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.
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.
Here’s another one to challenge your skills! A young male presents to your ED after minor chest trauma with pleuritic chest pain and slight shortness of breath. A chest x-ray is obtained which shows a large pneumothorax on the right. You insert a chest tube, and the procedure goes well.
Another x-ray taken immediately after insertion looks like this:
The lung is not yet fully expanded, but the patient already feels better.
What is wrong in this picture? Tweet or leave comments. Hints tomorrow if I don’t receive the correct answer.
Gunshots to the abdomen have a very high likelihood of causing damage that needs to be repaired. For this reason, the vast majority are immediately transported to the OR for laparotomy (celiotomy).
But there are a few situations in which advanced diagnostics can be justified prior to operation. Do you know what they are? Tweet or comment your answers. I’ll explain the details tomorrow.
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