basic chest trauma

1. THORACIC TRAUMA
PART I
ABHIJIT JOSHI,
NH

3. TEXTTHE EDWIN SMITH PAPYRUS
▸ the oldest known surgical treatise on trauma.
▸ written around 3000 BC.
▸ In this report of 58 cases, three were related to the chest: a
penetrating injury to the cervical esophagus, a stab wound to the
sternum, and blunt trauma resulting in rib fractures.
▸ is a scroll 4.68 meters or 15.3 feet in length.
▸ The papyrus begins by addressing injuries to the head, and
continues with treatments for injuries to neck, arms and torso,
detailing injuries in descending anatomical order like a modern
anatomical exposition. The title of each case details the nature of
trauma, such as “Practices for a gaping wound in his head, which
has penetrated to the bone and split the skull”.

5. 1. bony thorax
ribs, clavicles, scapulae, and sternum
2. lungs, pleurae, tracheobronchial tree
3. diaphragm
4. heart and great vessels
5. oesophagus
6. thoracic duct
IN ANY TRAUMA, MORBIDITY/MORTALITY IS
CAUSED DUE TO:
‣ loss of function of the part directly affected by
trauma
‣ loss of function of other organs dependent on the
traumatised organ
‣ breach of body defences/resources
‣ infection
‣ bleeding : critically low resources
(ischemia)

6. WHAT HAPPENS AFTER CHEST TRAUMA?
the chief organs of the thorax - the lungs and the heart have a
dynamic physical dimension.
they are hollow organs. THEIR JOB IS TO PULL AND PUSH
AIR/BLOOD.
their physics is their raison d'être.
other organs like the abdominal viscera, do not contribute to
the physics of the body as much as they do to the chemistry.
Hence spacial relationships if altered in the abdomen, do not
cause derangements... indeed, when we see gas under the
diaphragm, we aren't alarmed because that gas will derange
the function of some organ by compressing it, but the worry
out there is infection. Nor do we ever put a drain for a
hydrocoele!
spatial derangements do however play a role in organs
contained in tight cavities-- like the brain, or the forearm
muscles, but here again, the worry is ischemia -- which is a
more static kind of derangement than a dynamic
derangement.
However, when it comes to the Lungs and The Heart, small
spatial changes produce direct derangements of their
dynamics.
FEATURES COMMON TO ALL TRAUMA
infection
bleeding

7. MAIN INJURIES IN THORACIC TRAUMA
BLUNT PENETRATING
‣ RIB FRACTURES
‣ STERNAL FRACTURES
‣ CLAVICULAR FRACTURES
‣ SCAPULAR FRACTURES
‣ PULMONARY CONTUSIONS
‣ PNEUMOTHORAX
‣ HAEMOTHORAX
‣ S.C. EMPHYSEMA
‣ TENSION PNEUMOTHORAX
‣ FLAIL CHEST
‣ BLUNT INJURIES TO GREAT VESSELS
‣ BLUNT CARDIAC INJURIES
‣ TRACHEOBRONCHIAL INJURIES
‣ TRAUMATIC ASPHYXIA
‣ LARYNGEAL INJURIES
‣ DIAPHRAGM INJURIES
‣ CHEST WALL INJURY
‣ TRACHEAL AND BRONCHIAL PENETRATING
INJURIES
‣ PULMONARY INJURIES, HAEMOTHORAX,
PNEUMOTHORAX
‣ CARDIAC INJURIES
‣ GREAT VESSELS
‣ DIAPHRAGM
‣ OESOPHAGEAL
‣ AIR AND BULLET EMBOLISM

8. RIB FRACTURES
‣ Fracture of the ribs(ESP. 4-9) is the most common blunt
thoracic injury
‣ rib fractures represent an important indicator of trauma
severity.
‣ 81% PATIENTS HAVING 2 OR MORE RIB FRACTURES
HAVE ASSOCIATED PNEUMO/HAEMOTHORAX
‣ Chest radiography alone fails to diagnose rib fractures in
more than half of trauma patients with fractures; thus, the
addition of CT to the trauma evaluation improves the
sensitivity of the diagnosis of rib fractures.
‣ First rib fracture has particular significance because of the
great force required for it to occur and the likelihood that
intrathoracic vis- ceral injury has also taken place.
‣ The two most common sites of first rib fracture are at the
subclavian sulcus and in the neck of the rib posteriorly.
Subclavian artery and/or aortic arch angiography
(conventional or CTA) is indicated if the first rib fracture is
displaced posteriorly, the subclavian groove is fractured
anteriorly, there is widened mediastinum on chest
radiography, or there is an upper-extremity pulse deficit, a
concomitant brachial plexus injury, or an expanding
hematoma.

9. PARADIGMS OF MANAGEMENT OF UNCOMPLICATED RIB FRACTURES
‣ Although binders, cumbersome rib belts, and taping were advocated in the past, the
modern approach to treat- ment emphasizes relief of pain, prevention of atelectasis, and
optimization of pulmonary toilet.
‣ Interventions favored for short-term pain relief include epidural analgesia, inter- costal rib
blocks, intrapleural instillation of anesthesia, and intravenously giving opiates and oral
nonsteroidal anti-in ammatory drugs.42,51-53 More recently, continu- ous intercostal nerve
blockade has been explored as an analgesic adjunct at multiple institutions. Patients with
three or more unilateral rib fractures, managed with con- tinuous intercostal nerve blockade
through an extratho- racic, paravertebral approach, demonstrated signi cant improvement
in numeric pain scale scores and sustained maximal inspiration lung volumes.
CONTROL THE PAIN!!

10. LUNG HERNIA
‣ A rela- tively uncommon but potential long-term complication of severe blunt chest wall trauma is a
thoracic lung hernia.
‣ should be repaired, because they pose a constant threat of incarceration, pneumothorax, or
strangulation.

11. STERNAL FRACTURE
CAUSE/MODE OF
INJURY
PROBLEM WHAT TO DO? PROGNOSIS
RAPID DECELERATION
DUE TO SEAT BELT.
?UNDERLYING
CARDIAC INJURY
1. LATERAL CXR
2. ECG ON
ADMISSION
3. CARDIAC ENZYMES
‣ Mortality from isolated
sternal fractures remains
low (3.5%), and surgical
repair is uncommon
(<2%).66
‣ Some have suggested that
patients with isolated
sternal frac- tures, a normal
echocardiogram, and no
elevation of cardiac
enzymes in the early hours
of injury will have a benign
course.
‣ They advocate discharging
these patients home within
24 hours of arrival in the
ED.

13. SCAPULAR FRACTURE
▸ HIGH ENERGY IMPACT
▸ NECK, BODY
▸ ASSOCIATED INJURIES, LUNG CONTUSIONS COMMON
▸ OFTEN NOT SEEN ON SUPINE CXR.
▸ GENERALLY CONSERVATIVE MGMT—SLING, PAIN RELIEF AND FULL
RANGE MOTION EXERCISES
▸ COMPLICATION: BRACHIAL PLEXUS INJURY, CONSEQUENT
DISABILITY, LACK OF SENSATION IN EXTREMITY AND LONG TERM
NEED FOR AMPUTATION.

14. HAEMOTHORAX

15. In the normal unscarred pleural space, a
hemothorax is noted as a meniscus of fluid
blunting the costophrenic angle or
diaphragmatic surface and tracking up the
pleural margins of the chest wall when viewed
on the upright chest x-ray film. This is
essentially the same chest radiographic
appearance found with any pleural effusion.
Hemothorax is the presence
of blood in the pleural space.
The source of blood may be
the chest wall, lung
parenchyma, heart, or great
vessels. Although some
authors state that a
hematocrit value of at least
50% is necessary to
differentiate a hemothorax
from a bloody pleural
effusion, most do not agree
on any specific distinction.

16. HOW MUCH BLOOD CAN BE DETECTED?
CLINICALLY
physical exam can be unreliable and pt may
not have symptoms
CXR ERECT
takes approximately 400-500mls of blood to
obliterate the costo-phrenic angle
FAST <200 ML, >50ML
CT
VERY SENSITIVE, CAN DETECT LOCULATED
COLLECTIONS. USED TO QUANTIFY
COLLECTIONS.
a serial chest radiograph at 6 hours - reasonable time period to pick up a delayed
hemothorax or pneumothorax.

17. HOW TO DIFFERENTIATE HAEMO VS EFFUSION
WITH SURETY?
1. ASPIRATE
2. CT: Blood in the pleural space typically has an attenuation
of 35-70 HU

18. ‣ By the 18th century, some treatment for hemothorax was available; however, controversy
raged about its form. A number of surgeons, including John Hunter in 1794, advocated
the creation of an intercostal incision and drainage of the hemothorax. Those of the
opposing viewpoint believed that closure of chest wounds without drainage and other
conservative forms of management of bloody collections in the chest were proper
treatment.
‣ While Hunter's method was effective in evacuating the hemothorax, the creation of an
iatrogenic pneumothorax as a result of the procedure was associated with significant
morbidity. On the other hand, wound closure or conservative management posed the
possible risks of subsequent empyema with sepsis or persistent trapped lung with
permanent reduction of pulmonary function.
‣ Observing the advantages and dangers of both forms of therapy, Guthrie, in the early
1800s, gave credence to both viewpoints. He proposed the importance of early
evacuation of blood through an existing chest wound; at the same time, he asserted
that if bleeding from the chest persisted, the wound should be closed in the hope that
existing intrathoracic pressure would halt the bleeding. If the desired effect was
accomplished, he advised that the wound be reopened several days later for the
evacuation of retained clotted blood or serous fluid.
‣ By the 1870s, early hemothorax evacuation by trocar and cannula or by intercostal
incision was considered standard practice. Not long after this, underwater seal
drainage was described by a number of different physicians. This basic technique has
remained the most common form of treatment for hemothorax and other pleural fluid
collections to this day.

19. TEXTMANAGEMENT PRINCIPLES
▸ BLUNT TRAUMA, STABLE PATIENT, NORMAL CXR : REPEAT CXR IN
6 HRS AND EVALUATE. IF 2ND CXR IS NORMAL, DISCHARGE.
▸ PENETRATING TRAUMA, MINIMAL PNEUMO/HAEMO —> PUT TUBE
▸ Patients with minimal chest tube output and no air leak can have the
chest tube removed on the first hospital day and be discharged.
▸ Persistent bleeding mandates thoracotomy or video-assisted
thoracic surgery (VATS).
▸ Drainage of the pleural space with rees- tablishment of pleural
apposition can tamponade what is generally low pressure venous
bleeding and serves to seal an air leak.
▸ If thoracotomy is necessary, the general rule is to spare as much lung
as possible and to avoid anatomic resection.

20. TEXTMASSIVE HAEMOTHORAX
▸ Massive hemothorax results from the rapid accumula- tion
of more than 1500 mL of blood or one-third or more of the
patient’s blood volume in the chest cavity

21. TEXTMASSIVE HAEMOTHORAX, CONTD…
▸ In patients with massive hemothorax, the neck veins may be flat as a
result of severe hypovolemia, or they may be distended if there is an
associated tension pneu- mothorax. Rarely will the mechanical effects of
massive intrathoracic blood shift the mediastinum enough to cause
distended neck veins. A massive hemothorax is suggested when shock is
associated with the absence of breath sounds or dullness to percussion
on one side of the chest. This blood loss is complicated by hypoxia.
▸ Massive hemothorax is initially managed by the simultaneous restoration
of blood volume and decom- pression of the chest cavity.
▸ rapid crystalloid infusion are begun, and type-specific blood is
administered as soon as possi- ble. Blood from the chest tube should be
collected in a device suitable for autotransfusion.
▸ If 1500 mL of fluid is immediately evacuated, early thoracot- omy is
almost always required.

22. TEXTWHEN TO DO EMERGENCY THORACOTOMY?
1. initial output of 1500ml
2. output > 200ml/hr for 3 consecutive hrs
3. worsening physiological status irrespective of output
4. persistent need for blood transfusion
5. The color of the blood (indicating an arterial or venous source)
is a poor indicator of the necessity for thoracotomy.
6. Penetrating anterior chest wounds medial to the nipple line
and posterior wounds medial to the scapula should alert the
practitioner to the possible need for thoracotomy because of
potential damage to the great vessels, hilar structures, and the
heart, with the asso- ciated potential for cardiac tamponade.

23. TEXT
CLOTTED/RETAINED HAEMOTHORAX… FIBROTHORAX,EMPYEMA, PERMANENT LUNG
DYSFUNCTION
▸ Failure to adequately drain a haemothorax initially results in residual, clotted
haemothorax which will not drain via a chest tube. If left untreated, these retained
haemothoraces may become infected and lead to empyema formation. Even if
they remain uninfected, the clot will organise and fibrose, resulting in a loss of lung
volume which may result in impaired pulmonary function. Failure to adequately
drain a haemothorax is due to failure to initially diagnose the haemothorax or
inadequately draining the haemothorax (small chest tube, incorrect placement,
clotted tube).
▸ Diagnosis of retained haemothorax is usually made on CT, which shows one or
more loculated collections of blood. Surgery is indicated if there is evidence of
empyema (fever, raised white cell count, air-fluid levels on CT), or if the
haemothorax is large enough to cause lung volume loss. Surgery if possible
should be performed early, within the first 3-7 days following injury. At this time
the clot can be cleared with thoracoscopy or a mini-thoracotomy. If clot evacuation
is delayed beyond this time the inflammatory reaction in the pleura requires a
more formal thoracotomy with removal of this 'peel' and often formal
decortication
▸ https://www.youtube.com/watch?v=lUMGcHkLLj8 (VATS for organised
haemothorax)

24. PULMONARY
CONTUSIONS

25. PULMONARY CONTUSION

26. Pulmonary contusions or hematomas occur when blood accumulates within the lung
itself -- either within the lung tissue or within the alveoli

27. PULMONARY CONTUSION
‣ pulmonary contusion is the most common injury in blunt chest trauma.
‣ The mecha- nism of injury usually involves a sudden deceleration injury
‣ Although pulmonary contusions are generally associated with concomitant thoracic cage damage and
other visceral injuries, they can occur iso- lated without evidence of rib fracture.
‣ the pathophysiology of a pulmonary contusion is based on hemorrhage into adjacent alveolar spaces
rather than injury to the alveolar capillary wall itself. (?)
‣ Classic symptoms include dyspnea, tachypnea, hemop- tysis, cyanosis, and hypotension.
‣ Physical examination can demonstrate inspiratory rales, and decreased breath sounds on the affected
side.
‣ CT scan is the study of choice; it is more sensitive than radiography in detecting a pulmonary
contusion.
‣ All patients with a pulmonary contusion should be observed on supplementary oxygen in a hospital
setting, because of a tendency of their ven- tilatory status to deteriorate rapidly. By standard ATLS
protocol, patients with signi cant hypoxia with PaO2 less than 65 mm Hg and SaO2 less than
90% despite oxygen supplementation should be intubated and undergo ven- tilation within 1
hour after injury. A conservative fluid management strategy should be undertaken; however, if large
volumes of uid are necessary for resuscitation of associated extrathoracic injuries, a pulmonary artery
catheter should be placed.
‣ patients with pulmonary contusions are at a high risk of respiratory insufficiency and secondary
pneumonia because of the parenchymal damage and large systemic inflammatory response that
accompanies this injury.
‣ The mortality rate from an isolated pulmonary contusion is low, but when combined with other severe
injuries, it rises to as high as 50%.

28. FACTORS PREDISPOSING TO MORTALITY IN
LUNG CONTUSION
1. age
2. resuscitation volume
3. severity of parenchymal injury— as indicated by:
‣ PaO2/FiO2 ratio(P/F) ratio at 24 and 48 hrs.
‣ Pao2 alone does not correlate with the extent of lung
contusion, as hypoxic pulmonary vasoconstriction within
the injured lung tends to limit blood flow to contused
areas

29. INTUBATION AND EXTUBATION IN LUNG
CONTUSION
‣ CRITERIA FOR INTUBATION: By standard ATLS protocol, patients
with signi cant hypoxia with PaO2 less than 65 mm Hg and
SaO2 less than 90% despite oxygen supplementation should
be intubated and undergo ven- tilation within 1 hour after injury.
‣ BUT WHEN TO EXTUBATE ? … NOT SO CLEAR… reintubation after
extubation occurs not infrequently, and significantly increases
morbidity and mortality.
‣A recent retrospective study identified both a P/F ratio of less than
190 or an Alveolar-arterial (A-a) oxygen gradient greater than 100 mm
Hg as independent predictors of failed extubation after pulmonary
contusion.

30. FEW PEARLS ON LUNG CONTUSIONS
‣ Pulmonary contusion can occur without rib fractures or flail chest, particularly in young patients
without completely ossified ribs.
‣ respiratory failure can be subtle, developing over time rather than occurring instantaneously. The
plan for definitive management may change with time and patient response, warranting careful
monitoring and reevaluation of the patient.
‣ Patients with significant hypoxia (i.e., PaO2 <65 mm Hg [8.6 kPa] or SaO2 <90%) on room air
may require intubation and ventilation within the first hour after injury.
‣ Associated medical conditions, such as chronic obstructive pulmonary disease and renal failure,
increase the likelihood of needing early intubation and mechanical ventilation.
‣ Any patient with the aforementioned preexisting conditions who needs to be transferred should
undergo intubation and ventilation.
INTUBATE !!

32. TEXT
V/Q VS. CXR FOR LUNG CONTUSIONS & FLAIL CHEST
▸ In comparison with chest radiographs, V/Q studies were
able to detect abnormalities much earlier after chest
trauma. When performed serially, V/Q studies may also
prove useful for guiding therapy. At present, however, the
cost and labor intensity of the procedure has precluded its
widespread application in clinical practice.

33. FLAIL CHEST

34. TEXT
WHEN DOES IT OCCUR?
▸ WHEN 2 OR MORE CONSECUTIVE RIBS ARE FRACTURED
AT 2 OR MORE POINTS…. ATLS
▸ WHEN 4 OR MORE CONSECUTIVE RIBS ARE FRACTURED
AT 2 OR MORE POINTS…. SABISTON
▸ WHEN 3 OR MORE CONSECUTIVE RIBS ARE FRACTURED
AT 2 OR MORE POINTS…. MEDSCAPE

35. TEXT
Paradoxical chest wall motion manifests as a “caving in” of the flail segment on
inspiration, followed by a “bulging out” on exhalation. These movements are
dyssynchronous with the remainder of the thorax and its normal relationship to
diaphragmatic movement. During spontaneous inspiration, a flail occurs as a
consequence of atmospheric pressure on the surface of the chest pushing inward on
the unattached segment as the pressure within the pleural space decreases.
Thereafter, the flail moves outward as exhalation generates an increase in pleural
pressure.

36. TEXTWHY IS IT SO HARMFUL?
▸ PENDELLUFT EFFECT : In 1952, Jensen (5)
reintroduced a
hypothesis, first introduced by German physicians, that flail chest
causes acute respiratory insufficiency as a result of a “pendelluft”
effect. He theorized that inspiration might generate a pressure
gradient directed toward the healthy hemithorax. As a result,
during exhalation decreased intrathoracic pressure would be
generated within the injured hemithorax. It was postulated that
an inefficient pendulum-like motion of gas would occur in the
distal airways and interfere with the normal to-and-fro movement
of gas in the conducting airways, resulting in rebreathing and
inefficient alveolar gas exchange. Management of a flail chest
concentrated on the mechanical dysfunction of the chest wall,
and treatment was aimed at external stabilization of the flail
segment to minimize the pendelluft effect.
▸ THIS THEORY HAS NOW BEEN ABANDONED.

37. TEXTCONTUSION, COMPLIANCE, WORK OF BREATHING
▸ A paradigm shift occurred in our understanding of blunt chest
trauma after it was realized that injury to the lung parenchyma,
not abnormalities in chest wall mechanics, predisposed patients
to acute respiratory failure.
▸ PAIN —> SHALLOW BREATHING + IMPAIRED COUGH —>
ATELECTASIS
▸ Lung contusion causes a decrease in the patient’s functional
residual capacity (FRC) and a concomitant decrease in lung
compliance. The decrease in FRC necessitates an increase in the
magnitude of the pleural pressure swings. NOW, THE MORE
THE PLEURAL PRESSURE SWINGS REQUIRED, THE MORE THE
CHEST WALL EXCURSIONS REQUIRED… THIS ACCENTUATES
THE PARADOXICAL MOTION AND INCREASES WORK OF
BREATHING.

38. TEXTCONTD…
▸ NOW , INCREASED WORK—> INCREASED OXYGEN
REQUIREMENT… WHICH will have to be met by an
atelectatic, contused lung.
▸ also, increased work under hypoxemic conditions—>
muscle fatigue.
▸ all this —>respiratory failure.
▸ also, contusion + impaired cough —>inflammatory
cascade, debris —>further problems with gas exchange.

40. TEXTDIAGNOSIS, MONITORING
▸ CLINICAL
▸ imaging
▸ ROOM AIR PULSE OXIMETRY — AS SATURATION TENDS TO FALL, EVEN IF PaO2 is
maintained
▸ ABG : Pao2 does not correlate with the extent of lung contusion, as hypoxic
pulmonary vasoconstriction within the injured lung tends to limit blood flow to
contused areas (20). The Pao2/Fio2 ratio may be a sensitive marker of ultimate
mortality, but its usefulness has only been supported once the pulmonary contusion
has evolved.
▸ A Pao2/Fio2 ratio <300 was found to indicate an increased risk of developing acute
respiratory failure.
▸ hence, saturation is more important than ABG (?)
▸ V/Q:In comparison with chest radiographs, V/Q studies were able to detect
abnormalities much earlier after chest trauma. When performed serially, V/Q studies
may also prove useful for guiding therapy. At present, however, the cost and labor
intensity of the procedure has precluded its widespread application in clinical
practice.

41. TEXTPRINCIPLES OF TREATMENT
▸ KEEP PLEURAL PRESSURE ABOVE ATMOSPHERIC
PRESSURE AT ALL TIMES OF THE RESPIRATORY CYCLE,
SO THAT PARADOXICAL MOTION IS MINIMISED.
▸ PNEUMATIC
STABILISATION
▸ ANALGESIA
▸ CHEST WALL
STABILISATION

42. TEXTCONTD…
▸ Conservative therapy with emphasis on pain relief with thoracic
epidural analgesia is the mainstay of therapy in most centers.
▸ Patients with flail chest are distinct from those with multiple rib
fractures since they are at a higher risk of respiratory compromise
and often require early intubation. Endotracheal intubation is
required in more than two thirds of patients with Flail chest
▸ indicated for a respiratory rate greater than 40 breaths/minute, or
a PO2 of less than 60 mm Hg despite 60% face-mask oxygen.
▸ controlled intervention is often preferred to obviate sudden
respiratory decompensation and its subsequent morbidity.
▸ vigorous pulmonary toilet (e.g., intermittent positive pressure
breathing and frequent nasotracheal suctioning)

43. TEXTCPAP — TILL YOU INTUBATE, GIVE CPAP
▸ As soon as flail chest and pulmonary contusion are
diagnosed, CPAP therapy should be applied by face mask.
▸ Application of CPAP should not be delayed for several
hours while the pulmonary contusion evolves and gas
exchange deteriorates
▸ An optimal level of CPAP is defined as the airway pressure
required to minimize the elastic work of breathing and
minimize the pulmonary venous admixture, without
causing adverse hemodynamic effects.
▸ face mask CPAP was safe and effective for treatment of
arterial hypoxemia in spontaneously breathing patients
with early progressive respiratory insufficiency.

44. TEXTLIMIT FLUIDS
▸ at a rate sufficient to achieve adequate mean arterial
blood pressure and vital organ perfusion.
▸ the net input and output of IV fluids must be closely
monitored and the insertion of a PA catheter strongly
considered for measurement of left-sided (pulmonary
artery occlusion pressure) cardiac filling pressures to avoid
excessive fluid administration.

45. TEXTCHEST WALL STABILISATION
In a minority of cases, however, patients require
chest wall stabilization (Fig. 7-6).59,60 These
commonly are intubated patients with no
possibility of being weaned from the
ventilator because of a large unstable ail
segment of chest wall. However, recent meta-
analyses suggest that chest wall stabilization of
ail segments may have signi cant effects on
both morbidity and mortality. Patients who
underwent operative management for flail
chest were noted to have significantly
decreased duration of mechanical ventilation,
length of ICU stay, risk for pneumonia, need for
tracheostomy, and mortality.61,62 A recent
prospective randomized trial corroborated a
significantly decreased length of ICU stay in
patients under- going chest wall stabilization
for ail chest.

46. TEXT
UPCOMING PRESENTATIONS
▸ PNEUMOTHORAX
▸ S.C. EMPHYSEMA
▸ TRACHEO-BRONCHIAL INJURIES
▸ CARDIAC INJURIES
▸ GREAT VESSEL INJURIES
▸ ESOPHAGEAL, DIAPHRAGMATIC, LARYNGEAL INJURIES
▸ THORACIC IMAGING