Yesterday’s puzzle involved a young male who drove a handlebar into his abdomen. Little additional information was given, other than one slice of his abdominal CT scan. So what’s the problem?
The textbooks always associate handlebars with pancreatic and duodenal injuries, and these should always be looked for. However, the scan slice in this case was taken lower, within the pelvis. Too low to show you either of those organs.
As I’ve said before, be systematic when reading xray images. We automatically focus on the viscera and bones. Look at those areas, make sure you can identify each structure that you see, and look for any anomalies.
But don’t forget the soft tissue! In this case, the child doesn’t have much. Take a closer look at the same slice and see if you can figure it out by tomorrow.
You figure it out. As usual, you get limited information up front.
An early teenage male was doing some crazy stuff with his bicycle. Unfortunately, he slipped, striking his abdomen on the handlebar.
Using this image alone, figure out the problem. Comment below or tweet your guesses! More tomorrow and Thursday.
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.