and you get this watching noise coming out the washing noise. That's just where I think the diaphragm would be if the film was centered any lower. That's depression of the diaphragm. And that's where the left handed are from us. And this is just to go over the form. I just showed you the tension hemothorax, where we've got the sentinel clot, depression and the version of the diaphragm. Okay. And the two conditions are treated slightly differently for obvious reasons. We don't want the blood that's in the Hemi thorax. Two, uh, stop the tamponade effect it has on the bleeding intercostal vessel. Okay, so let's go to case number 12. Okay, So case number 12 is a patient who falls off a height and they have a lumber spine X ray. So they've jumped maybe 2030 ft to the ground off a bridge. And I want you to tell me what you think is wrong here. Just have a look at the lumber spine. There's the AP and there's the lateral. What do people thinking? Um, displacements. Left side. Now let's have a close look at the vertebrae as you go down the lumber spine. The pedicles are getting slightly further apart. Okay, that's normal, because the lower vertebrae have to support a greater weight than the upper vertebrae. Okay, And when we look at L1, that's t 12 because it's got a rib attached to it. That's L1. That's L2. That's L3. That's L4, and then we've got sacral ization of L5. That just means that the L5 vertebra looks a bit like the first sacral segment. Don't worry about that. And all all looks pretty good, really, that you get a slight hint that this might be slightly widened, but only a hint. But if you look on the lateral view, can you see that this is a very distorted vertebra? So those are one. There's L2, there's L3 and there's L4. So we've got a bit of vertebra protruding anteriorly, and it looks as if it's lost its vertebral height. So let's have a look on CT at this particular vertebra, and I'm going to put it immediately onto bone windows and I'm going to put the reconstruction next door to it. So as we scroll down, this is normal vertebra. There's the virtual body. There's the pedicle. Was the pedicle there? This is the LAMANNA, and this is the spine ist process. And this is the transverse process of the vertebra. So this is normal. This little cleft here is where the veins drain the venous blood supply, Uh, of the bone marrow. It's called a bass reversible plexus. And as you come down, you can see that we've got a fracture of this vertebra. It's called a burst fracture because the force has come from top to bottom. That's called a burst fracture, and you'll see that some of this vertebra has gone backwards into the spinal canal and some of the virtual has gone forwards, and you can see that this hematoma around the front now If there's hematoma around the front, what are the chances of there being hematoma at the back? Anyone Tell me what you think in the chat. Well, there's there's going to be hematoma around here, But look also at the significant narrowing of the spinal canal at the level of L4. And as we go from L4, there is the Aricept joints and those L5. So there's the facet joints nicely shown. There's the facet joint of. So it's the facet joint here between L4 and L5. That's normal. But the virtual body is completely smashed, and the posterior of fragment is now causing a compromise on the cord. A equina. So this patient urgently needs this decompressing, and it is a matter of a neurosurgical emergency. Okay, so this is, um, a so called burst fracture and constitutes a real emergency. Okay? And we then send the patient for an MRI scan to see what the consequences are for the cord require, uh, the cord required are, of course, the nerves that come off the Conus medal. Aris, uh, let me get the better, and you can see that the birth fracture is moving the virtual body backwards into the spinal canal and causing compression of the cold rock. Wanna just, uh, So it's a very important injury to to pick up both clinically and radiologically. Okay, Number 18. This patient has a severe occipital headache, and I want you to scroll through the case and tell me what you think the diagnosis is. Any thoughts? Anyone want to attempt the answer here? Okay, so what we've got is we've got blood in the basal systems which are causing dilatation of the temporal horns. Ortho lateral ventricles. So this patient has got early hydrocephalus due to a subarachnoid hemorrhage. So the blood is in the subarachnoid space around the basil systems. It's going into the Sylvian Fissure into the Sylvian Fissure. Here, it's causing hydrocephalus. And if you go a little bit lower, you can see the blood is actually tracking down in front of the medulla oblongata and through the frame and Magnum. And we've got delectation of the third ventricle, and we've got early dilatation of the lateral ventricles. Got blood in the posterior horns of the lateral ventricles, and we've got subretinal blood here. So this is a subarachnoid hemorrhage now, subarachnoid hemorrhage can be caused by trauma, or it can be spontaneous. And when it's spontaneous, it's usually associated with berry aneurysm or an aneurysm of the cerebral arterial circulation, usually around the circle of Willis. Okay, so you normally get aneurysms. We've got a bifurcation, and most bifurcation zones occur around the circle of Willis. And that's where you usually get, um, the aneurysm causing a bleed. I suspect the aneurysm is around the anterior cerebral artery or the anterior communicating artery. Um, if you just get blood above the level of the basal systems in the Sylvian fissure, this can be, uh, due to trauma. Okay, so it's very important to understand the context in which the patient presents. So if it's trauma, you're looking for, um, uh, blood in a different position to a ruptured berry aneurysm. Okay, I want to show you something which is very, very commonly missed. It's a diagnosis that is very commonly missed both by clinicians and radiologists. And the reason I'm showing it to you is I just want you to, uh, see that it can be easily Ms clinically easily Miss Radiologically. But I'm going to tell you how you can avoid this. So we've got a patient who has fallen over, and the doctors think that they may have dislocated their shoulder because they can't move the shoulder at all. Now most dislocations occur by the humeral head going down and immediately underneath the core record process. But this dislocation is almost at the same level as the normal, um, situation with the humiral head. But what sort of dislocation is this? And can anyone tell me why posterior dislocation? Excellent. That's exactly what it is. It's the most difficult dislocation to pick up, and the reason being is that in a posterior dislocation, the height of the humeral head doesn't change, but it goes backwards behind the glenoid. So there's the glenoid, and there's the humiral head. But what's happening is it gets trapped behind the glenoid, and normally, in a normal situation, the humiral head and the glenoid are parallel to one another, but this is larger at the top than it is at the bottom, so it's no longer parallel, and so this is a posterior desiccation. If you needed to get more evidence that this was opposed to a dislocation, you would do a lateral view or as we call a scapula y view. So you do the X ray that way. So you see, the GLENOID based on that becomes one aspect of the Y, and the chromium becomes the other aspect of the y. So it's called the scapula y projection, and that easily shows that the humiral head is then poster is the green of it. But actually that can be quite difficult to obtain if the patient is in, uh, lots and lots of pain, okay. And the last one I'm going to show you, which is quite important, is, uh, case number 11. Let's have a look at number 11. It's a passenger in a road traffic accident, 60 year old male, and you can see from the chest X ray that the ET tube is too low. So there's the Carina about here. Can everyone see that? By the way, just just say something can leave in the chest. Can you make out that the ET tube is too low? There's the left main bronchus, and there's a chest rain going in the right thorax. Over here, there's a chest rain going in the left Hemi thorax. Over here and the patient is supine. Okay. The CP angles look to be about at the right level. There's some overlapping of ribs suggesting that might be a fracture. Okay, around here and in fact, probably just there. But the most worrying thing of all is I can no longer see the aorta. Okay? And that tells me that there might be hematoma next to the aorta. So what we can do in see tears? We can do a CT angiogram, and we can look at the aorta to see whether or not it's been lacerated. So I'm going to change the layout. Gonna put three pains up and let's go through it so already I can see that there is a hematoma in the mediastinum. Just that little bit of gray behind the aorta is hematoma. And there you go. Hematoma. Adjacent to the left subclavian artery. There's the hematoma just around the aorta, which is making the aorta difficult to see. And we've got a lacerations of the aorta. Just, uh, so that aorta is lacerated and the patient has got pseudo aneurysm. Now I'm going to show you a slide in a minute or so to explain what happens here, but this needs to be corrected pretty quickly. Okay, because if it isn't corrected pretty quickly, the patient may have a rupture of this pseudo aneurysm, which is just here, and that can lead to exsanguination and the patient's death. So let me just show you what happens here. So when you get a compressive force on the aorta, there is a fixed point where the aorta joins the heart. There's a fixed point where the aorta is strapped to the thoracic spine, and the floppy bit of the aorta is the aortic arch. And so the week bit is going to be distal to the left subclavian artery, and you get this break in the intimate or the intimate and the media and worse case scenario, you get a break of all three layers, which leads to the patient's demise. So you've got torsion stressors around the aortic root and around the part of the aorta, dissolute to the left subclavian artery. Get bending stresses, and this leads to the pseudoaneurysm. And a pseudo aneurysm is where we've got a lacerations through the intima the media. But it stopped short of the adventitia, and it forms a false aneurysm. If the trauma is so severe as to cause this type of injury, you get a complete lacerations of the aorta, and then this leads to exsanguination and the patient's death, and then you get other degrees of abnormality. But this is what we are seeing in case number 11. We've got a false aneurysm due to the patient having There's the false aneurysm and you can see it's a lot better if you, uh, change it to bone windows. And what I'll do, we'll assume it's hip. There's the false aneurysm. Just there. Which is what we are seeing in this slide here. False aneurysm. Okay, um, it's 9. 30. Um, I'm sorry I started late. Um, but I'm, uh, in unfamiliar territory. Uh, sorry about the technical blip in the middle. I'm very happy to receive any questions. Uh, you may want to reserve them for the next time we do this, but I'm I'm going to do some trauma cases which I think are quite relevant for you guys at the present moment. If you would like me to do anything else in radiology, will you please feedback to the organisers so that they can get Get in touch with me, and I can show you exactly what you want. Because I'm conscious of the fact that your urgency for different types of radiology might be different from what we're teaching UK medical students at the moment. So please let the organizers know what you want. And I will, uh, deliver it, uh, in the next session. So thanks very much for your attention. I hope it was of some use. Uh, please do have a look at all the cases that I've shown and have a look at the recording. Once again, some of these concepts are quite difficult, and I hope I've explained them as easily as I can. Um, but I've tried to give you a practical view of how to manage these patient's clinically as well. Okay, so thank you very much and enjoy the rest of the day. Thank you very much, Doctor Curtis. I just like to remind everyone before you leave this meeting to do the feedback form. It's very important for us. Um and you've also got the certificate in the chaps, but please do the feedback. Thank you very much.