A 49-year-old man was struck by a van that was turning a street
corner. He had a transient loss of consciousness.
In the trauma resuscitation area, the patient was awake and alert,
but would repeatedly ask what had happened despite being told this
information on several occasions. He complained of left hip and
left-sided chest pain.
His vital signs were: blood pressure 110/70 mmHg, pulse
110 beats/min, respiratory rate 28 breaths/min,
SO2 100% on 10 L/min O2.
His physical examination was remarkable for contusions to the left
side of his face and head, palpable tenderness and crepitus over
the left lateral chest wall with diminished breath sounds on the left,
and tenderness, swelling, and inability to move the left hip due
A chest tube was inserted on the left without return of blood
or air. One liter of normal saline and 8 mg morphine sulfate were
administered intravenously. Repeat vital signs were as follows:
blood pressure 120/88 mm/Hg, pulse 88 beats/min,
respirations 18 breaths/min.
Radiographs of the cervical spine, chest, and pelvis revealed
a left chest tube, a left sixth rib fracture, and a left proximal
femoral fracture. Bedside sonography was negative for intraperitoneal
or pericardial blood.
The trauma service brought the patient to the radiology suite.
A head CT revealed a small traumatic subarachnoid hemorrhage. An
abdominal CT revealed a small splenic laceration and adjacent peritoneal
blood without active arterial extravasation of contrast. Cervical
spine CT was normal. An intertrochanteric femoral fracture was seen
on left hip radiographs. Left hand and wrist radiographs revealed
a fifth metacarpal shaft fracture.
The patient remained stable and was admitted to the surgical
intensive care unit for monitoring and eventual repair of his orthopedic
His chest radiograph is shown in Figure 1.
- Are any additional tests needed?
A 45-year-old man who was driving a small car struck a slow moving
vehicle that had stopped short in front of him while he was going
at approximately 30 miles per hour. He was wearing a seatbelt and
his air bag deployed. The front end of his car was crushed inwards
but there was no intrusion into the vehicle’s front passenger
There was no loss of consciousness. He complained of pain in
the anterior chest, but had no shortness of breath.
His vital signs were as follows: blood pressure 120/70
mm/ Hg, pulse 84 beats/min, and respiratory rate
20 breaths/ min. On examination, his anterior chest wall
was mildly tender, without crepitus. His breath sounds were normal.
He had mild upper abdominal tenderness. There were superficial abrasions
of his right eyebrow and nose.