Emergency ultrasound : Answer to case of the month november 2013

15 Nov

So here  it is … the answer to the emergency ultrasound case of the month november 2013

Brought to you by Amber Hoek. Emergency Medicine Resident, HAGA Teaching Hospital, The Hague . 

She came across this case during her Emergency Ultrasound Rotation at the Emergency Department of the Westfriesgasthuis in Hoorn.

A unexpected finding during a routine EFAST….with a brilliant clip….Enjoy !!

a 27-year-old male visited the ED with chest pain and respiratory distress.

3 weeks ago he was involved in a high speed motor vehicle crash, and fell from a dyke into the water. He refused to go to the hospital, however the day after he went to the ED because of chest pain on the left side. The Emergency Physician did a full physical exam and made a chest X-ray and shoulder X-ray. Only a left clavicle fracture was found.

Chest X-ray 3 weeks ago:

CHEST x ray ultrasound case of the month

Today the patient comes back with progressive chest pain on the left side and dyspnea since one week. He also has a fever of 39.0 °C

Vital signs: blood pressure 134/95 mmHg, heart rate 112/min, Sat. 100%, temperature is 37.8 °C. Auscultation: decreased breath sounds on the left with rales.

-What is your most likely diagnosis?

-What would you do next?

While the patient gets some fluids and waits for the chest X-ray, we do an EFAST:

-What’s your diagnosis now and what would you do now?

Answer & Outcome

Left upper quadrant view:

Collapsed lung with intra thoracal fluid and large clot

hematothorax aangeduid

Chest-X-ray:

Total opacification of the left hemithorax

with mediastinal shifting

Hematothorax chest X ray        

Chest CT ( with tube ) showed no rib fractures

Hematothotax CT

Diagnosis:       Massive hematothorax.

Outcome

A chest tube was placed in the ED and a total of 3000ml blood was drained.

Patient was admitted and treated with i.v. antibiotics and discharged after a few days

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