A Story In Three Radiographs
Published by Vijay July 16th, 2009 in Chest, Medicine, Quizzes, Radiography, Radiology, casebook…
A small mental excercise for medical bloggers.
See the following three portable (bedside) chest radiographs that were taken in an ICU setting. They are in sequence.
See if you can guess the story that they tell.
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Start Slide Show with PicLens Lite
I can’t work out what sort of line is in the first image - is that a supraclavicular subclavian? - but something’s gone wrong, awfully awfully wrong, and there’s a haemothorax on the right (loss of diaphragmatic silhouette sign, heart pushed to the left) which has been completely drained by CXR 3.
That’s very good, Hildy. And fast
The line in CXR-1 is an Internal Jugular cannula. You’re right about things having gone horribly wrong. The line must have pierced the wall of the SVC. Huge hemothorax. ICD drained about 1.5 litres of blood. Thankfully no surgical intervention was required to stop the bleeding.
not good when you pump a whole bunch of fluid directly into the right hemithorax.
iatrogenic hydrothorax
iatrogenic hemothorax, bongo. not good at all.
don’t know the time elapsed between each–pleural effusion? That’s a healthy mediastinal shift in #2. Dunno. Stuck in larval stages here. ;P
Time elapsed between CXR #1 & #2 - about 30 minutes. CXR #3 was taken a day later.
Yay, I beat bongi to the punch! That’s the good/bad thing about casualty and the rotating shifts; my sleep is all messed up and I have the time to read medblogs.
Speaking of which, does anyone know how I can email bongi?
Looks to me that the chest drain is a bit low, 6th or 7th interspace. Lucky the liver wasn’t drained. ;P
Good Lord! 2 iatrogenic injuries on the same patient!
IJV line piercing the Pleura and a low ICD - low enough to pierce the Liver’s Superior surface.
Look at the CXR - the drain is below the R hemidiaphragm! Radiologically, I am sure that the ICD is thru the Liver!
What next, the surgeon leaving the gauze & needle holder while suturing the liver!
Chest tube is inferior, in perfect dependent position - remember, the PA projection height of the liver reflects the highest but anterior part of the liver - the diaphragm swoops inferiorly as you go from A to P.
Right Hemothorax with Mediastinal Shift and Lung Compression ?? Iatrogenic
ICD Done
Mediastinal Shift and Lung Compression Reversed
Abishek & QuietusLeo the chest tube was intentionally inserted at an inferior location to facilitate easy drainage. Texas Surgeon got it right. The posterior costophrenic recess is located considerably lower than the lateral recess. The chest tube is behind the dome of the diaphragm. Not through the liver.
Really interesting.. and the comments even more so!
Nice work!