Emergency & Trauma – ChestDB.com

Case 59

Emergency & Trauma / Age 31-60, Dialysis, Peritoneal Dialysis, Pneumoperitoneum, Rigler's Sign

This radiograph shows pneumoperitoneum in the form of free air under both hemidiaphragms. Under the left hemidiaphragm, air is seen on both sides of a GI tract structure (bowel or stomach). This is known as Rigler’s sign, though typically this is most useful on supine abdominal radiograph where air under the diaphragm is not a reliable finding due to patient position. The lungs are clear.

The differential for pneumoperitoneum includes the emergent finding of perforated bowel and should always be suspected in a patient with abdominal pain. Pneumoperitoneum can also be seen in a few more benign settings. One is a history of abdominal surgery in the past few days, particularly laparoscopic surgery, as it takes time for the air introduced to the peritoneal space to be absorbed. The other is air that is inadvertently introduced by patients on peritoneal dialysis. This patient had an unremarkable abdominal exam and was on peritoneal dialysis, so the air was attributed to the dialysis.

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Case 58

Emergency & Trauma / Age >61, Atelectasis (Compressive/Passive), Layering Pleural Effusion, Pleural Effusion, Portable, Silhouette Sign

This radiograph shows a left layering pleural effusion. This appearance is the result of pleural fluid layering in the basal and posterior pleural space due to gravity in a semi-recumbent position. Despite the image being labeled as “UPR” (upright), portable exams performed with the patient in a bed or gurney are rarely fully upright. As the x-ray photons pass through the effusion, they create a gradient effect in the craniocaudal direction as photons pass through more and more fluid relative to air the the more inferior they are relative to the patient. There is often some degree of compressive atelectasis associated with effusions, which contribute to this effect. This implies that the fluid is not loculated.

If the combined effusion and atelectasis is large enough to cover the entire hemidiaphragm, as in the case, there is “silhouetting” of the diaphragm and it is no longer distinguishable on radiography. The heart borders can also be silhouetted in the same way, but the effusion must be large enough to cover the entire heart.

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Case 56

Emergency & Trauma, Infectious/Inflammatory / Age <30, Mononucleosis, Splenomegaly

This radiograph shows a soft tissue opacity in the left upper quadrant without bowel gas. The stomach bubble is oriented vertically and deviated toward the midline, suggestive of mass effect. This appearance is expected in the right upper quadrant where the liver occupies the majority of the space, but the left upper quadrant typically has stomach or bowel gas. The differential for this appearance is broad and includes mass, splenomegaly, and ascites (if the bowel is sufficiently decompressed). Further investigation with CT or ultrasound would be advised. The rest of the exam is unremarkable.

This patient went on to CT which showed marked splenomegaly. Give their young age and reported history of recent illness, this was presumed to be sequela of prior mononucleosis.

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Case 53

Emergency & Trauma / Age 31-60, Artifact, Dislocation, Elastic Band, Ponytail

This radiograph shows a left anterior shoulder dislocation in a trauma patient. The humeral head projects inferior and medial to the glenoid. No associated fracture is evident, though dedicated shoulder imaging should be performed to evaluate for Bankart and Hill-Sachs lesions. The patient’s hair is in a ponytail with an elastic band which can be seen projecting over the cervical spine and should not be confused with a foreign body. The remainder of the exam is unremarkable.

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Case 52

Emergency & Trauma / Age <30, Continuous Diaphragm Sign, Macklin Effect, Pneumomediastinum, Pneumopericardium

This radiograph demonstrates extensive pneumomediastinum. There is marked symmetric subcutaneous emphysema in the chest wall and neck. The muscle fibers of the pectoralis muscles are appreciable, indicated subpectoral air. Streaky lucencies are seen in the superior mediastinum extending to the neck, a classic finding in pneumomediastinum. A single lucent line is seen just above the diaphragm that appears to connect the left and right pleural spaces. This is called the “continuous diaphragm sign” and indicates pneumomediastinum. By following this line to the left and the right of the heart, the pericardial edges are appreciated several centimeters from the myocardium, indicating marked pneumopericardium. The medial wall of the aorta is also appreciable due to air in the posterior mediastinum.

These findings were ultimately attributed to the Macklin effect. CT excluded tracheal and esophageal leaks and interstitial emphysema was identified.

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Case 46

Emergency & Trauma, Infectious/Inflammatory / Age 31-60, Consolidation, Infection, Lobar Pneumonia, Pneumonia

This radiograph demonstrates a right upper lobe consolidation most consistent with lobar pneumonia in this patient with a cough and elevated white count. The consolidation has poorly defined margins with the exception of the inferior margin, which is sharp and linear. This is due to the consolidation abutting the minor fissure. The position of the consolidation superior to the minor fissure definitively localizes it to the right upper lobe. Uncomplicated community acquired lobar pneumonia does not typically cross fissures. While malignancy is not entirely excluded, a mass would be unlikely to respect the fissural boundary without exerting mass effect.

The exam is otherwise unremarkable.

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Case 43

Emergency & Trauma, Mediastinum / Acute Aortic Syndrome, Age <30, Portable, Traumatic Aortic Injury, Widened Mediastinum, Widened Vascular Pedicle

This previously healthy young patient presented to the emergency department after a motor vehicle collision. There is marked widening of the vascular pedicle and loss of the normal contour of the aortic arch. This finding is consistent with acute traumatic aortic injury. The lungs are clear and there are no radiographically evident fractures.

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Case 40

Emergency & Trauma, Infectious/Inflammatory / Age 31-60, Pneumonia

This case demonstrates multiple poorly defined opacities in the right lung. In a clinical setting suspicious for infection, this finding is most consistent with multifocal pneumonia as was the case here.

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Case 39

Emergency & Trauma, ICU/Surgery, Mediastinum / Age 31-60, Chest Tube, Clamshell Sternotomy, Lung Transplant, Pneumopericardium, Pneumothorax, Portable

This case demonstrates both a right pneumothorax and pneumopericardium. In this case, the cause was iatrogenic during a bronchoscopy. A right chest tube is in place, though a small apical pneumothorax is still visible.

Clamshell sternotomy closure hardware is also seen, indicating that this is a lung transplant patient.

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Case 34

Emergency & Trauma / Age <30, Atelectasis (Compressive/Passive), Central Venous Catheter, CVC, Kerley B Lines, Pleural Effusion, Portable, Pulmonary Edema

This radiograph demonstrates typical findings of pulmonary edema. The vessels are hazy with indistinct margins. Kerley B lines are seen peripherally. There are bilateral layering pleural effusions creating a gradient of opacification extending from the bases. Bibasilar opacities are silhouetting the diaphragm and the right heart border, representing a combination of pleural effusions and associated atelectasis.

A dual-lumen central venous catheter is also in place.

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