Correct!
3. Contrast-enhanced thoracic CT
Among the choices listed, contrast-enhanced CT would be most useful for confirming the working diagnosis of left hemothorax due to intercostal artery laceration resulting from left rib fractures. Lateral decubitus chest radiography is useful for confirming the presence of small pleural effusions and assessing whether or not such effusions are amenable to percutaneous drainage (when the decubitus image is performed with the affected thorax in a dependent position) or detection of pneumothorax (when the decubitus image is performed with the affected thorax in a non-dependent position). However, there is no uncertainty regarding the presence or absence of left pleural effusion in this patient. 99mTc-ventilation-perfusion scintigraphy is commonly used to assess for suspected acute or chronic thromboembolic disease or to assess for differential lung perfusion prior to thoracic surgery, but thromboembolic disease is not a likely cause for the patient’s acute deterioration, and 99mTc-ventilation-perfusion scintigraphy would not be a good test choice for such an acutely ill patient. Similarly, cardiac MR is not a suitable test for acutely ill patients, and probably would not provide any additional information not already known through recent echocardiography. Thoracentesis is commonly employed to sample or drain pleural effusions, but in a critically ill patient with presumed hemothorax, merely removing the left pleural liquid would not address the potential bleeding; if anything, such removal could reduce any pressure-related hemostatic effects the large hemothorax is providing. Finally, when pleural drainage of a large hemothorax is performed, it is typically conducted through placement of a large-bore surgically-placed thoracostomy tube, not bedside small-bore temporary catheter drainage.
A left-sided thoracostomy tube was placed by cardiothoracic surgery and the patient underwent thoracic CT (Figure 4).
Figure 4. Left: Axial contrast-enhanced thoracic CT in soft-tissue windows. Right: video of CT scan.
Which of the following is the most accurate description of this this patient’s CT findings? (Click on the correct answer to proceed to the sixth of eight pages)