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OpenAthens Shibboleth
Special Feature
Oct 2011

Image of the Month—Quiz Case

Author Affiliations


Author Affiliations: Department of Surgery, University of Calgary, Calgary, Alberta, Canada.

Arch Surg. 2011;146(10):1211. doi:10.1001/archsurg.2011.262-a

A 46-year-old restrained male driver involved in a high-speed head-on collision presented with hemodynamic instability (systolic blood pressure = 90 mm Hg, heart rate = 139 beats/min) following prehospital intubation for hypoxia. Extensive bruising to the patient's left hemithorax with a large flail segment and subcutaneous emphysema were noted. His trachea was midline with reported bilateral equal breath sounds on auscultation. Bilateral tube thoracostomy was performed. Despite aggressive fluid resuscitation, the patient remained transiently hemodynamically unstable. Although the initial supine anteroposterior chest radiograph displayed a mild rightward mediastinal shift, there was no evidence of an overt residual pneumothorax (Figure 1). The focused assessment with sonography for trauma examination also identified a small amount of perisplenic fluid concurrent to a normal pericardial space.

Image not available

Figure 1. Supine anteroposterior chest radiograph revealing subcutaneous emphysema, rib fractures, pulmonary contusions, and a rightward mediastinal shift.

What Is the Diagnosis?

A.  Hemorrhage from the splenic laceration

B.  Tension occult pneumothorax

C.  Traumatic brain injury

D.  Spinal cord injury