Radiology Review

When It All Comes Crashing Down

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When It All Comes Crashing Down image

A 40-year-old construction worker was remodeling a home when the roof collapsed. The patient’s head, face, and chest were reportedly struck by a large metal support beam. He was taken to a local facility, where he was found to have decreased level of consciousness and was combative. He was intubated for airway protection and sent to your facility for tertiary level of care.

History is limited. On arrival, you note a male patient who is intubated and sedated. His blood pressure is 90/60 mm Hg and his heart rate, 130 beats/min. A large laceration on his forehead and scalp has been primarily closed. His pupils are unequal, but both react. Neurologic exam is limited secondary to sedation.

As you complete your primary and secondary surveys, a portable chest radiograph is obtained (shown). What is your impression?


When It All Comes Crashing Down image


The radiograph shows that the patient is intubated. The lungs are clear overall. There is a fractured, slightly displaced left clavicle. Of concern, though, is the widened appearance of the mediastinum. In patients with blunt chest trauma, there should be a high index of suspicion for a great vessel injury, warranting a chest CT with contrast for further evaluation. Fortunately, in this patient's case, CT was negative.

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