Tag Archives: pop quiz

Pop Quiz: What I See…

Yesterday, I showed you an x-ray of a trauma patient and asked you to tell me all the pertinent things that you saw. Here’s the x-ray again:

image

And here’s the list of all the things that struck me about it. Tomorrow, I’ll explain how I figured them all out from just this x-ray.

  • The patient is a female
  • She is still on a backboard
  • She was stabbed with a long, professional cooking knife
  • The assailant was right handed
  • The course of the knife is left to right, superior to inferior, and anterior to posterior
  • She was unstable, either blood pressure or respirations
  • The patient was intubated, most likely due to hypotension and unresponsiveness (BTW, the tube is deep and needs to be pulled back)
  • There is a moderate left hemothorax
  • The mediastinum is shifted to the right
  • A deep sulcus sign is present, either from a pneumothorax that is not easily visible, or from a large hemothorax (more likely the first one)
  • Intra-abdominal and diaphragmatic injury is almost certain
  • A pulmonary contusion is present on the left
  • The stab enters the antero-lateral chest
  • It does not involve the arm or axilla
  • The patient needs a chest tube now
  • She must be taken to the OR immediately after the tube

Some of these are easy, some are not. Let me know if you found anything else by tweeting or commenting below.

Pop Quiz: What Do You See?

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.”

image

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!

What The Heck? Pop Quiz

You are working in your local emergency department and are notified of an incoming trauma patient. The victim was involved in a car crash at highway speeds, was not restrained, and was partially ejected from the driver’s side window.

Pre-arrival report from the medics indicate that he has a BP of 146/90, pulse of 130, and a respiratory rate of 36. He is very dyspneic and complains that he can’t breathe. They state that the only abnormality that they found on their exam was some bony crepitus over the left lateral chest.

When he arrives, he is exactly as billed. O2 saturations are 82%, and he is in obvious respiratory distress. Breath sounds are quite diminished on the left.

What are the potential diagnoses?

What do you do next? Here are your choices:

  • Examine the airway
  • Apply supplemental oxygen
  • Intubate
  • Obtain a chest x-ray
  • Decompress the left chest with a needle
  • Insert a chest tube
  • Proceed to the operating room
  • Obtain a CT scan of the torso

Please tweet or leave comments with your suggestions. I’ll review your choices on Monday, and provide some followup information. Final answer on Tuesday!

Knife To The Back – The Conclusion!

To summarize: stab to the back, prone position, stable vitals, awake and alert and breathing easily. The patient had a chest xray which showed some likely hemothorax. He was sent to CT (prone) and the image obtained looked like this:

They key points to note are:

  • The injury is completely above the diaphragm. No need to worry about an intra-abdominal problem.
  • The amount of hemothorax is moderate. It is not enough to mandate a thoracotomy. At least for now.
  • There is a significant pneumothorax. You can’t see it due to the windows used, but the lung has separated from the chest wall by about 3cm.
  • The track of the knife was directed laterally.
  • No significant vascular structures were involved, and there is no contrast extravasation.

Final management: The patient was returned to the ED, and the knife was deftly removed and processed properly as evidence. The patient was then turned supine and a 40 Fr chest tube was inserted using procedural sedation. About 400 cc of blood was drained and reinfused. A repeat chest xray was obtained, which showed some residual hemothorax and near resolution of the pneumothorax. He was then admitted for frequent vital signs and drainage measurements for two shifts. Afterwards, he was placed in our chest tube management protocol. The tube was removed and he was discharged two days later. There were no complications.

Pop Quiz! Hint Hint!

Yesterday I hit you with a chest x-ray after chest tube insertion in a young man who presented with a pneumothorax. The lung was not yet expanded (chest x-ray taken less than 5 minutes after the procedure).

So what’s wrong? I had a lot of good guesses yesterday (@ResusReview, @uclamutt, and others in the comments to name a few), but nobody quite got it. Yes, the lung is not up yet. No, the tube is not in a fissure. The person inserting the tube worked up a sweat doing it, taking about 10 minutes to get it in. But some air came out initially, and the tube rotated freely on its axis.

Any ideas? Tweet or comment! Answer tomorrow.