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Post by pbruss on Dec 26, 2014 3:30:41 GMT -5
63 yo male was in MVC on 12/22, complained of left chest wall pain. had CXR that was read a normal ad discharged home with an incentive inspiromoter. came back in on the 26th by EMS for SOB and vomiting since his last visit. on exam hypotensive, tachycardic and hypoxic. lungs sound clear. attached is his CXR from his current visit (first image) and his previous visit (2nd image). what is you interp and treatment? Attachments:
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Post by hackman on Dec 26, 2014 12:15:00 GMT -5
The sternotomy wires are deviated more to the right in the follow up film so he could be more rotated to the right. Left hemidiaphragm appears more elevated and I see some free air under the diaphragm. I see lung markings throughout both fields and he has clear breath sounds so I do not think pneumo. This, in combination clinical presentation, is a traumatic diaphragmatic rupture until proven otherwise and I would consult surgery as long as patient does not have impending airway issues
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Post by pbruss on Dec 26, 2014 19:44:40 GMT -5
Well done. Any other findings?
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Post by Bjs04f on Dec 27, 2014 7:52:37 GMT -5
still looks like some air along the heart border concerning for a pneumomediastinum, could be bronchial or esophageal injury
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Post by kemple on Dec 27, 2014 10:32:03 GMT -5
Subq air, most likely a pneumomediastinum. Could be small basilar PTX I would think on CT you would find some air and he gets some Chest Tubes.
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Post by pbruss on Dec 29, 2014 2:28:29 GMT -5
exactly right. the sub Q air is obvious but there is linear air visible around the mediastinal structures. (circled in red in the first attached image). also, if you look at the CXR from his first visit to the ER, there are multiple rib fractures seen but missed by the radiologist. (circled in red in the second attached image) Attachments:
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