EM REMS

One of my colleagues had a patient come in after a high-speed motor vehicle collision (MVC) and the patient turned out to have a blunt aortic injury (BAI).  Luckily she saved the images for EMREMS:

This first image is a portable AP Chest Xray.  There are multiple findings:

1.  The ETT tube is slightly high, this was corrected (see Post Intubation Eval)

2.  Chest tube is inserted in the left side and the patient has subcutaneous emphysema.  The chest tube could have been put in further but seems to be working.

3.  Notice the loss of normal contour of the aortic knob (aka “indistinct aortic knob”).

4.  The trachea is displaced to the patient’s right

5.  The upper mediastinum seems a little wide although not drastically.

6.  There is loss of the aortopulmonary window (AP window)

For comparison I have a normal AP Chest Xray and have arrows pointing to the normal AP window and aortic knob:

The patient’s Chest Xray is worrisome for traumatic aortic dissection.  Here is the patient’s Chest CT which confirms the diagnosis:

In the first image one can see a rough inner surface of the aorta indicating intimal disruption and hematoma.  A dissection flap can be seen in the second image.  Hematoma can be seen on both images surrounding the aorta and tracking in the mediastinum.

What are some other signs on Chest Xray that would get you worried about BAI? (Comments are encouraged)

Stay tuned in the future for a “Radiology Rules” 3X5 card with Chest Xray signs of BAI.

Author:  Russell Jones, MD

Image contributor:  Kendra Grether-Jones, MD

This young woman was playing rugby with “the boys” when she fell on one of the other player’s bent knee.  She has pleuritic chest pain and palpable tenderness along the right chest wall anterior axillary line below the armpit (right about where you’d put a chest tube…hint…hint).

This case demonstrates the power of knowing what you are looking for.  As you probably noticed she has a small, subtle pneumothorax best seen between ribs 3 and 4:

Its always a good idea to take the time when you are ordering radiology studies to help out your radiology friends and describe the area of concern and what you are looking for.  This can help them identify subtle findings such as this small pneumothorax.

The patient was treated with supportive care, observed over night, and discharged the next day after a repeat chest xray showing no significant progression.

Author:  Russell Jones, MD

69-year-old male fell from a tree

Contributor:  Russell Jones, MD

Date: 4/25/2012

This guy fell from a tree about 12 feet up…

Here is his Chest X-ray:

What is wrong with this picture?

Answer 

Pneumothorax!

On the right side of the radiograph subcutaneous air can be seen lateral to the chest wall. Subcutaneous air with no physical exam supporting a puncture or a laceration is highly suspicious of a pneumothorax. Other sources of subcutaneous air can be from tracheal or laryngeal injury but usually this is associated with large subcutaneous air tracking in the area of the neck (but can be extensive).

The radiograph, however, is indicative of a small pneumothorax. The right lung appears to be fully inflated and it doesn’t show a deep sulcus sign.

This guy was seen at a level I trauma center and thus trauma was notified and recommended a CT scan to look for concominant injuries. Specifically their concern was liver injury and multiple occult rib fractures. A CT of the chest and abdomen were ordered with IV contrast to evaluate for these injuries as well as to quantify the severity of the pneumothorax.

CT chest:

On the Chest CT under lung window a small anterior pneumothorax can be seen. Other findings included a small pulmonary contusion in the right lower lobe and 2 non-displaced rib fractures (7 and 8).

The question is…does this guy need a tube thoracostomy (chest tube)?

I’ll leave the management decisions up to you…