Okay, once again here’s the x-ray of an unfortunate trauma patient:
Lets walk through the things I found so you can see how I knew:
The patient is a female – note the hook and eye clasps in the center of the image.
She is still on a backboard – there are parallel vertical lucencies on either side of the spine which are the longitudinal wood feet of old fashioned backboards (this image is 20 years old, before plastic was invented, haha)
She was stabbed with a long, professional cooking knife – apparent from the length and shape of the blade
The assailant was right handed – the blade was inserted into her left chest
The course of the knife is left to right, superior to inferior, and anterior to posterior – this is the typical trajectory from a right-handed assailant
She was unstable, either blood pressure or respirations – the patient has an ET tube, but no IV line yet
The patient was intubated, most likely due to hypotension and unresponsiveness – same as the last item
There is a moderate left hemothorax – the hemithorax is not completely opaque, so this is probably in the vicinity of a liter or so.
The mediastinum is shifted to the right – even though there may be slight rotation of the chest
A deep sulcus sign is present, either from a pneumothorax that is not easily visible, or from a large hemothorax – the shift and sulcus suggest that there is some tension physiology. Since the hemithorax is not opaque (not a massive amount of blood), there is probably a significant pneumothorax component.
Intra-abdominal and diaphragmatic injury is almost certain – from the depth and trajectory of the knife. It can’t miss everything!
A pulmonary contusion is present on the left – note the extra opacity surrounding the knife entry. This is bleeding into the lung parenchyma.
The stab enters the antero-lateral chest – if it were posterior or more lateral, the patient would be rotated off of it, or the arm would be abducted
It does not involve the arm or axilla – given the presumed entry into the chest at the base of the handle, it will be too far anterior to involve the arm or axilla
The patient needs a chest tube now – duh!
She must be taken to the OR immediately after the tube – double duh!!
Sometimes we are way too focused. Commonly, trauma professionals will look at a lab result / image / patient / etc and only see what they are looking for.
Here’s an exercise to help you break out of that trap. I want you to look at this image and make a list of all the non-trivial things you see and think about that are pertinent to the case. Like “there is a knife in, on, or under the patient” and not like “the patient has ribs.”
Tomorrow, I’ll go over my list of 16 items. See if you can find them all, or more! On Thursday, I’ll explain how I figured out each item. Good luck!
Hit me with your key findings via Twitter, or comment below!
By popular demand, here’s our short (8 minute) humorous video on the basics of the extended FAST exam. Courtesy of Michael Zwank MD from Regions Hospital. From Trauma Education: The Next Generation 2014.
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