What does the X-ray show? What is the next move?
Waiting room cases are like artillery rounds – the one you don’t hear is the one that kills you. In this case, the alert triage nurse ordered up the CXR so that this fellow with the pneumothorax (PTX) would get recognized earlier and fixed. The subcutaneous air was also evident clinically. The patient’s examination showed diffuse and expanding subcutaneous swelling with the classic “rice crispies” or soft-crunching feeling that confirms the diagnosis in the setting of trauma. Because of difficulty in seeing the presumed PTX and the patient’s good tolerance of the injury, we elected to define its size and location with a CT scan prior to chest tube placement (see right). There was only a small air leak present in the chest tube system which resolved quickly.
This case was a little unusual, with a large amount of subcutaneous air associated with a small-to-moderate sized PTX. This amount of subcutaneous air can occur with minor trauma or post-operatively, but is classically associated with massive air-leak. With high-risk truncal trauma or deceleration injury, this amount of air is seen with injuries to the trachea and/or major bronchus. As is seen in this case, air can track well up into the neck (can be seen on a lateral c-spine film) and down along the abdominal wall. On the CT, air is also present in the pericardium.