Life in the Fast Lane Medical Blog
Emergency Medicine education blog
A 57 year old female car driver presents following a head on collision with a bus at 60Kph. Her observations are listed below.
| HR | 98 | /min | |
| BP | 130/90 | mmHg supine | |
| RR | 24 | /min | |
| SpO2 | 98 | % |
| a. | Describe and interpret her Xray | (40%) |
| b. | Outline your management options | (60%) |
Chest X-Ray
About Peter AllelyTrained in Ireland and Australia now living in Perth and working as an Emergency Physician. Main work related interests are Trauma, Cardiology, Simulation training and Protocol development...Real interests are work avoidance, football, Arthouse films and satire + Peter Allely | Contact
PDF 
She has a grossly widened mediastinum, at least one rib fracture on the left (of 6) that is obvious, and a haemopneumothorax on the left. She is currently haemodynamically stable so I'd consider sending her through the scanner before or after inserting an ICC and calling cardiothoracic surgery. The question is whether that widened mediastinum is haemomediastinum or a traumatic aortic dissection; if it is the latter, I'd aggressively reduce her heart rate and pulse pressure with intravenous (?esmolol) and arterial invasive blood pressure.
The right lung field looks pretty good.
Findings:
A -- right lung field looks normal, left lung field appears to have a pleural effusion / haemothorax. There may be a hint of some infiltrate in the right lower zone near the right heart border ?early ARDS. There appears to be a left-sided pneumothorax but I can't tell how large it is.
B -- there is a a fracture of the 6th rib laterally with associated subcutaneous emphysema. There may be a second fracture of this rib near the left hilum.
C. heart looks normal.
There is a widened mediastinum which appears to have two components:
- enlarged aortic arch possibly due to a traumatic dissection
- widened left paratracheal stripe suggestive of a haemomediastinum.
What to do:
- ABCs.
- the numbers look good so we can go for some more definitive treatment and diagnosis:
— ICC left-side
— CT aortogram
— arterial line and central line
— IV esmolol to reduce pulse pressure / heart rate
— cardiothoracic review / transfer to somewhere with cardiothoracic surgery for thoracoscopy / mediastinoscopy
I agree with hildyx but adding to that there is a deep slucus sign of the L) hemidiaphragm and R) clavicle fracture which is grossly displaced
Hildyxv -- I removed your first comment so that it didn't detract from your superlative second!
Hildyxv -- I removed your first comment so that it didn't detract from your superlative second!
All of the above are great answers. However there is one miss= R) clavicle fracture
sorry, couldn’t find the official answer to this VAQ. I agree that there must be suspicion of aortic dissection but I do also think that this xray shows a ruptured diaphram on the left with intrathoraxic abdominaI contents.
Anyone mention big boobs? Gonna be impossible to put ICC….