Evening shift. All the rooms are full and there’s an unspeakable number of patients in the waiting area. Triage calls with a simple request. “I have this fellow here,” he narrates, “who says he was hit with a bat in the left chest. Vitals are OK, he’s all swollen on that side. He’s a little juiced-up, but I think he might have some broken ribs. I’m going to order up a chest X-ray while he waits.” Sounds reasonable, you think. The other phone rings – Dr. Somebody-on-Call for an admission story. “OK, go with it. I’ll check him in a little while.” Maybe tomorrow, you think, as you plan your phone strategy for the four admission charts sitting on your desk. You jot down the fellow’s name so you don’t forget to check the X-ray.A short while later, the tracking board happily informs you that bat-man’s X-ray is done. Between phone calls, you pull up the X-ray on the viewer (see below). You curse under your breath, drawing a smile from a neighboring nurse and a glare from the unit clerk. The phone rings again. “Let me call you back,” you tell one of the hospitalists. A brief stroll to the waiting area and you find the patient in question. Under his shirt you feel some tenderness and compressible swelling on the affected side. He is breathing comfortably despite the injury. “Hey doc, can you do something? This swelling is getting worse.” Yeah, no kidding, you think. “We’ll get you right back sir.”
What does the X-ray show? What is the next move?
Waiting room cases are like artillery rounds – the one you don’t hear is the one that kills you. In this case, the alert triage nurse ordered up the CXR so that this fellow with the pneumothorax (PTX) would get recognized earlier and fixed. The subcutaneous air was also evident clinically. The patient’s examination showed diffuse and expanding subcutaneous swelling with the classic “rice crispies” or soft-crunching feeling that confirms the diagnosis in the setting of trauma. Because of difficulty in seeing the presumed PTX and the patient’s good tolerance of the injury, we elected to define its size and location with a CT scan prior to chest tube placement (see right). There was only a small air leak present in the chest tube system which resolved quickly.
This case was a little unusual, with a large amount of subcutaneous air associated with a small-to-moderate sized PTX. This amount of subcutaneous air can occur with minor trauma or post-operatively, but is classically associated with massive air-leak. With high-risk truncal trauma or deceleration injury, this amount of air is seen with injuries to the trachea and/or major bronchus. As is seen in this case, air can track well up into the neck (can be seen on a lateral c-spine film) and down along the abdominal wall. On the CT, air is also present in the pericardium.