Pneumothorax and pulmonary contusions in multitrauma patient

Case contributed by Dr Dayu Gai

Presentation

This 21 year old male was involved in a motorbicycle accident. A chest X-ray was performed.

Patient Data

Age: 20
Gender: Male
  • There are patchy airspace opacities seen in the right upper lobe, reflecting either pulmonary contusion or haemorrhage.
  • Lucency is seen adjacent to the left heart border suggestive of a pneumothorax.

Case Discussion

Chest injury is a common occurrence in the trauma setting, with up to one third of admitted trauma patients sustaining serious chest injuries1.

Pulmonary contusions are a common thoracic trauma injury and occurs in 30-75% of patients sustaining major chest injuries. Common mechanisms of injury include falls and motor vehicle accidents5

Pathologically, pulmonary contusions are the result of haemorrhage from a pulmonary laceration into the surrounding alveolar spaces2.

While radiograph and CT are both used for initial assessment and evaluation, both have their limitations. Radiograph has a poor sensitivity and will miss many diagnoses of pulmonary contusion. This is often because the pathological change doesn't occur until 6 hours later. The radiograph will often be the first imaging performed on admission, and these changes haven't occurred yet. On the other hand, CT may be overly sensitive, picking up subtle parenchymal changes which have no or minimal clinical impact.

Chest radiograph may show singular or multiple patchy alveolar infiltrates consistent with intra-alveolar haemorrhage. 

Pneumothorax is defined as the presence of air between the parietal and visceral pleura3. It can be divided into simple and tension pneumothoraces. While diagnosis has been typically with a plain radiograph, CT and more recently ultrasound have been shown to be more sensitive and specific for diagnosing pneumothorax4. Chest radiograph findings may include the following:

  • increased thoracic volume
  • increased rib separation
  • flattening of heart border
  • mediastinal deviation
  • mid-diaphragmatic depression

Case contributed by A/Prof Pramit Phal.

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Case information

rID: 32005
Case created: 9th Nov 2014
Last edited: 24th Nov 2015
System: Chest
Inclusion in quiz mode: Included

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