Management of unilateral opacity on chest X-ray in the setting of trauma

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Fagg, Damen
Rashid, Muddassir
Wullschleger, Martin
Patel, Bhavik
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An 86‐year‐old male was referred to the emergency department following a fall from standing height. Clinical observations include oxygen saturations of 90% on 3 L oxygen via nasal prongs, moderate work of breathing, heart rate of 100 bpm and blood pressure of 100/60 mmHg. On examination of the chest, there was moderate‐sized bruising in the right posterior thoracic region, trachea was central and air entry was slightly reduced on the right side. The patient had significant medical co‐morbidities including ischaemic heart disease with a previous inferior ST‐segment elevation myocardial infarction and was on dual antiplatelet therapy for three subsequently placed coronary artery stents. Other significant co‐morbidities included severe aortic stenosis (aortic valve mean pressure gradient of 63.8 mmHg). A chest X‐ray was performed on admission demonstrating a right mid zone opacity and small pneumothorax (Fig. 1). Contrast‐enhanced computed tomography (CT) trauma series demonstrated a right extrapleural haematoma with an arterial blush from the right ninth intercostal artery (ICA), 9th–12th rib fractures and an associated right haemopneumothorax (Fig. 2a). In view of the multiple medical co‐morbidities and the likely poor outcomes with major surgical intervention, the decision to proceed for angiography and coiling was made. Digital subtraction angiography (DSA) was performed which demonstrated active bleeding from the right seventh, eighth and ninth ICAs. Subsequently, the seventh and eighth ICAs were embolized with 4‐mm coils and the ninth ICA was embolized with small volume of Histoacryl glue (Fig. 3). The patient remained haemodynamically stable through his stay in the high dependency unit without the need for an intercostal catheter. Subsequently, on Day 3, the patient was discharged to the ward.

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ANZ Journal of Surgery

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Fagg, D; Rashid, M; Wullschleger, M; Patel, B, Management of unilateral opacity on chest X-ray in the setting of trauma, ANZ Journal of Surgery, 2019