Hx: A prison guard is stabbed by an inmate. He is stabbed in the upper back on the left side resulting in a small puncture wound just medial to the scapula. He has immediate onset of back pain then has progressive shortness of breath, diaphoresis, and pain with inspiration. No anterior chest pain. On EMS arrival they find him in moderate respiratory distress, diaphoretic, and coughing up blood tinged sputum. Once in the ambulance, he is noted to have increasing inspiratory pain, tachycardia, and work of breathing. A needle decompression is performed in the midclavicular line, 3rd intercostal space however there is no rush of air and no relief of pain. An IV is placed, and he arrives with an oxygen non-rebreather mask in place.
PMHx: none
SocHx: no alcohol, tobacco, or drugs.
Exam:
- Vitals: HR110, BP 140/90, RR 30, sat 100%, temp 98.6 (37C)
- General: Diaphoretic male in moderate distress, appears in pain.
- HEENT: normal
- Chest wall: decompression catheter in the midclavicular line, 3rd intercostal space, no blood or air moving through catheter. No subcutaneous emphysema.
- Neck: supple
- Resp: tachypneic, breath sounds equal, shallow respirations, coughing with blood tinged sputum
- Cardiovascular: tachycardic, pulses equal all extremities, no murmurs
- Abdomen: Soft, non-tender, non-distended
- Back: single small (1cm) puncture wound just medial to the left scapula.
- Neuro: awake and alert, no deficits, GCS 15
Differential:
- Pneumothroax
- Hemothorax
- Pulmonary Injury
- Posterior Rib Fracture
- Intercostal Neve Injury
- Intercostal Muscle Injury
ED Course:
- IV pain medication is administered after examination.
- IV fluid bolus is given
- Portable chest X-ray is obtained (image below)
- Patient continues to complain of pain and produce blood tinged sputum with cough. He remains hemodynamically stable.
- Subsequently, a CT of the chest is obtained demonstrating the following:
Hospital Course:
The patient remained hemodynamically normal. He was becoming more comfortable with pain medication. The admitting team chose to monitor him instead of placing a chest tube, given the small size of the pneumothorax without evidence of worsening. The patient did well and was discharge 1 day later in good condition.
Discussion:
This case demonstrates the importance of further investigation when the clinical examination does not match the radiological results. The patient arrived in obvious distress and pain but he had equal breath sounds and his initial chest X-ray was normal. However, further investigation with CT imaging revealed the culprit injury.
It is important to remember that the posterior thorax (upper back) is just as vulnerable to penetrating injury as the anterior chest. Although there is a thicker layer of muscle tissue and fat on the back, a penetrating injury has access to the thoracic cavity, the lungs, the spine, and even the aorta. In addition, the posterior approach can also access the diaphragm, spleen and liver. When assessing a trauma patient with a penetrating injury to the back, careful attention should be paid to all of these vulnerable structures. This case is a good example of the damage a seemingly innocuous penetrating skin wound can cause. It was unclear what weapon was used. It was also unclear how far it penetrated his back. CT imaging revealed injury to the left lung deep into the parenchyma. Communication with the tracheo-bronchial tree caused the patient’s blood tinged sputum. Fortunately, this patient did well and did not require any further interventions for his injuries.