Presentation
Unheralded syncope. Fall from standing height. Right sided chest pain and pneumothorax. Shocked state with hypoxemic respiratory failure. Right intercostal drain inserted.
Patient Data
Large occlusive thrombus in the distal aspect of the left main pulmonary artery, extending into both upper and lower lobe pulmonary arteries and segmental branches. Further thrombus within the anterior basal segmental branch of the right lower lobe pulmonary artery. Flattening of the interventricular septum suggestive of acute right heart strain. Reflux of IV contrast into the intrahepatic IVC and hepatic veins. Right sided pneumothorax, with an ICC entering the posterior pleural space from the 5th intercostal space laterally. Collapse involving almost the entirety of the right lower lobe with intense enhancement.. Linear band of atelectasis at the left lower lobe. Multiple right sided rib fractures. ETT in situ, with the tip at the mid thoracic trachea.
Case Discussion
This is a case of massive acute pulmonary embolism causing hemodynamic instability in the setting of trauma. It demonstrates the classic features of right heart strain such as flattening of the interventricular septum as well as inferior vena cava contrast reflux 1. The "polo mint" sign can also be visualized on the axial plane. This patient required urgent intubation as well as inotropic support.
An additional finding is the marked enhancement of the atelectatic portion of the right lower lobe.
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