Radiology Review

Is Diagnosis Up in the Air?

Author and Disclosure Information

Is Diagnosis Up in the Air?

An air ambulance emergently transports a young woman from the scene of a motor vehicle collision to your facility. The details of the accident and age of the patient are unknown. The air ambulance crew had intubated her en route for a decreased level of responsiveness and for airway protection.

The patient is brought to your trauma bay, where you note an intubated female teenager who is unresponsive, with a Glasgow Coma Scale score of 3T. She has a blood pressure of 80/40 mm Hg; heart rate, 150 beats/min; and O2 saturation, 94%.

Her pupils are equal and react bilaterally, albeit sluggishly. Her right leg was placed in an immobilizer by the air ambulance crew because they had noted a right thigh deformity.

Before completing your primary survey, you obtain a portable chest radiograph (shown). What is your impression?


Is Diagnosis Up in the Air?


The radiograph shows 3 abnormalities:

(1) The endotracheal tube is in the right mainstem bronchus—a finding that in part leads to

(2) A whiteout of the left lung; the latter is due partly to collapse and atelectasis and partly to a possible pneumothorax.

(3) There is evidence of free air under the left hemidiaphragm, which is concerning for an intra-abdominal injury, such as a perforated viscus.

The patient’s endotracheal tube was partially withdrawn, and a left chest tube was placed. Subsequent CT of the abdomen confirmed the finding of free air. She was then taken to the operating room for an emergent laparotomy.

Next Article: