Tag Archives: GSW

Answer: Can you find the abnormalities?

December 2, 2013


I gave you this xray a couple days ago, can you find all the abnormalities?


1.  Intubated into the right mainstem bronchus

2.  Metallic foreign bodies coursing up the left chest to the neck

3.  Completely opacified left lung:  differential diagnosis of pulmonary contusion, hemothorax, or complete atelectasis from right mainstem intubation

4.  There is a chest tube in the right chest cavity, it looks to be in good position but could be coursing into the fissure between the left lobes

5.  Deep sulcus sign on the left side indicates possible pneumothorax vs. hemothorax

6.  Orogastric tube courses below the diaphragm in good position

7.  Subcutaneous emphysema in upper neck

8.  Two radiodense objects in the midline cardiac silhouette near the mid-portion of the coursing orogastric tube

Interestingly, this patient was shot in the chest coursing to the upper neck and the bullet was found in his posterior pharnyx.  He had a tooth found on chest CT (calcified opacity seen below) among other injuries.   Later EGD intraoperatively showed two tooth fragments in the stomach.  The radiodensities seen #8 above were presumed to be these teeth in the esophagus.


Image Contributor:  Julie Phan, MD

Author:  Russell Jones, MD

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Can you find all the abnormalities?

November 28, 2013


This patient came in after a reported gunshot wound.  Can you find all the abnormalities in this xray?



Answer to follow.

Image Contributor:  Julie Phan, MD

Author:  Russell Jones, MD

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Ruptured globe…

May 4, 2013

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Fight broke out at the local prison and this man was shot in the face with a rubber bullet…

Ruptured globe 5Ruptured globe 4Ruptured globe 3Ruptured globe 2Ruptured globe 1

The “brain” weighting CT (first figure) shows a ruptured globe with hemorrhage into the orbit.  The remainder of the figures are in “bone” weighting and show various fractures:

  1. Sagittal view of a comminuted fracture of the ethmoid sinus (medial orbital wall)
  2. Sagittal view of a comminuted fracture of the maxillary sinus (inferior orbital wall)
  3. Sagittal view of a posterior orbital fracture
  4. Coronal view re-demonstrating the ethmoid and maxillary sinus fractures

This poor fellow ended up losing his eye and going back to prison.

Author:  Russell Jones, MD

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Gun Shot Wound (GSW) to the head..

November 9, 2012


Working an overnight the other day and had an interesting GSW present to the ED.  This man was reportedly found in the driver’s seat of a car very near the entrance to the ED parking lot.  GCS was 3, he was intubated shortly after arrival.  He had a large stellate laceration on top of his head just left of midline.  It extended from about where you’d expect the coronal suture line to be, all the way to the poterior-most portion of his occiput (kinda like the bullet skipped off the top of his head and made a big laceration).   His GCS was low because of this:

This is a good example of an acute subdural hematoma from penetrating trauma.  It appears the bullet damaged many of the bridging vessels and acute blood can be seen as a white layering density on the right side of the image.  Remember, acute blood is hyperintense with higher Hounsfield Units (HU) similar to bone.  As it matures it will eventually become darker and darker until it is less intense than brain tissue.

This CT is also a good example of mass effect.  Mass effect is a term used most often in head imaging because of the limited volume of the closed cranial vault.  If an extraneous volume is added to the vault it will compress or displace brain tissue thus causing “mass effect.”  Mass effect is most often caused by blood, tumors, edema, or obstruction of CSF flow (1).  The best way to assess for mass effect is to look at the ventricles, the falx cerebri, and the overall symmetry of the brain.  In the example above one can see the lateral ventricles are displaced to the left of the image (patient’s right side) and the falx bends in that direction because of the subdural blood.  Clinically this causes decreased mentation, signs of herniation, and eventual respiratory arrest due to compression of the respiratory centers of the brainstem.

How do we know this is subdural blood not epidural?  Remember, subdural blood crosses suture lines, epidural blood does not.  Also, subdural blood tends to easily distribute throughout the contours of the brain (causing a convex shaped collection) whereas epidural blood forms a lenticular shaped collection.  Subdural blood is in the space between the dura and the arachnoid while epidural blood is between the skull and the dura.  The other significant difference is that subdural blood is usually venous (sometimes can be arterial) and epidural blood is usually arterial (classically from the middle meningeal artery).  Arterial and venous blood cannot be differentiated on imaging but it may be distinguishable by the timing of the patient’s clinical symptoms after trauma.

The second image has been switched to bone windows and one can appreciate the bony damage from the bullet.

There were two predominant theories about how the patient got to the ED parking lot:  1.  He was shot and had time to drive to the ED while the blood collected in the subdural space.  2.  He was shot in the ED parking lot.  All of us reassured ourselves that is was definitely number 1, not the latter!


1.  Broder JS, Preston R.  “Imaging the Head and Brain.” In: Broder JS.  Diagnostic Imaging for the Emergency Physician.  Elsevier Saunders, 2011.

Author:  Russell Jones, MD

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