a pulmonary pummelling…

The Case.

This patient has been in your ED for over 24 hours waiting for a CCU bed. He presented with vomiting and syncope, but acquired left sided rib fractures during his collapse. He has been comfortable for most of the day on nasal-prong oxygen and a morphine PCA.

You are asked to see him as he has sudden worsening of his left-sided chest pain. He has become clammy and hypoxic.

This is what you see….

What’s going on ?
What are you going to do now ??

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probe prevents probe…

Recently, a colleague of mine was wanting to perform a diagnostic tap on a patient with cough, fever and a CXR suggesting a left sided pleural effusion….

I was asked to perform a bedside USS to mark out the safest place to perform the pleural aspirate.

I percussed the chest to the dullest point and then slapped the ultrasound on (left posterior chest wall, longitudinal plane, just below tip of scapula).
This is what I saw…

Needless to say the needle was re-sheathed and the procedure aborted. I am convinced that if we were going by x-ray and clinical examination alone we would have created more problems for this guy.

What made a difference….

  1. Turner JP, Dankoff J. Thoracic ultrasoundEmerg Med Clin North Am. 2012 May;30(2):451-73.
  2. Ultrasound Podcast Episode 31 (Pneumothorax & Pleural Effusion) & Episode 32 (Pneumonia & ARDS)
  3. Sonocloud

just a tablespoon…

This is the story of a 59 year old man who presented to our ED with a complaint of haemoptysis. He is otherwise well, takes no regular medications and besides his ’50 per day’ smoking history (over 40-odd years) he has no health concerns or past medical problems.

On the morning of presentation he had his usual morning ‘cough and splutter’ and was surprised to find blood in his tissue. He then proceeding to expectorate a small blood clot. “Its not that big, just a tablespoon”. He may have had some right sided pleuritic chest pain with it.

He looks well, with no increased work of breathing. Room air saturations of 94%.  Good air entry with mild end expiratory wheeze. Normal cardiac examination.

This is his CXR…..

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