SonoCase: Motorcycle victim: needs OR! But wait…

So, this case that I just had the other day is an example of an “oldy but goody” reason why bedside ultrasound rocks, especially in the blunt trauma victim with multiple injuries. 40 year-old motorcycle helmeted driver going moderate speed was T-boned by a car and fell onto his left side. He c/o severe left leg pain and mild left lower back pain, with STABLE (and yes, I mean, stable/normal/not worrisome vitals – HR 72, RR 16, BP 148/90, O2 sat 97%RA) with a clear primary trauma survey, and a secondary that revealed a small abrasion on his cheek, no left sided chest wall tenderness, nontender abdomen, no pelvis instability, an obvious deformed open fracture of his left tibia/fibula, and left lower posterior rib cage tenderness without crepitance or bruising. An E-FAST was done… which includes evaluation for intrathoracic, intraperitoneal and pericardial free fluid with the addition of bilateral lung views for pneumothorax evaluation. Using the linear probe, and placing it on the anterior chest wall, 2nd intercostal space, mid-clavicular line, with the indicator toward the patients head, you can screen for pneumothorax (absence of lung sliding and comet tail artifacts come down from the pleural line which you would normally see). This was his Lung view on the left:

This was his lung view on the right:

The rest of his FAST scan was negative, and we knew right then and there – left sided PNEUMOTHORAX!!!! We ordered for supplemental oxygen, and, of course, had a bedside Chest XRay done to complete the trauma evaluation:

So, there are some parts of the chest missing (namely, the lower portion and costophrenic angles) on this not-so-great picture from my iPhone, but the trauma team and I did not appreciate a pneumothorax on this image. And, it just goes to show those darn studies were right, US is more sensitive than a CXR. The patient went to CT and the OR got ready for his tib/fib, but my astute resident said that we should place a chest tube prior to the intubation as this could go bad and get worse (hello tension!) after intubation – and that would be just poor form – so, our trauma colleagues agreed and in went the chest tube after return from CT, The tube, by the way, I also confirmed by US guidance  for its intrathoracic placement (of course, this is a new thing and a CXR also confirmed it): the tube (double arrow) seen as the hyperechoic walled (bright) structure with shadow posteriorly next to the larger rib in the transverse view (image on your left) and you can see it enter the pleural cavity in the longitudinal view (image on your right): The landmark picture was not the actual victim, just a very nice medical student who allowed us to place the tough tape for the picture. Gotta love them! Pretty cool stuff, I tell ya!!

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