Category Archives: General

Answer: What The Heck Video! Part 2

This patient was involved in a motor vehicle crash with significant chest trauma. They’ve been intubated and are oxygenating and ventilating well. What to do next?

First, the endotracheal tube was a bit deep, which can create its own problems. It was pulled back a few centimeters. Since the patient was hemodynamically stable, a CT angio of the chest would be very helpful to try to figure out the pathology. Here’s a representative slice from the scan.

There are a few striking findings here:

  • Extensive subcutaneous emphysema
  • Large pneummediastinum around the heart
  • Significant injury to the left lung (note the pneumatocele, an air filled collection)
  • Atelectasis of the left lung despite repositioning of the ET tube

The combination of of the above is highly suggestive of a large airway injury. Since the entire lung was affected, it is most likely a mainstem bronchus injury. Usually, these are accompanied by a large air leak from the chest tube, but not in this case.

This prompted the bronchoscopy shown two days ago. The image is oriented such that the left mainstem bronchus was on the right side of the video. A bronchial tear is visible on the lateral aspect, just before the takeoff of the upper lobe bronchus. You can get the impression of a beating heart beating somewhere nearby. And when the camera pops through the laceration, you can actually see the thoracic aortic coursing away toward the diaphragm!

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Answer: What The Heck Video! Part 1

Several of you figured this one out! The patient was involved in a high speed car crash and was brought to the ED in respiratory distress.  Decreased left sided breath sounds were noted. The following xray was obtained.

Opacity is noted in the left lung field, and a modest pneumothorax is seen on the right. Bilateral first ribs are fractured, and the left second through fourth ribs are also broken. The patient was intubated and bilateral chest tubes were inserted.

There was minimal blood from the left chest tube, and a small amount of air from the right. Note the extensive subcutaneous emphysema.

What should we do next? Are any other diagnostic tests indicated? Could the endotracheal tube placement be part of the problem?

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Answer: Finding Rib Fractures On Chest Xray

There was a lot of chatter regarding my practical tip yesterday, rotating the chest xray to better visualize rib fractures. Here’s the quiz xray from yesterday: 

And here’s the lateral view:

The fracture is perfectly placed on the most lateral aspect of the left 9th rib. You can download the full size rotated jpg here if you are having a hard time seeing it on the reduced size image above. Piece of cake!

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Practical Tip: Finding Rib Fractures On Chest Xray

Here’s a neat trick for finding hard to see rib fractures on standard chest x-rays.

First, this is not for use with CT scans. Although chest CT is the “gold standard” for finding every possible rib fracture present, it should never be used for this. Rib fractures are generally diagnosed clinically, and they are managed clinically. There is little difference in the management principles of 1 vs 7 rib fractures. Pain management and pulmonary toilet are the mainstays, and having an exact count doesn’t matter. That’s why we don’t get rib detail x-rays any more. We really don’t care. Would you deny these treatments in someone with focal chest wall pain and tenderness with no fractures seen on imaging studies? No. It’s still a fracture, even if you can’t see it.

So most rib fractures are identified using plain old chest xray. Sometimes they are obvious, as in the image of a flail chest below.

 

But sometimes, there are only a few and they are hard to distinguish, especially if the are located laterally. Have a look at this image:

 

There are rib fractures on the left side side on the posterolateral aspects of the 4th and 5th ribs. Unfortunately, these can get lost with all the other ribs, scapula, lung markings, etc.

Here’s the trick. Our eyes follow arches (think McDonald’s) better than all these crazy lines and curves on the standard chest x-ray. So tip the x-ray on its side and make those curves into nice arches, then let your eyes follow them naturally:

 

Much more obvious! In the old days, we could just manually flip the film to either side. Now you have to use the rotate buttons to properly position the digital image.

Final exam: click here to view a large digital image of a nearly normal chest xray. There is one subtle rib fracture. See if you can pick it out with this trick. You’ll have to save it so you can manipulate it with your own jpg viewer. If you find it, tweet it out to me! Let’s see who gets it first!

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