Pneumocath in pulmonary artery and left atrium
Severe motor vehicle accident. Arrested while still trapped in vehicle, requiring CPR and emergency pneumocath placement.
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The left sided pneumocath passes through the inferior aspect of the pulmonary outflow tract, over the left coronary artery and the tip passes into the left atrium. There are locules of gas in the left subclavian vein and brachiocephalic vein. The left ICC is not clearly in the pleural space. While it may run in an accessory fissure, the tip lies against the mediastinum and the distal 7cm is occluded. Small left pneumothorax.
The right ICC terminates in the soft tissue in the right upper thorax, and is not in the pleural space. Moderate right pneumothorax. No thoracic aortic injury. Patchy right middle lobe and lower lobe and left lingula airspace consolidation.
Patchy right upper lobe ground glass opacification. Right subcutaneous emphysema. Extends into the pretracheal and right carotid facial spaces. The tip of the ETT is 1cm from the carina.
Multiple rib fractures bilaterally.
Right: 1st posterior,anterior and lateral are comminuted; 2nd posterior (comminuted), lateral (comminuted) and anterior; 3rd posterior (displaced), lateral (displaced) and anterior; 4th posterior (displaced and comminuted), lateral (displaced); 5th posterior (displaced and comminuted), and lateral (displaced); 6th posterior and lateral (mildly displaced); 7th lateral (comminuted and displaced); 8th posterolateral.Left: 1st lateral (displaced); 2nd lateral; 3rd anterolateral; 4th lateral; 5th anterolateral; 6th anterolateral; 7th anterior.
Minimally displaced fracture of the right clavicle at the junction of the mid and distal thirds. No sternal fracture.
Thoracic spine: No fracture. Alignment is normal.
1. Left pneumocath passes into the pulmonary outflow tract and left atrium as in close proximity to the left coronary artery.
2. The right and second left ICCs are misplaced.
3. Multiple bilateral rib fractures including flail segments as described.
4. Bilateral pneumothoraces.
The malposition of the left intercostal pneumocath was recognised at the time of insertion, and was capped after pulsatile blood was encountered. The tube was wisely left in situ.
The patient died 6 days later of intracranial injuries, with his outcome unaltered by the malpositioned line.