The Chest Xray you never want to see…

April 3, 2013

Chest XR, Non-Trauma, Respiratory, XR

…but probably most of us have!  One of the senior residents gave me this Chest Xray on a person that came in with cardiac arrest:


This Chest Xray demonstrates a large pneumothorax on the right side with tension phenomena.  Tension Pneumothorax is when the air trapped in the pleural space places pressure on the mediastinal structures and you see a shift of the mediastinum in the opposite direction.

Physiologically this means that the anatomy has changed and blood flow back to the central circulation is limited by not only mechanical obstruction but increased intrathoracic pressure.

After thoracostomy:

T Ptx 2

Remember, tension pneumothorax is one of the 5h’s and 5T’s that cause cardiac arrest.  However, its unclear if this is a post CPR pneumothorax or if this was the cause of the cardiac arrest.  You can see some deformities suspicious for rib fractures mid-way down the right lung fields.  There was no indication of trauma in the patient’s presentation so these may be old or a complication of chest compressions…this could be a source of pneumothorax as well as the positive-pressure from endotracheal intubation.  Incidentally, the chest tube is inserted slightly far with kinking in the upper lung but it appears to be working with reexpansion and relief of the tension phenomena.

Author:  Russell Jones, MD

Image Contributor:  Ryan Hunt, MD

About emrems411

EMREMS: Radiology in Emergency Medicine

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3 Comments on “The Chest Xray you never want to see…”

  1. docskalski Says:

    In regards to the posterior rib fractures at T7 and T8 on the right, are posterior rib fractures common with compressions? I’d expect them to be more lateral.


    • emrems411 Says:

      Good question. I don’t know the answer but I would bet that lateral fractures are more common with compressions. I’m not aware of any studies that would provide the answer.

      Thanks for the comment and for following the blog! I appreciate the input.



  1. Spontaneous tension pneumothorax - October 2, 2013

    […] have all had the experience of the tension phenomena in the setting of trauma, or in the iatrogenic setting, particularly in conjunction with positive […]

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