Chest trauma and approach to testing

Here is the submitted question:  “A man involved in an MVA with multiple rib fractures, bruising over his chest and blah blah blah. 
CXR shows widened mediastinum, tracheal deviation, bronchial displacement and loss of the aortic knob.
 They ask the next best step in the management of this patient. The choices are Angiography of the chest, CT Chest, MRI Chest, TEE and urgent surgical consult. 
The answer that they give is CT CHest.
I understand that CT would best define what we’re looking at, but USMLE World and one of my review books says that TEE is sensitive and specific and can be used to pick up an aortic rupture. Wouldn’t that be the more logical test in this situation given the time frame
ANSWER
The TEE, CT angiogram and MRA are all equally sensitive in the detection of aortic aneurysm.
 
With multiple trauma, however, the Chest CT is better to look at all the detail to be found in the chest.  The problem with this question is NOT the testing issue, it is the fact that with such severe clinical presentation , you can easily mke the case for going straight to the Operating room.
 
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2 Responses to “Chest trauma and approach to testing”

  1. tyro Says:

    There’s a lot missing in that question. You should never get a chest x-ray with a deviated trachea. You should see a deviated trachea on your primary ATLS survey and if present, a chest tube should be placed, probably after a needle thoracostomy. If the patient is deviated due to a tension hemothorax and you get greater than 1-1.5 L of blood out, you’re going to the OR, not the scanner. If you’re saying it’s a bad question because ‘surgical consult’ is arguably a better answer, then I totally agree with you.

    As to whether MRI or TEE are even feasible in this patient, the answer in almost any facility I know of is an emphatic no. CT scans are much more readily available, will be preferred by your surgeon if you get a scan at all, and are much faster than either, so if you have a patient with normal vital signs, it’s easy to say that CT is the best imaging option.

    Am I missing something here?

    • Conrad Fischer Says:

      QUite right! I would not be screwing around with Scans and plans when he needs a needle in the chest man!

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