OK tonight I have a trauma case for you.
Billifred is a 24 year old man whom lives with his partner. There relationship took a turn for the worse this evening when she found her sister’s underpants in his car.
Billifred is a “lover, no a fighter…” but tonight he was forced to defend himself against a series of stabbings. He is brought in by taxi with multiple bleeding wounds.
Editorial note: Presentation by taxi carries a significantly increased risk of serious badness in my world. Ambulance services are essentially free, so they often get used as a public transport service. However, if you are sick / worried enough to fork out $20 for a cab fare – there is a good chance that you are actually pretty sick. Auto triage is a real thing IMHO.
On arrival he is bleeding from cuts to both hands and his ulnar forearms. He has blood on his leg from wounds on his lateral calf. There is a small spot of blood on his left shirt pocket. He is not really very cooperative. When asked what happened he says he “fell whilst sharpening his hunting knife…”
Obs: HR 120/min, RR 28/min, SpO2 on RA = 90% but up to 98% on 6L/min HM, BP140/100. He looks sweaty and anxious.
After stripping off his shirt you see a 1 cm stab wound just below the clavicle on the (L) anterior chest, midclavicular line…
So – control the bleeders – he gets a tourniquet to his arm to stem the loss from the cuts there and then needs a chest US…. bugger, the O&G doc has taken the machine to labour ward.
After securing IV access x2 and giving him some analgesia the radiographer pops in and does a quick portable CXR. It is a rough shot with him breathing fast, not really vertical and taking shallow breaths.
Whilst you are waiting for the films to be processed ( yes, we still use actual plastic films!!) the Bedside US machine reappears. So you do a quick chest scan looking for pneumothorax or haemothorax on the left.
You scan from the clavicle down the anterior chest and… no sliding. A static pleural line with no sliding. His right chest is normal with good sliding easily seen. The heart looks good and there is no pericardial effusion.
Being a super-sleuth sonowarrior, you scan now across the chest laterally towards the bed looking for a lung point [contact point] – and at about the posterior axillary line you see this: CLICK TO SEE US CLIP
Now – that is golden – a good sized pneumothorax with the whole anterior chest showing no sliding and a lung point around laterally. The evidence suggests 100% specificity for US when a clear lung point is seen.
A quick look at the left lung base shows a small effusion ~ 1cm deep, looks like partially clotted blood with mixed echo texture .
Meanwhile the friendly radiographer has returned with the plain film and the verbal report is ” ALL Clear, no pneumothorax…” Here is the CXR…
Alright then – we will pause the case at this point.
This is the “le moment decisif” the point in time where you need to decide what are you going to do next.
(A) Crack on a put in a chest tube
(B) Sit on the patient, admit and observe.
(C) Fly them to the closest CT scanner (1000 km away) for a CT chest.
We covered the pneumothorax / Airplane transfer debate a while back in Clinical Case 108.
(D) Something else / smarter??
You have about 20 minutes of suturing time to think about it as you close his lesser injuries.
You even decide to repeat the chest US after sewing up his limbs – and it looks the same – pneumothorax to the posterior axillary line with a small effusion – stable in size.
OK let me know how you will play this one.