Triage walks back a 42-year-old male who has been stabbed in the left shoulder by his girlfriend (OK, I admit I am curious why, but first things first). He has bilateral breath sounds, but is not taking deep breaths due to pleuritic pain on the left side. Pulse oximetry is 98% on RA, and other vitals are normal. Heart tones are also normal, and you don’t palpate any subcutaneous air on the L side. The stab wound is just lateral to the scapula in the posterior axilla, with no local hematoma.
A portable CXR is taken (shown below). With pain meds on board, the patient’s symptoms are better. He asks to leave, stating, “I’m OK, she didn’t get anything important.”
What does the X-ray show?
What is your next move?
Conclusion on next page
Dx: A Partially Collapsed Lung
Clinically and by X-ray, there are several clues to a more serious injury. Often, patients with a small pneumothorax have significant pleural-based pain, even in the absence of major physical and X-ray findings. Certainly, mechanism of injury also contributes to the concern for PTX.
The great finding on this case is the X-ray, however. Even though there is no visible PTX, there is a small strip of subcutaneous air on the L side of the thoracic cavity (see arrows). This, along with the small PTX, was confirmed by CT scan. Traditional teaching is to repeat the CXR in about six hours and consider admission if it gets larger or the patient develops symptoms.
“Sir, you have a partially collapsed lung on that side. You should stay here for a while and get another X-ray in a few hours.” That did the trick, and the patient agreed to stay. He ended up with gradual expansion of the PTX, a chest tube and admission. Note to patient: wear Kevlar – and find a new girlfriend.
Dr. Dallara practices Emergency Medicine in Virginia and North Carolina, and directs the Emergency Medicine PREP Course. www.emprepcourse.com