0:01

This is a 35-year-old firefighter who was

0:04

involved in a workplace incident, fighting fires, but also was in a blast incident

0:10

and was presenting to the ED after experiencing shortness of breath.

0:14

So in the trauma bay, portable x-ray was obtained.

0:19

And let's go through this.

0:20

So in our approach of looking

0:21

at the lungs, what we notice here is kind of a focal patchy opacity

0:25

here in the upper lung zone. The hilar area looks normal.

0:30

The heart is not enlarged.

0:31

The lung base looks fine.

0:33

On the right side, the lower and mid lung zones look fine.

0:36

Again, we have an upper lobe predominant patchy opacity here.

0:40

We'll take a look at the bones

0:42

given the blast. We'll look at the soft

0:44

tissues to make sure that there's no foreign bodies.

0:47

And the bones and the soft tissues look fine.

0:49

Underneath the diaphragm looks fine.

0:51

But certainly, we have here patchy opacities bilaterally.

0:55

Given a blast injury,

0:56

I would certainly be concerned about any evidence of pulmonary contusion

1:00

given the force. You know, I don't see any rib fractures.

1:03

But certainly in trauma, you can have rib fractures with contusions.

1:07

Certainly, it could be inhalation injury as well.

1:09

We recommended a CT.

1:11

So let's take a look at that CT and see if we can better characterize these findings.

1:15

Again, I like to look at the scout view

1:17

for either confirmation or lay of the land.

1:20

So multiple overlying monitoring wires, but the upper low predominant opacity

1:26

that we saw in radiograph persist on the CT.

1:29

And let's just go through the lung windows and see what correlates.

1:33

So here in the right upper lung zone,

1:37

we do see kind of scattered ground glass opacities.

1:41

We're also seeing it bilaterally in the left upper lobe.

1:43

And so that's probably where we're seeing on the radiograph.

1:46

We also see it involves portions

1:48

of the right lower lobe, spares the right middle lobe and the rest

1:55

of the right lower lobe. Coming back on the left,

1:59

it really looks like it's predominantly in the upper lobe,

2:03

but we have a component in the posterior portion here,

2:06

the apical portion of the left lower lobe as well.

2:09

We can see a little bit of...

2:11

could be some mucus that's sitting here in the airway.

2:14

But predominantly speaking, his airways are not inflamed.

2:19

They don't look too thick.

2:21

There's not secretions or particulate

2:24

matter in them, given that there was a blast.

2:27

And so I'm not necessarily thinking this is infection, which can be ground glass.

2:31

But certainly in the setting of a blast

2:33

injury, whether or not this represents pulmonary contusion.

2:37

Now, if this kind of resolved within

2:38

a short period of time, that's good for contusion.

2:41

If he doesn't have anything that looks infection related, that's not likely.

2:44

His airways look pretty good, and he's satting okay.

2:48

You know, it may not necessarily be sort

2:49

of an inhalation injury of sorts, so we can put a differential on this.

2:53

But again, given the context of what happened, common things being common,

2:57

I would attribute this to the blast injury itself.

3:00

We want just to take a look at the other

3:02

aspects of the lungs and the other windows.

3:05

So we don't see any pneumothorax.

3:07

We do see actually, pleural effusions down here at the bases.

3:11

And it's interesting because

3:12

on that frontal radiograph, there wasn't evidence of pleural effusion.

3:15

On the frontal scout view, there is an evidence of pleural effusion.

3:18

But when you look at the scout

3:20

on the lateral view, you do actually see significant blunting

3:23

bilaterally of the costophrenic angles compatible with small pleural effusions.

3:28

And when you look at them here on the CT, you're able to appreciate not just

3:34

the pleural fluid, but also the associated atelectatic lung

3:37

that's layering right along there. That's it right there.

3:41

So we're seeing that finding as well.

3:44

Just to kind of round things out below

3:46

the diaphragm, the solid abdominal organs look fine.

3:49

Taking a look at the vessels, the aorta looks fine.

3:53

The thyroid looks fine.

3:56

The mediastinum coming through.

3:58

We don't see any nodes.

4:00

The main pulmonary artery looks normal.

4:03

The heart and the pericardium are normal.

4:06

We'll look at the vessels really quickly to make sure that we're not missing any

4:10

evidence of pulmonary emboli.

4:14

And those are normal.

4:16

We'll take a look at the bones and the soft tissues, and we will be done.

4:20

Don't see any lymph nodes or any foreign bodies that have been embedded.

4:25

This firefighter has not been impaled, which is good news for him.

4:30

Take a look at the bones.

4:32

Don't see any evidence of fractures.

4:35

Don't see any aggressive osseous lesions so far.

4:39

We don't have, on this exam, a sagittal series.

4:44

We will take a look at the coronal,

4:46

and it's just to redemonstrate some of the findings

4:49

we've already talked about.

4:51

Bilateral ground glass opacities before you run the bones.

4:58

But again, we're able to see nicely the vertebral bodies

5:02

and their heights are preserved, the disk spaces are maintained.

5:07

There aren't any fractures.

5:10

So again, a nice situation and a nice case of screening, x-ray is good for big things.

5:16

You're able to see the subtle,

5:18

hazy opacities that are seen bilaterally in a patient who's experienced trauma,

5:22

a couple of differentials that exist at that point.

5:24

But then, the CT is used for follow up and further characterization.

5:29

The pleural effusions we actually didn't

5:31

see or appreciate on the x-ray, but we saw those on the CT.

5:34

We were able to better understand that the ground glass opacities were not

5:39

just in the upper lobes, but also seen in the apical segments of the lower lobes.

5:44

When a patient with a blast injury, these could be differential as including

5:49

blast injury, contusions, and we see bilateral pleural effusions,

5:55

all of which would help explain the patient's shortness of breath.

5:59

So, again, CT as a problem-solving tool and the right clinical context,

6:04

but it's really helpful when you get good information on the x-ray on the clinical

6:08

situation and then use that to determine how the CT might be helpful.