Case 58

51 years old male with medical history of Parkinson's disease, s/p fall with injury to the chest. Pt states that he was walking in the street, when he tripped, fell and hit his chest. No LOC. Not on AC. Patient is complaining of pain in his chest, increased stiffness and  swelling over R clavicle and R arm,  difficulty breathing. Denies any palpitations, sob, cp before falling. Denies headache, n/v, other extremity pain, back pain, neck pain.

ROS
Eyes:  No visual changes, eye pain or discharge.
ENMT:  No hearing changes, pain, discharge or infections. No neck pain or stiffness.
Cardiac: Pain over R distal clavicle and midsternal.  No edema.
Respiratory:  +SOB. No cough or respiratory distress.
GI:   No nausea, vomiting, diarrhea
GU:  No dysuria, frequency or burning.
MS:  R arm and clavicle pain and swelling. No myalgia, muscle weakness, back pain.
Neuro:  No headache or weakness.  No LOC.
Skin:  No skin rash, abrasion, laceration.

PE
GCS: 15
GENERAL: in distress due to pain
HEAD:  Atraumatic, Normocephalic
EYES: EOMI, PERRL, conjunctiva and sclera clear
NECK: No Tracheal Deviation. No Mid-line tenderness C-spine. Supple. No JVD.
CHEST/LUNG: R sided chest tenderness. 5 x5 cm  hematoma, lungs clear to auscultation bilaterally;
HEART: Regular rate and rhythm; No murmurs, rubs, or gallops
ABDOMEN: Soft, Nontender, Nondistended; Bowel sounds present
EXTREMITIES:  2+ Peripheral Pulses,
NEUROLOGY: non-focal deficits

Labs, Radiology, Cardiology, and Other Results: FAST exam negative

 CXR

CXR

 CT Scan

CT Scan

QUESTIONS

  1. What is most concerning in blunt trauma to the chest as demonstrated by the images above?

  2. What tests/imaging modalities would you perform?

  3. What findings might you see on bedside echo?

  4. What do you see on this lung ultrasound?

  5. How would you manage this patient?

ANSWERS

  1. Cardiac and lung contusion. This patient has a pulmonary hematoma secondary to sternal fracture.
  2. EKG, ECHO, cardiac enzymes, CXR, and lung ultrasound.
  3. Wall motion abnormality, usually of the right ventricle. The right heart is most commonly injured due to its position closest to the anterior chest wall. 
  4. You will see B-lines in various lung fields, which in the setting of blunt force trauma would represent pulmonary contusion. You may also see hypoechoic/anechoic sharply demarcated fluid in various lung fields with a swirling pattern, strongly indicative of a hemothorax.  Other major pulmonary injuries that should definitely be considered on ultrasound would be pneumothorax, which can be identified by absence of lung sliding, otherwise known as a “barcode sign.”
  5. Observe all patients with cardiac monitoring, interval assessment of cardiac markers, SpO2 monitoring, chest tube placement as needed, and pulmonary physical therapy.