A large chest wound was clinically obvious. A chest radiograph performed after intubation showed subcutaneous emphysema, an anterior rib fracture, and a right-sided pneumothorax. He was then taken to the operating room for further management.
CT angiogram showed multiple large acute pulmonary emboli, most significantly in the distal right main pulmonary artery (image 1 and 2). Additional pulmonary emboli were noted in the bilateral lobar, segmental, and subsegmental levels of all lobes. There was a peripheral, wedge-shaped consolidation surrounded by groundglass changes in the posterolateral basal right lower lobe that was consistent with a small lung infarction (image 3).
At completion of this TBL the learner should be able to: 1. Choose appropriate ventilator settings and adjustments for a patient with lung injury or obstructive lung pattern 2. Troubleshoot an alarming ventilator 3. Set up the most common ventilator in their ED 4. Set up the equipment needed for transtracheal jet ventilation.
Radiography shows a dilated, gas-filled structure that fills nearly the entire left hemi-thorax. Lung markings are visible in the uppermost portion of the left hemi-thorax. There is mediastinal shift to the right. In the visualized portion of the abdomen, dilated loops of bowel are also visualized. This constellation of findings is consistent with a tension gastrothorax.
Non-contrast CT of the chest demonstrates hyper-densities within both central and sub-segmental pulmonary arteries bilaterally (see yellow arrows). The right ventricle is dilated.
Chest x-ray and bedside ultrasound revealed a large right pleural effusion, estimated to be greater than two and a half liters in size.
In the lateral view chest x-ray, there is a Hampton’s Hump, a pleural based, wedge-shaped opacity at the base of the right lung, representing lung infarction (black arrow). These findings correlate with the sagittal view on CT angiography of the chest. The CT chest also shows a filling defect in the distal posterior basal segmental pulmonary artery (white arrow), as demonstrated by the absence of contrast enhancement in the distal portion of the vessel. This is associated with an opacification of the lung parenchyma distal to the occlusion (red arrow), representing lung infarction.
Keywords: pediatrics, retractions, respiratory, pulmonary
