Trauma & Lung transplantation Flashcards
@# (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
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.
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
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.
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. 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.
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
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.
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
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.
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. 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.
(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
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.
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
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.
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
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.
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
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.
(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
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).
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
(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.
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) 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%).
@# 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) 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.
(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
(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.
