16 July 2009

Chest Trauma

Chest Trauma
by:Kent J. Blanke, D.O., FACOS
Thoracic Trauma
Penetrating Chest Injuries
* Majority are stab wounds or gunshot wounds (GSW)
* Lower mortality rates--less likely to include multiorgan injury
* 85% of penetrating chest wounds can be treated with tube thoracostomy and supportive measures
Penetrating Chest Trauma
* Wounds that enter or exit inferior to the nipple or the posterior tip of scapula may perforate the dome of the diaphragm.
* Any penetrating wound such as this should be considered to have an abdominal component until proven otherwise.

Penetrating Chest Trauma: Treatment
* ATLS protocol: A,B,C,D,E’s
* Emergency management
o Needle thoracentesis
o Tube thoracostomy
o Subxiphoid pericardotomy
o Video assisted thoracic surgery (VATS)

Work-up of Penetrating Chest Trauma
* Physical examination
o Look, Listen, Feel
o Contusions, diminished or absent breath sounds, SQ emphysema can readily be found
* CXR- best, least expensive and fastest initial evaluation
* Ultrasound-may soon replace CXR as initial radiographic study in chest trauma
* Angiography- to look for great vessel injuries
* CT Scan: for better evaluation of chest wall and parenchyma
* Transesophogeal Echocardiography

Penetrating Chest Injuries
* Operative intervention required for:
o Massive or persistent bleeding
o Massive air leak
o Tracheobronchial injuries
o Esophageal perforation
o Cardiac or great vessel injuries
o Post-traumatic empyema
* Wounds that enter or exit inferior to the nipple or the posterior tip of scapula may perforate the dome or the diaphragm.
* Any penetrating wound such as this should be considered to have an abdominal component until proven otherwise.

Penetrating Chest Trauma:Indications for Mechanical Ventilation
Intrapulmonary Foreign Bodies
* Bullets, fragments: indications for removal
Intrapulmonary Foreign Bodies
Pulmonary Parenchymal Laceration
High Velocity Missile Injuries
Blunt Chest Trauma
Categories of chest wall injuries
* Open pneumothorax
* Contusion and Hematoma
* Sternal fractures
* Scapular fractures
* Flail chest
* Intercostal vessel injury
Categories of Intra-thoracic Injuries
* Pulmonary
o Pneumothorax, hemothorax
o Pulmonary contusion
o Pulmonary laceration
* Vascular
o Great vessel disruption (Ao dissection, pulmonary vasculature)
* Cardiac
o Blunt Cardiac Injury, Penetrating injury

Work-up of Blunt Chest Trauma
* Physical examination
o Look, Listen, Feel
o Contusions, diminished or absent breath sounds, SQ emphysema can readily be found
* CXR- best, least expensive and fastest initial evaluation
* Ultrasound-may soon replace CXR as initial radiographic study in chest trauma
* Angiography- to look for great vessel injuries
* CT Scan: for better evaluation of chest wall and parenchyma
* Transesophogeal Echocardiography

Categories of chest wall injuries
* Contusion and hematoma

Categories of chest wall injuries
* Open pneumothorax
* Pneumothorax
Operative Intervention for Hemothorax
* As noted previously
* Hemothorax: massive = initial drainage more than 1,000 cc or
* Continuous bleeding of 200 cc/hr for 2 hrs

Fractured Ribs: Chest Wall Trauma
Blunt Cardiac Injury
Categories of chest wall injuries
* Sternal fractures
Categories of chest wall injuries
* Scapular fractures
* Flail chest
Pulmonary Contusion
Intra-thoracic Trauma: Pulmonary Contusion
Intra-thoracic Trauma: Great Vessel and Mediastinal Trauma
* Aorta
* Pulmonary vessels
* Tracheobronchial lacerations
* Esophageal lacerations

Intra-thoracic Trauma: Great Vessel and Mediastinal Trauma—Work-up
* Plain CXR to identify thoracic aorta injuries
* Look for air in the mediastinum
* Persistent airleak should cue into:
o Bronchopulmonary or tracheobronchial injury
* Mediastinitis, tube feedings in chest tube or saliva in chest tube should cue into:
o Esophageal injury
* Bronchoscopy
* Esophagoscopy
* CT
* Serial CXR

Initial CXR of Concern

Indications for Angiography
* Lateral deviation of the NGT in esophagus
* Widened mediastinum (>8cm)
* Loss of visualization of the aortic knob
* Hematoma of the Left cervical pleura (pleural cap)
* Depressed left main stem bronchus
* Rt lateral deviation of the trachea
* Widened mediastinum (>8cm)
* Forward displacement of the trachea on the lateral CXR
* Fx of the 1st or 2nd rib
* Massive chest trauma w/ multiple rib fx
* Fx or dislocation of the thoracic spine
* Major deceleration injury
Complete Aortogram

Chest Trauma.ppt


Radiographic Findings in Blunt Chest Trauma

Soft Tissue Radiographic Findings in Blunt Chest Trauma
By:Jonathan Yarris MSIV

* Trauma is the leading cause of death in patients < 40 years
* 4th leading COD overall
* 80% of trauma is due to blunt mechanisms

Blunt Chest Trauma (BCT)
* Seen in about ½ of blunt trauma cases
* ~20% of trauma deaths attributable to BCT
* Etiology: typically deceleration injury
* Radiographic evaluation should begin immediately after initial trauma team assessment

Approach to Trauma Radiographs
* Initial exclusion of life threatening injuries
* Followed by search for less critical injuries
* Life threatening Injuries:
Deep Sulcus Sign
Tension Pneumothorax
Tension PTX
Pulmonary Contusion
Laceration with Pneumatocele
Pulmonary hematoma
Pulmonary Contusion with pneumatocele
Blunt Cardiac Injury (BCI)
Great Vessel Injury
Thoracic Aorta Injury
Intimal Flap with double lumen
Airway Injury
* Tracheobronchial tears are uncommon
* Leads to persistent PTX
* Specific Symptom: persistent PTX after chest tube placement
* Finding: “Fallen Lung Sign”, pneumomediastinum, pneumopericardium, sub cut. Emphysema
* ET Tube balloon inflation >2.8cm implies tracheal rupture
* Etiology: alveolar, tracheobronchial or esophageal rupture
* Most common cause: alveolar rupture due to sudden increased intra-alveolar pressure (Macklin Effect) with air tracking centrally
* Findings:
o Air outlining mediastinal soft tissues and parietal pleura.
o Continuous diaphragm sign
Pneumopericardium with tamponade
Esophageal Injury
* Skeletal injuries:
* Diaphragm injuries:

Radiographic Findings in Blunt Chest Trauma.ppt


Lung Examination: Abnormal

Lung Examination: Abnormal
By:Arcot J. Chandrasekhar, M.D.

Illustrative Pathological problems
* Consolidation
* Atelectasis
* Pleural effusion
* Pneumothorax
* Mass
* Diffuse lung disease

* General Examination
* Mediastinal position
* Chest expansion
* Lung resonance
* Breath sounds
* Adventitious sounds
* Voice transmission
* Respiratory rate
* Pattern of breathing
* Cyanosis
* Clubbing
* Weight
* Cough
* Hospital setting
* Effort of ventilation
* Shape of thorax

Respiratory Rate
* Bradypnea: rate less than 8 per minute
* Tachypnea: rate greater than 25 per minute

Pattern of Breathing
* Kussmals
* Sleep apnea
* Cheyne strokes
* Pursed lip breathing
* Orthopnoea: Short of breath in supine position, gets some relief by sitting or standing up.

Sleep apnea syndrome
Central Cyanosis
Significance: Clubbing Observed In:
* Intrathoracic malignancy: Primary or secondary (lung, pleural, mediastinal)
* Suppurative lung disease: (lung abscess, bronchiectasis, empyema)
* Diffuse interstitial fibrosis: Alveolar capillary block syndrome
* In association with other systemic disorders
Effort of Ventilation
* Person appears uncomfortable. Breathing seems voluntary.
* Accessory muscles are in use, expiratory muscles are active and expiration is not passive any more.
* The degree of negative pleural pressure is high.
* The respiratory rate is increased.

Resting Size and Shape of Thorax
* Barrel chest
* Kyphosis
* Scoliosis
* Pectus excavatum
* Gibbus
Barrel Chest
AP Diameter = Transverse Diameter
Tracheal Position: Mediastinum
Chest Expansion
Percussion: Decreased or Increased Resonance is Abnormal
* Dullness
* Hyper resonance
* Traube's space

Breath Sounds: Diminished or Absent
* Intensity of breath sounds, in general, is a good index of ventilation of the underlying lung.
* Breath sounds are markedly decreased in emphysema.
* Symmetry: If there is asymmetry in intensity, the side where there is decreased intensity is abnormal.
* Any form of pleural or pulmonary disease can give rise to decreased intensity.
* Harsh or increased: If the intensity increases there is more ventilation and vice versa.
* Bronchial breathing anywhere other than over the trachea, right clavicle or right inter-scapular space is abnormal.
* In consolidation, the bronchial breathing is low pitched and sticky and is termed tubular type of bronchial breathing.
* In cavitary disease, it is high pitched and hollow and is called cavernous breathing. You can simulate this sound by blowing over an empty coke bottle.

Bronchial breathing
Pleural Rub
Voice Transmission (tactile fremitus, vocal resonance)
* Asymmetrical voice transmission points to disease on one side.
* Increased:
* Decreased
* Qualitative alteration:
Voice Transmission
Whispering Pectoroliquy
Normal whisper

Lung Examination: Abnormal.ppt


Thoracic Trauma

Thoracic Trauma

Dave Lloyd, MD
Introduction to Thoracic Injury
* Vital Structures
* 25% of MVC deaths are due to thoracic trauma
* Abdominal injuries are common with chest trauma.
* Prevention Focus

Anatomy and Physiology of the Thorax
* Thoracic Skeleton
* Diaphragm
* Associated Musculature
* Physiology of Respiration
* Trachea, Bronchi & Lungs
* Mediastinum
* Heart
* Contraction Cycle
* Great Vessels
* Esophagus
* Blunt Trauma
* Penetrating Trauma
Pathophysiology of Thoracic Trauma
Injuries Associated with Penetrating Thoracic Trauma
* Closed pneumothorax
* Open pneumothorax (including sucking chest wound)
* Tension pneumothorax
* Pneumomediastinum
* Hemothorax
* Hemopneumothorax
* Laceration of vascular structures
* Tracheobronchial tree lacerations
* Esophageal lacerations
* Penetrating cardiac injuries
* Pericardial tamponade
* Spinal cord injuries
* Diaphragm trauma
* Intra-abdominal penetration with associated organ injury

Pathophysiology of Thoracic Trauma Chest Wall Injuries
* Contusion
* Rib Fractures
* Sternal Fracture & Dislocation
* Flail Chest
* Simple Pneumothorax
* Open Pneumothorax
* Tension Pneumothorax
* Dyspnea
* Progressive ventilation/perfusion mismatch
* Hypoxemia
* Hyperinflation of injured side of chest
* Hyperresonance of injured side of chest
* Diminished then absent breath sounds on injured side
* Cyanosis
* Diaphoresis
* Hypotension
* Hypovolemia
* Tracheal Shifting
* Hemothorax
* Blunt or penetrating chest trauma
* Shock
* Dull to percussion over injured side
* Pulmonary Contusion
* Myocardial Contusion
* Bruising of chest wall
* Tachycardia and/or irregular rhythm
* Retrosternal pain similar to MI
* Associated injuries
* Chest pain unrelieved by oxygen
* Pericardial Tamponade
* Dyspnea
* Possible cyanosis
* Beck’s Triad
* Weak, thready pulse
* Shock
* Kussmaul’s sign
* Pulsus Paradoxus
* Electrical Alterans
* Myocardial Aneurysm or Rupture
* Traumatic Aneurysm or Aortic Rupture
* Other Vascular Injuries
* Traumatic Esophageal Rupture
* Tracheobronchial Injury
* Traumatic Asphyxia
* Scene Size-up
* Initial Assessment
* Rapid Trauma Assessment
* Ongoing Assessment
* Ensure ABC’s
* Anticipate Myocardial Compromise
* Shock Management
* Rib Fractures
* Sternoclavicular Dislocation
* Flail Chest
* Open Pneumothorax
* Tension Pneumothorax
* Hemothorax
* Myocardial Contusion
* Pericardial Tamponade
* Aortic Aneurysm
* Tracheobronchial Injury
* Traumatic Asphyxia

Thoracic Trauma.ppt


Artificial Airways

Artificial Airways

* A tube or tube-like device that is inserted through the nose, mouth, or into the trachea to provide an opening for ventilation

Types of Artificial Airways
* Oropharyngeal airways
* Nasopharyngeal tubes
* Orotracheal tubes
* Nasotracheal tubes
* Tracheostomy tubes
* Esophageal obturator airway
* Cricothyroid tubes

Indications for Artificial Airways
* Relief of airway obstruction -guarantees the patency of upper airway regardless of soft tissue obstruction.
* Protecting or maintaining an airway N. have 4 main airway protect. reflexes 1. Pharyngeal reflex - 9th & 10th cranial nerves gag and swallowing
* Reflexes (cont’d) 2.Laryngeal -vagovagal reflex - will cause laryngospasm 3.Tracheal -vagovagal reflex - cough when a foreign body or irritation in trachea 4.Carinal -cough with irritation of carina
* Facilitation of tracheobronchial clearance
- mobilization of secretions from the trachea requires either an adequate cough or direct suctioning of the trachea
* Facilitation of artificial ventilation
- ventilation with a mask should on be used for short periods d/t gastric insufflation

Hazards of Artificial Airways
* Infection d/t bypassing the normal defense mechanisms that prevent bacterial contamination
* Ineffective cough maneuver
* Impaired verbal communication
* Loss of personal dignity

Oropharyngeal Airway
* Device designed for insertion along the tongue until the teeth &/or gingiva limit the insertion
* Lies between the posterior pharynx and the tongue and pushes the tongue forward
* Will activate the gag reflex, should use on unconscious patient
* Correct sizing of airway is imperative

Hazards of Oropharyngeal Airway
* If too small, may not displace tongue or may cause tongue to obstruct airway or may aspirated
* It too large, may cause epiglottis impaction
* Roof of mouth may be lacerated upon insertion
* Aspiration from intact gag reflex

Nasopharyngeal Airway
* Located so that it can provide a clear path for gas flow into the pharynx
* Is a soft rubber catheter
* Can be tolerated by the conscious patient
* Useful for patient with a soft tissue obstruction who have jaw injury or spasm of jaw muscles
* Proper sizing and insertion

Orotracheal Airway
* Used in conditions of, or leading to respiratory failure
* Usually the method of choice in emergencies that do not involve trauma to the mouth or mandible
* Oral route in usually easiest
* Accomplished by using a laryngoscope to directly visualize the trachea

Nasotracheal Airway
* More difficult route than oral
* Requires a longer and more flexible tracheal tube
* Insert through nose by touch and when in oropharynx use larynoscope and forceps (can perform “blind”)
* Usually N. T. tube is better tolerated by patient than oral

Tracheostomy Tube
* Tracheostomy is performed through the anterior tracheal wall either by the open method or percutaneous method
* Performed usually to prevent or treat long-term respiratory failure
* Decreases anatomic deadspace by 50%

Complications and Hazards of Tracheostomies
* Postsurgical bleeding
* Infection
* Mediastinal emphysema
* Pneumothorax
* Subcutaneous emphysema
* Stoma collapse (should not be moved or changed first 36 hours)

Esophageal Obturator Airway (EOA)
* Place in the esophagus to prevent stomach contents from entering the lungs while the patient is being artificially ventilated
* Cuff must be passed beyond carina before inflated
* Inflated cuff with 35 cc air
* Mask must fit tightly to ensure ventilation

Pharyngealtracheal Lumen Airway (PTL)
* Double-lumen airway combining an EOA and an endotracheal tube
* Designed to be inserted blindly
* Has an oropharyngeal cuff and a cuff that can seal off either the trachea or the esophagus

Other Specialized ET Tubes
* Rae Tube, directs the airway connection away from the surgical field
* Endotrol Tube, controls the distal tip for intubation
* Hi-Lo Jet Tube, for high freq. jet ventilation
* Laser Flex Tube, reflects a diffused beam if comes in contact with tube
* Endobronchial Tubes

Artificial Airways.ppt


Thoracic Trauma

Thoracic Trauma
By:EMS Professions
Temple College

Thoracic Trauma
* Second leading cause of trauma deaths after head injury
* Cause of about 10-20% of all trauma deaths
* Many deaths due to thoracic trauma are preventable
* Prevention Strategies
* Mechanisms of Injury
* Anatomical Injuries

What structures may be involved with each injury?
* Often result in:
o Hypoxia
o Hypercarbia
o Acidosis
* Ventilation & Respiration Review
* General Pathophysiology
* Initial exam directed toward life threatening:
o Injuries
o Conditions
* Assessment Findings

Specific Injuries
Rib Fracture
* Management
Sternal Fracture
* Management
Flail Chest
* Management
Simple Pneumothorax
* Management
Open Pneumothorax
* Management
Tension Pneumothorax
* Management
* Management
Pulmonary Contusion
* Management
Cardiovascular Trauma
Myocardial Contusion
* Management
Pericardial Tamponade
* Management
Traumatic Aortic Dissection/Rupture
* Management
Traumatic Asphyxia
* Management
Diaphragmatic Rupture
* Management
Diaphragmatic Penetration
Esophageal Injury
* Management
Tracheobronchial Rupture
* Management
Pitfalls to Avoid

Thoracic Trauma.ppt


Nervous system in the abdomen and pelvis

Nervous system in the abdomen and pelvis

Targets of NS in abdomen and pelvis
Abdominal muscles (motor)
Body wall & parietal peritoneum (sensory)
Perineal muscles (motor)
(eg. external anal sphincter)
Perineal skin (sensory)
Sweat glands, erector pilae & sm mm of BVs in abdominal and perineal skin
Foregut smooth muscle & glands
Midgut smooth muscle & glands
Kidneys and suprarenal glands
Hindgut smooth muscle & glands
Blood vessels of GIT
Pelvic viscera and blood vessels
Smooth muscle & glands of reproductive tract
Blood vessels in erectile tissue

Gray rami of chain
splanchnic nerves:
Lumbar splanchnic nerves
Sacral splanchnic Nerves
Prevertebral ganglia

Pelvic splanchnic nerves
Intramural ganglia/enteric nervous system
Abdomino-inercostal nerves
L1 spinal nerve
Pudendal nerve
ANS in the abdomen and pelvis:
important principles
Autonomic nerves are found in plexuses along the blood vessels or other major structures
In thorax:
In abdomen:
In pelvis:
Prevertebral plexus for abdominal viscera
Several parts: named for adjacent vessel or region

Lecture Plan
* Parasympathetic innervation of GIT and other structures
* Sympathetic innervation of GIT and other structures
* Referred pain
* Somatic nerves of the abdomen, pelvis and perineum
* Sympathetic
* Parasympathetic
ANS Divisions
Parasympathetic division
Intramural neurons are part of the enteric nervous system:
Parasympathetic Vagal trunk dissection
Left and right vagus nerves
Anterior (left) and posterior (right)
vagal trunks
Esophageal plexus
Pelvic splanchnic nerves
Targets of NS in abdomen and pelvis
Foregut smooth muscle & glands
Midgut smooth muscle & glands
Hindgut smooth muscle & glands
Pelvic viscera
Blood vessels in erectile tissue
Supply motor fibers to intramural ganglia
Greater thoracic splanchnic nerve
Targets of NS in abdomen and pelvis
Foregut smooth muscle & glands
Midgut smooth muscle & glands
Kidney, adrenal gland
Blood vessels of GIT
Hindgut smooth muscle & glands
Pelvic viscera (involuntary sphincters)
Smooth muscle and glands of reproductive tract
Lumbar splanchnic nerves
Sacral splanchnic nerves
Gray rami of chain ganglia
Lecture plan
* Parasympathetic innervation of GIT and other structures
* Sympathetic innervation of GIT and other structures
* Referred pain
* Somatic nerves of the abdomen, pelvis and perineum
Pain in the abdomen
Somatic pain
Example of visceral pain afferents
conveyed with sympathetic system
e.g. from stomach
* Pain originating from one structure but perceived as coming from another. Thus, pain from an organ can be perceived as originating from a somatic structure.
* Due to cross-talk in the CNS sensory pathways? brain misperceives origin of pain
* You can predict the site of referral, if you know the entry segment of visceral afferents, and the body’s dermatome map.
Involvement of parietal serous membranes
and much more are covered in this presentation.

Nervous system in the abdomen and pelvis.ppt


Fetal outcomes: Comparison of gestational diabetes

Fetal outcomes: Comparison of oral agents with diet controlled and insulin controlled gestational diabetes
By:Amanda Hatton, MD
* Amanda Hatton, MD
* Selman Welt, MD
* Samuel Prien, PhD

* Gestational diabetes affects from 1-14% of pregnant mothers1
* Levels of diabetogenic placental steroids and peptide hormones (estrogen, progesterone, chorionic sommatomammotrophin) rise linearly throughout the second and third trimester resulting in progressively increasing tissue resistance to insulin2
* Maternal insulin resistance requires a significant increase in pancreatic insulin production to more than twice non-pregnant levels
* Failure to adequately compensate for increased demand of insulin production leads to maternal hyperglycemia followed by fetal hyperglycemia

Fetal health implications
* Fetal hyperglycemia leads to fetal hyperinsulinemia which has detrimental consequences to fetal growth and well-being2
* Promotes storage of excess nutrients leading to macrosomia
* Drives catabolism of oversupply of fuel, using energy and depleting fetal oxygen stores
* Episodic fetal hypoxia leads to increased adrenal catecholamines causing hypertension, cardiac remodeling, and hypertrophy
* Hypoxia also causes stimulation of erythropoietin which in turn increases hematocrit level and causes poor circulation and postnatal hyperbilirubinemia
* At birth fetal hyperinsulinemia in absence of maternal glucose supply leads to hypoglycemia

Treatment of GDM
* Glycemic monitoring, dietary regulation and medical therapy are used to control diabetes and prevent postnatal sequelae
* Insulin discovered in 1922, successful management of diabetic pregnancies became possible and the frequency of antepartum fetal death decreased by one half2
* Glycemic control must be instituted early and aggressively if excellent newborn outcome is to be achieved
* Oral agents such as acarbose and glyburide are aimed at augmenting insulin supply, decreasing insulin resistance, and limiting postprandial hypoglycemia
* These agents have been shown to be an effective and safe alternative, since they do not significantly cross the placenta in vitro3

* To compare fetal outcomes in mothers with gestational diabetes treated with:
* Diet - ADA diet, weight dependent, 3 meals and 3 snacks
* Oral agents
* Acarbose - alpha-glucosidase inhibitor, reversibly inhibits enzymes in the small intestine, delaying cleavage of oligosaccharides and disaccharides to monosaccharides
* Glyburide - sulfonylurea compound, stimulates insulin release from the pancreatic beta cells, reduces glucose output from the liver and also increases insulin sensitivity at peripheral target sites
* Insulin – weight based split mix dose of NPH and Novolog, insulin pump therapy, or long acting insulin with supplementation
* This study was submitted to the IRB and was found to be exempt from formal IRB review

Experimental Design
* Retrospective chart review
* Identify mothers seen at Texas Tech Health Science Center (Lubbock) with gestational diabetes who were treated and delivered between January, 2005 and January, 2008
* Includes pregestational diabetics and those diagnosed by random blood sugar >200mg/dL or at least two abnormal values on a 3 hour 100g glucose challenge
* All patients were provided with diabetic education, including nutrition guidance at the onset of their prenatal care in the case of preexisting diabetes or soon after diagnosis

General Treatment Guidelines
Materials and Methods
* Review mother’s and infant’s charts to compare outcomes of different treatment modalities
* Class of gestational diabetes
* Treatment and changes in treatment
* Level of control
* Complications of pregnancy
* Mode of delivery
* Fetal weight
* Delivery complications
* Fetal complications (hypoglycemia, hyperbilirubinemia, respiratory distress)
* Patients diagnosed 36 weeks gestation will be excluded

Statistical Analysis
* Continuous data will be evaluated with an analysis of variance (ANOVA)
* Discrete data will be evaluated with a Chi-Square or Mann-Whitney U test
* We expect to find similar fetal outcomes in diabetic mothers with blood glucose levels that are well controlled by diet, oral agents or insulin
* Thus far we have noted that there are no noticeable differences in outcomes pending a greater number of chart reviews and statistical analysis


Fetal outcomes: Comparison of gestational diabetes.ppt


Ultrasonographic features of endometrium

Ultrasonographic features of endometrium in pre- and postmenopausal women
By:C. Tracy Suit, MD
Cornelia de Riese, MD
Samuel Prien, PhD
Kelsey Kelso, BS


* The endometrium is a dynamic tissue
o Menstrual cycle
o Postmenopausal
o Exogenous hormones

Transvaginal US
* Non-invasive
* Relatively inexpensive
* Good safety profile
* Readily available

Normal endometrium
* Menstrual phase
* Proliferative phase
* Secretory phase
* In the follicular phase, the endometrium becomes relatively hypodense
* As the cycle progresses the endometrium becomes more hyperechoic
* Ovulatory period = trilaminar endometrium
* Usually disappears 48 hours after ovulation
* Postmenopausal women
* A small amount of fluid may be considered normal

Premenopausal—Differential Diagnosis
* Often due to normal proliferation under hormonal influences
* Can include:
o Polyps
o Polypoid growths
o Hyperplasia or cancer
o Submucosal fibroids
* Important distinction: symptoms
* Exogenous hormones
Postmenopausal—differential diagnosis
* Polyps
* Hyperplasia or cancer
* Fibroids
Associated sonographic findings
* Polyps: cystic spaces
* Hyperplasia: regular/homogeneous echotexture
* Cancer: irregular margins, indistinct borders between the endometrium and myometrium, heterogeneous echotexture, complex fluid

Study objective
* To evaluate the predictive value of endometrial thickness and descriptive sonographic appearance on pathology in pre- and postmenopausal women
* 1903 gynecologic ultrasounds of the endometrium were performed between January, 2004 and January 2009
* Stratification: Of these, 367 had pathology performed within 3 months of the ultrasound
* The patients were then divided into either pre- or post menopausal after review of the chart
* Each US was critically evaluated for:
o Endometrial thickness
o Descriptors of the endometrium
Exclusion criteria
* No corresponding pathology (EMB, curettage, or hysterectomy) within 3 months of the US
* No measurement of the endometrial thickness or distortion by fibroids so that the endometrium could not be meaningfully evaluated
* Patient less than 18 years old
* Pathology was classified into groups:
o Benign: proliferative or secretory, atrophic, or chronic endometritis
o Precancerous or cancerous: simple hyperplasia with or without atypia, complex hyperplasia with or without atypia, endometrial cancer
* Endometrial descriptors were compared with pathology using a Chi-Square analysis
* Endometrial thickness and age were compared using a Student’s t-test
Result: Postmenopausal group
Results: Premenopausal group
* Confirmed that endometrial thickness is increased in pathological conditions such as hyperplasia and cancer
* But hyperplasia was diagnosed often within the “normal” ranges, especially in the premenopausal women
* In the postmenopausal group, complex hyperplasia and cancer were diagnosed with an endometrial thickness of 3 and 5 mm, respectively
* In premenopausal women, the average endometrial thickness in women with pathology was still in the normal range for secretory endometrium
* In addition, no simple hyperplasia was diagnosed in the postmenopausal group—when pathology was found, it was much more likely to have become frank cancer
* Heterogeneity and irregularity in echo pattern were significantly more likely to be associated with hyperplasia or cancer in the premenopausal group. It may have not reached significance in the postmenopausal women due to the smaller sample size.
* One weakness of the study is the low rate of pathology
* DO THE EMB in symptomatic women

* What can the sonohysterogram add?
* We need to correlate findings to ethnicity, metabolic and exogenous as well as endogenous hormonal influences to further define high risk scenarios.

Ultrasonographic features of endometrium in pre- and postmenopausal women.ppt


General Internal Medicine Lectures

General Internal Medicine Lectures in ppt format from
Texas Tech University Health Sciences Centre School of Medicine


15 July 2009

Physiology Presentations

Physiology Presentations from ksums.net

Properties of Cardiac Muscle.ppt

Endo Introduction.ppt

Renal Physiology.pdf

Male Reproductive System.pdf

Endo Thyroid gland.pdf

Female Reproductive System.pdf

Respiratory physiology.ppt

Acid Base Regulation.ppt

Acid Base Regulation Modified.ppt

Acid Base Abnormality

Parathyroid Gland%20& Calcium Homeostasis.ppt

Pregnancy and Lactation.ppt

The Endocrine Pancreas.ppt

The Adrenal gland - Aldosterone.ppt

The Adrenal Gland Glucocorticoids.ppt

The Adrenal Gland Medulla.ppt



The Large Intestine.ppt

MMC and Vomiting.ppt

MN_Neuromuscular Junction.ppt

MN_Excitable Tissues.ppt


12 July 2009

Males Embriology Presentations - Part-2

Males Embriology Powerpoint Presentations from ksums.net

Development of respiratory system

Pharyngeal Arches Pouches and Clefts Part-2

Tongue Thyroid.ppt

Face,nose, palate dev.ppt

Body cavities.ppt

Digestive system.ppt Part-2

Dev. Urinary System.ppt

Appendicular Skeleton.ppt

Male Genital System.ppt

Deve. of axial skeleton system.ppt

Devel. of genital system

Dev. of Digestive system

Dev. of female genital system

Male Genital system

Axial skeleton.ppt


Males Embriology Presentations - Part-1

Males Embriology Powerpoint Presentations from ksums.net


Ovarian & Uterine Cycles.ppt



Bilaminar & Trilaminar Discs.ppt

Ectoderm Derivatives.ppt

Ectoderm Derivatives.pdf

Folding_of Embryo.ppt


Fetal Membranes.ppt

Heart Tube & Pericardium.ppt

Development of Heart.ppt

Aortic Arches.ppt

Viens associated with heart.ppt


Female Embriology Presentations - Part-2

Female Embriology Powerpoint Presentations from ksums.net

Pharyngeal arches.ppt

Development of face.ppt

Body cavities Primitive Mesenteries and Diaphragm.ppt

Foregut Derivatives.ppt

Midgut & Hindgut Embryo.ppt

Urinary Embrio.ppt

Male genital system.ppt

Female genital system.ppt

External genitalia.ppt

Skull & mandible.ppt

Vertebral column.ppt

Appendocular limb.ppt

Skin Embryo.ppt

Appendicular & limb.ppt


Female Embriology Presentations - Part-1

Female Embriology Powerpoint Presentations from ksums.net


Ovarian and Uterine Cycles.ppt



Bilaminar & Trilaminar Embryonic Disc.ppt

Ectodermal Derivitives.ppt

Mesodermal derivatives.ppt

Fetal Membranes.ppt


Development of Heart.ppt

Aortic Arches.ppt

Development of viens

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