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If you look over in the column to the right, you’ll see three tools to help you:
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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!
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?
What The Heck? Video!
Here’s a very interesting one. This is 2 minute video of a bronchoscopy performed on a patient who was involved in a head-on car crash.
What’s the diagnosis? And be exact, there are many possibilities here. Comment or tweet your best guesses!
Source: Personal archive. Not treated at Regions Hospital.
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!