pulling apart cases from the ED...
The Case.
This patient has been in your ED for over 24 hours waiting for a CCU bed. He presented with vomiting and syncope, but acquired left sided rib fractures during his collapse. He has been comfortable for most of the day on nasal-prong oxygen and a morphine PCA.
You are asked to see him as he has sudden worsening of his left-sided chest pain. He has become clammy and hypoxic.
This is what you see….
What’s going on ?
What are you going to do now ??
Add your thoughts here… (optional)
A few days ago I was looking after a 31/40 gestation restrained passenger from low-speed MVA with a slight seatbelt abrasion in her RIF & mild suprapubic pain. She looked well, HR 70 with BP 108 systolic and no features of peritonism.
As I placed the US-probe on for her FAST, this was the first image I acquired…..
The case:
A motorcyclist is minding his own business, stationary at a set of lights and is rear-ended by a car at ~60-70km/h. He is thrown 10 meters or so from his bike and lands on his left side. Remarkably he is systemically well, except for significant left lateral chest wall pain !!
You think he has reduced air-entry on the left side, but is he’s not dyspnoeic, nor hypoxic. The remainder of his primary survey is unremarkable.
This is his supine CXR…
EFAST showed no evidence of free intraperitoneal fluid, but this is what I saw on the chest….
… well it wasn’t really a tonne; more like a dozen or so individual bricks falling from a height of 3-4 metres that peppered and glanced a patient I saw 48 hours ago.
Whilst he presented as a ‘trauma’ and was cleared of any significant injury, his greatest concern was his left ankle which was swollen and tender diffusely. He felt that as he was attempting to dodge the falling bricks, his ankle buckled and went under him (demonstrating an extreme plantar flexion mechanism with his good ankle).
These are two of his original xrays.
