The stem
A 15-year-old boy has a chest injury and severe breathlessness.
Chest X-rayImages on Radiopaedia
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Case courtesy of Naqibullah Foladi, Radiopaedia.org. View the case. Licensed CC BY-NC-SA 3.0.
The examiner’s questions
Question 1Describe the chest X-ray.Show the model answer
The left hemithorax is hyperlucent and hyperexpanded with no lung markings. The left intercostal spaces are widened, the left hemidiaphragm is depressed, and the mediastinum is shifted to the right.
Question 2What is the diagnosis?Show the model answer
Left-sided tension pneumothorax.
Question 3Should this X-ray have been taken?Show the model answer
Ideally not. Tension pneumothorax is a clinical diagnosis: respiratory distress, tachycardia, low blood pressure, trachea deviated away, absent breath sounds, hyperresonance and distended neck veins. It is treated before any X-ray.
Question 4What is the immediate management?Show the model answer
High-flow oxygen and immediate decompression with a needle or finger thoracostomy, according to the current trauma protocol, followed by a chest drain in the fifth intercostal space within the safe triangle.
After you answerThe teaching pointShow
An X-ray of a tension pneumothorax shows a diagnosis that was missed at the bedside. The examiner will ask what you would have done before the film.
Related: Model clerking: blunt abdominal trauma →
Source case on Radiopaedia: “Tension pneumothorax”, by Naqibullah Foladi.
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