FROM THE BLOGOSPHERE
was consulted and ordered a stat Echocardiogram and started the patient on ACS
protocol. The echo showed an EF of 30 percent, an akinetic mid/distal anferoseptum
and an akinetic apex. Cardiology initially
thought this was consistent with stress cardiomyopathy in the setting of trauma, but
couldn’t rule out cardiac ischemia due to
direct cardiac trauma. They planned to treat
medically and cath in the morning.
Throughout the evening, he developed
worsening ST elevation in his lateral leads
and his troponin continued to rise, up above
60 by midnight.
The on-call interventional attending at
Jewish was consulted and the decision was
made to transfer the patient to Jewish for
emergency cath - final result: 100 percent
LAD occlusion, secondary to direct cardiac
trauma.
This is a rare injury, but one to keep in
the back of your mind. It can occur in previously healthy, relatively young patients.
Of note, the presentation can be delayed up
to several days. Typically the mechanism of
trauma is an MVA, but there are several case
reports occurring after crush injuries, being
hit in the chest by a soccer/rugby ball, and
my personal favorite, one listed as “struck
in the chest by an umbrella tip” (no word on
whether umbrella MI-5 related.)
Meg Pusateri, MD, practices as a University of Louisville pg 2 emergency medicine
resident.
POSITIONING IS EVERYTHING
Shaun Reynolds, MD
W
hen using a chest x-ray to look
for a pneumothorax, positioning of the patient is everything.
The first chest x-ray below is an upright
film of a man who fell 30 feet from a deer
stand and was found to have a right pneumothorax. The outside facility staff who
first saw him did not perform any other
imaging and did not send the patient with
a cervical collar.
supine chest x-ray on someone, remember
the low sensitivity of this test for pneumothorax. The optimal plain film is an upright
chest x-ray (inspiratory and expiratory if
possible).
Upright Chest x-ray from OSH (fig.1)
Portable, supine Chest X-ray in Room 9
(fig.2)
CT showing the Right Pneumothorax (fig.3)
When the patient arrived we laid him down
and placed a c-collar and assumed that his
spine was not “cleared” yet. When we shot
the portable, supine chest x-ray in room 9
we couldn’t see a pneumothorax and the
radiologist read was also no pneumothorax.
But using the ultrasound, an EFAST was
performed (Extended Focused Assessment
with Sonography for Trauma) and that
showed a pneumothorax. The subsequent
Chest CT verified it.
Therefore the next time you get a Room 9
36
LOUISVILLE MEDICINE
fig. 2
fig. 3
fig. 1
Shaun Reynolds, MD, practices as a University of Louisville pg 2 emergency medicine
resident.