Trauma & Lung transplantation Flashcards

1
Q

@# (MSK) 5) A young patient suffers a fractured femur and acetabulum in a road traffic collision and undergoes intramedullary nailing and plateand- screw internal fixation of the acetabulum. He is well until 8 days postoperatively, when he develops acute shortness of breath and right-sided chest pain. A chest radiograph shows only a small right-sided pleural effusion. What is the most likely diagnosis?

a. fat embolism

b. bronchial pneumonia

c. pulmonary embolism

d. pneumothorax

e. hyperventilation due to pain

A

c. pulmonary embolism

Pulmonary embolism is a common complication following immobility and major surgery, particularly orthopaedic surgery of the pelvis. It typically occurs 7–10 days post-surgery. Chest radiograph findings can be normal but include small effusion, collapse or consolidation, elevation of the hemidiaphragm, a prominent pulmonary artery and hypertransradiance of the affected side (Westermark sign).

Fat embolism is preceded by long bone injury in 90% of cases but usually occurs within 36 hours of the injury, and is much less common than pulmonary embolus from deep vein thrombosis even in the context of major trauma. Pneumonia and pneumothorax do of course occur in postoperative patients, but it would be reasonable to expect associated findings on the chest film. Hyperventilation should be a diagnosis of exclusion once other potentially serious causes have been excluded.

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2
Q

11) Which of the following best describes the radiographic changes seen in acute rejection of a lung transplant?

a. mosaic perfusion and air trapping

b. pleural effusion and septal thickening with no left ventricular dysfunction

c. bilateral consolidation at the bases

d. increased lung volumes

e. globular heart and bat-wing perihilar consolidation

A

b. pleural effusion and septal thickening with no left ventricular dysfunction

Acute rejection usually develops 7–10 days post-surgery.

Most patients experience at least one episode during their life. Clinically, there are reduced arterial oxygen levels without infection, associated with fatigue and reduced exercise tolerance.

Chest imaging findings include ground glass opacity, heterogeneous perihilar opacification and new enlarging pleural effusion with septal thickening, with no signs of left ventricular failure.

Pleural edema, peribronchial cuffing and airspace shadowing may also occur.

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3
Q

15) A 32-year-old male presents with increasing shortness of breath following a road traffic accident, in which he sustained multiple long bone fractures. At 48 hours post-injury, his chest radiograph is normal. The next day a V/Q scan shows patchy, mottled, peripheral perfusion defects. The following day a chest radiograph shows patchy, bilateral, alveolar infiltrates. What is the most likely diagnosis?

a. fat embolism

b. thrombotic embolism

c. atypical infection

d. pulmonary contusions

e. pulmonary edema

A

a. fat embolism

In a patient who has sustained multiple fractures, fat embolism should always be considered when a patient is short of breath in the presence of a normal chest radiograph. This manifests on a V/Q scan as mottled peripheral perfusion defects. Chest radiograph remains normal for up to 72 hours, when discoid atelectasis, diffuse alveolar infiltrates and consolidation may develop. Fat embolism may precede the development of acute respiratory distress syndrome. Pulmonary contusions usually manifest earlier, within the first 24 hours.

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4
Q

30) A 19-year-old male presents following blunt chest trauma, with dyspnea, chest pain and hemoptysis. A chest radiograph shows bilateral pneumothoraces, subcutaneous emphysema and bilateral fractures of multiple upper ribs. The pneumothoraces fail to resolve despite chest drains and he needs intubation and ventilation. Which finding at CT would be most suggestive of the diagnosis of tracheal injury?

a. pneumomediastinum

b. bilateral pneumothorax

c. mediastinal haematoma

d. focal overdistension of endotracheal tube cuff

e. chylothorax

A

d. focal overdistension of endotracheal tube cuff

Tracheobronchial injury secondary to blunt trauma presents with non-specific symptoms and signs.

Persistent pneumomediastinum, pneumothorax or subcutaneous emphysema despite treatment is suggestive.

Associated findings are fractures of the upper three ribs and posterior dislocation of the sternoclavicular joints.

The diagnosis is confirmed by bronchoscopy. In intubated patients, focal overdistension of the cuff of the endotracheal tube is seen when the balloon bulges into the defect.

Mediastinal haematoma is more suggestive of vascular injury

and chylothorax is more suggestive of thoracic duct injury.

These may occur in association with tracheobronchial injury.

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5
Q

37) A 57-year-old man presents with chest pain and fever after an episode of vomiting. A chest radiograph shows a small left pleural effusion and pneumomediastinum. Which investigation will best establish the diagnosis?

a. CT of the chest

b. barium swallow

c. water-soluble contrast swallow

d. MRI

e. transoesophageal echocardiogram

A

c. water-soluble contrast swallow

Oesophageal rupture is the most likely diagnosis. CT may be able to elicit suspicious signs, such as mediastinal gas, oesophageal thickening and pleural effusion, but cannot make a definitive diagnosis. A contrast swallow is best in confirming the diagnosis, but barium should not be used due to its potential to cause a severe inflammatory reaction and worsening mediastinitis.

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6
Q

40) A 37-year-old male presents to accident and emergency following smoke inhalation in a fire. He feels well and a chest radiograph is normal. The following day he re-presents feeling short of breath and unwell. What are the most likely findings on the chest radiograph now?

a. pulmonary edema

b. pleural effusions

c. upper-zone consolidation

d. diffuse reticular change

e. pneumothorax

A

a. pulmonary edema

Inhalation of noxious gases, including smoke, produces focal or diffuse pulmonary edema. With smoke this may be delayed by 1–2 days. Bronchiolitis obliterans may then ensue after 1–3 weeks, especially with chemical inhalation.

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7
Q

(MSK) 44) Following major trauma, which of the following fractures of the thoracic skeleton is most likely to indicate a significant injury to the underlying intrathoracic viscera?

a. glenoid

b. scapular blade

c. clavicle

d. first rib

e. sternum

A

d. first rib

First rib fracture is considered a harbinger of major trauma, with approximately two-thirds of fractures being associated with major chest injury and carrying a significant mortality. The anatomy of the first rib is such that it is protected from the minor insults that often break other ribs, and fracture of the first rib usually indicates violent blunt trauma to the thorax. Associated local injuries include damage to the brachial plexus, major vascular structures and the underlying lung and heart. There is also an association with significant abdominal injury, but the major cause of death in patients with a first rib fracture is an associated head injury. It is rare for a first rib fracture to be an isolated finding.

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8
Q

71) In patients undergoing lung resection for malignancy, which imaging investigation is the best predictor of postoperative lung function?

a. perfusion scintigraphy

b. ventilation scintigraphy

c. ventilation and perfusion scintigraphy

d. helical CT of the lungs

e. dynamic MRI of the lungs

A

b. ventilation scintigraphy

It is possible to estimate postoperative lung function (FEV1 (forced expiratory volume in 1 s)) with ventilation and perfusion scintigraphy, either in isolation or combination. However, ventilation scintigraphy is the best predictor of postoperative FEV1. This does underestimate the value; therefore, patients with borderline lung function should not necessarily be denied surgery on the basis of the result. CT and MRI have not been shown to be helpful in assessing postoperative lung function.

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9
Q

72) A 42-year-old male suffers a chest injury in a road traffic accident. The presenting chest radiograph shows fractures of the fifth and sixth ribs on the right side with patchy airspace changes. He is admitted and has supportive care. A repeat chest radiograph shows the consolidation to have largely resolved, but a rounded opacity is now present with an air–fluid level. He is otherwise well. What is the most likely diagnosis?

a. abscess

b. bronchopleural fistula

c. bronchogenic cyst

d. pulmonary infarct

e. pulmonary laceration

A

e. pulmonary laceration

Pulmonary lacerations occur following trauma disrupting the lung parenchyma. The typical appearance is of a rounded cavity containing blood and/or air. On plain films, consolidation due to contusion often obscures the laceration. The laceration appears as a rounded/ovoid opacity with a pseudocapsule of compressed lung (2–3mm), and may be fully opacified, be filled with air or have an air–fluid level. Complications are uncommon and include abscess (causes fever), bronchopleural fistula (causes pneumothorax) and progression. Bronchogenic cysts could present as an incidental finding after trauma but are usually mediastinal in location. The less common intrapulmonary bronchogenic cysts may cavitate. Pulmonary infarcts may present post-trauma due to immobilization and other risk factors causing pulmonary embolus, but these do not usually cavitate.

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10
Q

@# 73) A 52-year-old man presents 1 year post-heart transplantation and has a routine follow-up chest radiograph. This shows multiple nodules of varying sizes, with enlarged hilar lymph nodes. What is the most likely diagnosis?

a. graft-versus-host disease

b. aspergillosis

c. cytomegalovirus infection

d. post-transplantation lymphoproliferative disorder

e. Epstein–Barr virus infection

A

d. post-transplantation lymphoproliferative disorder

Post-transplant lymphoproliferative disorder (PTLD) occurs after bone marrow or solid organ transplantation, usually within 2 years. The type of tumor varies. This can produce single or multiple lung nodules with or without hilar and mediastinal lymphadenopathy. The nodules may be diffuse, subpleural or peribronchial and may have a surrounding halo of ground-glass opacification.

The findings in graft-versus-host disease are of bronchiolitis obliterans – hyperinflation, bronchial dilatation and wall thickening, reduced vascularity/mosaic perfusion, and air trapping. In the acute phase, it often presents as non-cardiogenic pulmonary edema.

Aspergillosis presents with nodular opacities or consolidation, which may have a halo of ground-glass opacification, but occurs in the first 30 days.

Cytomegalovirus infection usually occurs within the first 6 months after bone marrow transplantation, with a variety of appearances.

Epstein–Barr virus is a causative factor in PTLD but is not in itself a cause of the pulmonary changes.

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11
Q

(MSK) 79) A young women attempts to commit suicide by jumping from a third-storey window, sustaining a fall of 15 metres. In addition to bilateral lower limb and spinal fractures, she suffers a blunt deceleration injury to the mediastinum. CT findings are of a large mediastinal haematoma and a focal area of irregularity in the contour of the wall of the aorta, which appears otherwise normal. Which segment of the thoracic aorta is most commonly affected by tear or transection?

a. root

b. ascending

c. isthmus

d. arch

e. descending

A

c. isthmus

Ninety per cent of traumatic thoracic aortic injuries occur at the aortic isthmus, just distal to the origin of the left subclavian artery.

The isthmus is the section between the origin of the left subclavian and the attachment of the ligamentum arteriosum, and is about 1.5 cm in length in a normal adult.

The mechanism is usually rapid deceleration (but it can be due to direct trauma) as in a fall from a height or a road traffic collision. The isthmus is thought to be particularly vulnerable to the shearing forces that occur with deceleration compared with the descending aorta, as it is relatively mobile and can be bent over the left bronchus main stem and left pulmonary artery.

A more recent theory is that this part of the aorta is particularly vulnerable to being crushed by the surrounding bony thorax (manubrium, clavicle and first rib) at the point of maximum deformation during high-energy injury.

The ascending aorta is the site for injury in only 5% of those who survive to reach hospital, but is more prevalent in cadaveric studies due to the high association of fatal cardiac injuries. The mechanism here is thought to be torsional forces or a waterhammer effect (a sudden increase in intrathoracic pressure).

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12
Q

39- A previously healthy 24-year-old man presents following an RTA with pelvic and lower limb fractures. 3 days after admission he becomes progressively breathless and has a headache. Examination shows a petechial rash- CXR is normal; V/Q imaging demonstrates multiple peripheral sub segmental defects. What is the most likely diagnosis?

(a) Pulmonary embolism

(b) Pneumocystis infection

(c) Acute interstitial pneumonitis

(d) Fat embolism

(e) Pulmonary contusions

A

(d) Fat embolism

In fat embolism the radiographic features often progress to diffuse opacification with clearing in 7—14 days; ARDS may develop. The mottled appearance at V/Q is quite different from that seen with large pulmonary emboli. Neurological features are generalized may progress from irritability to seizures and com.

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13
Q

50- A 56-year-old man undergoes single lung transplantation for sarcoid-related lung disease. At day 10 post-operatively he becomes increasingly dyspneic- The CXR shows increased consolidation within the graft lung.
What is the most likely cause for these appearances?

(a) Acute rejection

(b) Aspergillus infection

(c) Cytomegalovirus infection

(d) Post-transplant lymphoproliferative disorder

(e) Recurrent sarcoidosis 18

A

(a) Acute rejection

Acute rejection typically presents within the first 4 weeks, CXR may be normal, or show edema, worsening consolidation, peribronchial thickening, new pleural effusions, or septal lines without evidence of LVF.

Infection in the first 4 weeks of transplantation is almost invariably bacterial.

Acute rejection is the only other condition common within the first month and is extremely common after 1 week.

CMV, PTLD and Aspergillus infection typically occur more than 4 weeks post transplantation; recurrent disease would also be expected later, but is more common in sarcoid (35%) than other conditions (< 1%).

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14
Q

@# 4 Regarding lung transplantation, which of the following conditions would not be suitable for a single lung transplant, and would necessitate a double-lung transplantation?

(a) Bronchiectasis

(b) Emphysema

(c) Idiopathic pulmonary fibrosis

(d) Primary pulmonary hypertension

(e) Sarcoid

A

(a) Bronchiectasis

Suppurative lung disease, such as cystic fibrosis and bronchiectasis, necessitates double lung transplant to prevent the spread of infection from native lung to the graft.

The other conditions can be treated with single lung transplantation, although patients with PPH or emphysema may also be offered double lung transplantation.

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15
Q

(MSK) 69 A young man was involved in an RTA 48 hours ago and is currently an inpatient in the trauma centre. He becomes dyspnoeic. Fat embolism is suspected. Which features would be very unusual in this condition?

(a) A normal chest radiograph at 48 hours

(b) Bilateral diffuse alveolar infiltrates at 48 hours

(c) Petechiae

(d) Neurological symptoms

(e) Cardiomegaly

A

(e) Cardiomegaly

The onset is 24-72 hours after trauma (the chest radiograph may be normal up to 72 hours). The radiographic appearance can be similar to pulmonary oedema, however, the heart size is normal.

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16
Q
  1. A 26 year old man suffers a blunt injury to his chest in a road traffic accident. The most common abnormality seen on CT as a result of blunt thoracic injury is:

a. Pneumothorax

b. Pulmonary laceration

c. Haemothorax

d. Tracheo-bronchial injuries

e. Pulmonary contusion

A
  1. e. Pulmonary contusion

Pulmonary contusion is the commonest manifestation of blunt trauma and indicates trauma to alveoli with alveolar haemorrhage without significant alveolar disruption. Whilst plain film changes may not be apparent for up to six hours, CT will demonstrate changes almost immediately post-trauma and signs of resolution can be seen as early as 48 hours. If unresolved, it may progress to ARDS

17
Q

@#e 45. Eight days after lung transplantation for alpha-1 antitrypsin deficiency, a 45 year old man develops pyrexia, breathlessness and desaturation. HRCT reveals perihilar heterogenous opacities and ground glass changes with new pleural effusion and septal thickening. Which of the following is the most likely cause?

a. Reperfusion oedema

b. Acute rejection

c. Anastomotic dehiscence

d. Post-transplantation PCP infection

e. Hyperacute rejection

A
  1. b. Acute rejection

Hyperacute rejection presents within hours of the transplantation. Reperfusion oedema usually presents within 24 hours of the transplantation, peaking by about day four. Posttransplant infections can be broadly divided into those occurring within the first month (gram-negative bacteria, fungi (candida, aspergillosis)) and those occurring after the first month (CMV, PCP). Anastomotic dehiscence is usually an early feature, but the presentation and features are not those described.

18
Q
  1. A patient is admitted with a comminuted femoral fracture. Initially he is quite well, but goes to theatre for internal fixation of the fracture. His clinical condition deteriorates after 24 hours and he develops fever, hypoxia, and confusion. The clinical team have noted a rash and at the same time as requesting a CT chest, request a CT brain ‘?meningitis secondary to epidural’. The CT chest reveals widespread peripheral areas of ground-glass opacification (GGO) and air-space consolidation. There are no septal lines or pleural effusions. A follow-up radiograph 10 days later reveals complete resolution. What is the most likely diagnosis?

A. Multiple pulmonary contusions.

B. Pulmonary oedema secondary to anaesthetic medication.

C. Fat embolism.

D. ARDS.

E. Pneumococcal meningitis.

A
  1. C. Fat embolism.

This is an infrequent complication of long bone fracture, occurring in 1–3% of patients with simple tibial or femoral fractures, but in up to 20% of those with more severe trauma. Less commonly it can be caused by major burns, pancreatitis, haemoglobinopathy, tumours and liposuction. A complication of pulmonary, cerebral, and cutaneous symptoms (petechiae secondary to coagulopathy), it typically occurs within 12–24 hours after the traumatic event. The time lapse between the traumatic event and the radiographic abnormalities is usually 1–2 days, which allows differentiation from traumatic contusion. The radiographic findings resemble ARDS, although a peripheral distribution of consolidation is described. V/Q scanning will reveal multiple peripheral perfusion defects. In practice it is the clinical features such as the rash, confusion, and coagulopathy, as well as the presence of a fracture, which raise the suspicion of fat embolism.

19
Q

61 A 42-year-old man became dyspnoeic two days after a road traffic accident where, among other injuries, he sustained a pelvic, left femoral and right humeral fracture. On examination he was febrile, cyanosed and confused. A number of petechial haemorrhages on his chest and abdomen were noted and you are contacted to review his chest radiograph as it appears normal. What is the most likely diagnosis?

a Pulmonary embolism

b Fat embolism

C Disseminated intravascular coagulation

d Bacterial septicaemia

e Adult respiratory distress syndrome

A

61 Answer B: Fat embolism

Fat embolism is caused by obstruction of pulmonary vessels by fat globules following major skeletal trauma. Onset is typically 24-48 hours following trauma. The CXR is often normal in the acute phase, progressing to consolidation and atelectasis thereafter.

20
Q

62 A 62-year-old female patient became unwell 10 days following right lung transplantation. She was short of breath, febrile and lethargic and her oxygen saturations had deteriorated over the previous three days. Her chest radiograph showed heterogeneous peri-hilar airspace opacification, septal thickening and a right pleural effusion. The heart size was unchanged compared to previous radiographs and the upper lobe pulmonary vessels were not distended. Transbronchial lung biopsy showed a mononuclear cell infiltrate and alveolar oedema. What is the most likely cause for the patient’s dyspnoea?

a Biventricular heart failure

b Post-transplantation staphylococcal infection

C Bronchiolitis obliterans syndrome

d Reperfusion oedema

e Acute transplant rejection

A

62 Answer E: Acute transplant rejection

The clinical picture is that of acute rejection within the lung transplant. This condition usually responds to high-dose intravenous steroids.

Bronchiolitis obliterans syndrome (i.e. chronic rejection) is an obliterative bronchiolitis that develops in transplanted lung after three months. Findings include air trapping, mosaic perfusion and bronchiectasis.

21
Q

62 A 47-year-old male patient became markedly hypoxic 24 hours after bilateral lung transplantation for idiopathic pulmonary fibrosis. The patient did not have any other significant medical history. He had not been extubated due to increasing oxygen demands over the preceding hours and his chest radiograph showed perihilar airspace opacification and bibasal pleural effusions. He was afebrile and was not fluid overloaded. What is the most likely diagnosis?

a Reperfusion syndrome

b Cardiogenic pulmonary oedema

C Acute transplant rejection

d Post-transplant lymphoproliferative disease

e Post-transplantation infection

A

62 Answer A: Reperfusion syndrome

The acute onset (within 48 hours) and lack of fluid overload indicate a diagnosis of reperfusion oedema over acute rejection and cardiogenic pulmonary oedema respectively.

Reperfusion syndrome is due to increased permeability due to lymphatic disruption, ischemia, trauma and pulmonary denervation.

It is the most common immediate post-operative complication following lung transplantation.

22
Q

26 A 34-year-old fit and well female presented with a two-week history of right sided pleuritic chest pain and tenderness following a recent chest infection, which had cleared after treatment with antibiotics. She is not short of breath. A bone scan showed a solitary focus of Tc-99m-labelled MDP uptake in the region of the lateral tenth right rib and no other abnormalities. What is the most likely explanation for these findings?

a Pulmonary infarct from pulmonary embolus

b Solitary metastasis from an occult primary

C Cough fracture

d Costochondritis

e Residual infection

A

26 Answer C: Cough fracture

This finding should be taken into context with the clinical history. If the patient had a history of malignancy, was older or had comorbidities, this finding should be viewed with more suspicion. Cough fractures can follow infection or inflammation or occur after fitting.

23
Q

32 A 70-year-old gentleman suffered from shortness of breath following a total hip replacement and a ventilation/perfusion scan was performed, which showed a mismatched perfusion defect. What is the most likely cause?

a Emphysema

b Pulmonary hypertension

C Fat embolism

d Pleural effusion

e Lung collapse

A

32 Answer C: Fat embolism

In fat embolism, the perfusion defect is greater than the ventilation defect, resulting in a mismatched perfusion defect.

With pulmonary infarction secondary to an embolus, there can be a matched ventilation/perfusion defect.

Lung collapse, pleural effusion and emphysema result in mismatched ventilation defects.

24
Q

57 A patient with advanced acute myeloid leukaemia became acutely breathless following a large blood transfusion. He was markedly tachypnoeic at rest and blood gas analysis revealed type 1 respiratory failure. His coagulation screen showed a prolonged activated thromboplastin time and the fibrinogen level was markedly reduced. The on-call haematologist suspects disseminated intravascular coagulation (DIC). What imaging feature is most in keeping with pulmonary haemorrhage?

a Bibasal consolidation and atelectasis

b Bibasal atelectasis and ground-glass change with small pleural effusions

c Mid and upper zone patchy consolidation and atelectasis

d Bilateral patchy segmental and lobar consolidation and ground-glass change

e Confluent consolidation in a dependent distribution

A

57 Answer D: Bilateral patchy segmental and lobar consolidation and groundglass change

There are many causes of pulmonary haemorrhage including bleeding diathesis, trauma, haemorrhagic pneumonia and drug-related haemorrhage. Pulmonary haemorrhage in association with renal disease is common (e.g. Wegener’s granulomatosis/Goodpasture’s syndrome). The hallmark of diffuse pulmonary haemorrhage on imaging is multifocal consolidation and ground-glass change.

25
Q

@# 46. An 18-year-old man was brought to the Accident & Emergency Department. The patient was the driver of a car involved in a road traffic accident. What is the most common/expected abnormality on chest CT?

(a) Pneumothorax

(b) Flail chest

(c) Clavicle fracture

(d) Diaphragmatic injury

(e) Oesophageal rupture

A
  1. (a) Pneumothorax

Pneumothorax, lung contusions and rib fractures are the most common expected abnormalities in blunt trauma to chest, seen in more than two-thirds of cases. Other abnormalities are far less common.

26
Q
  1. Which of the following are correct regarding thoracic trauma: (T/F)

(a) A normal erect CXR virtually exclude acute thoracic aortic injury.

(b) Uncomplicated pulmonary contusion on CXR begins to resolve after at least 7 days.

(c) Air bronchograms are a common CXR feature of pulmonary contusion.

(d) Pulmonary lacerations appear as ovoid lucent areas.

(e) Main bronchial injuries are more common than tracheal injuries.

A

Answers:
(a) Correct
(b) Not correct
(c) Not correct
(d) Correct
(e) Correct

Explanation:
Air bronchograms are usually absent in pulmonary contusions as result of blood filling the airways.
Uncomplicated pulmonary contusions begin to resolve after 48-72 hrs. Complete resolution is seen usually by 10-14 days.

27
Q
  1. Which of the following are true regarding blunt pulmonary trauma? (T/F)

(a) Pulmonary contusions show radiographic resolution in 48 hours.

(b) Bronchial rupture is always accompanied by pneumothorax.

(c) Traumatic diaphragmatic rupture is more common on the left side.

(d) A normal chest radiograph has a good negative predictive value for aortic rupture.

(e) Aortic rupture most commonly occurs at the aortic root.

A

Answers:
(a) Correct
(b) Not correct
(c) Correct
(d) Correct
(e) Not correct

Explanations:
Bronchial rupture is frequently (70%), not always associated with pneumothorax. The falling lung sign is typical and refers to displacement of lung to the dependant position.
Aortic rupture is the most common at ductus arteriosus level.