Ventral tension pneumothorax.

Chest injuries are the cause of death in 25% of trauma fatalities and a major contributing factor in an additional 50%. Pneumothorax, the second most common chest injury, may often be overlooked, and this oversight may lead to deterioration, significant complications, and/or death. This case report describes such a failure because of a rare abnormal localization (ventral) of the pneumothorax and the shortcoming of a supine anterior­posterior chest x­ray film in the trauma room. A 56­year­old patient was admitted to the first aid department after he had jumped off the roof of a three­story building in a suicide attempt. The patient was awake and complained about pains in both forearms, the right ankle, and the lower back. Physical examination, with the patient lying on a first aid stretcher, revealed a noninvasive blood pressure of 110/65 with a pulse rate of 88. Head and neck showed no abnormalities and auscultation of the lungs was normal. There was no shortness of breath. Abdomen and extremities showed no abnormalities, except signs of closed forearm fractures on both sides. Initial x­ray films made of the chest (Figure 1) and the pelvis showed no abnormalities. Further radiography of the patient showed unstable fractures of lumbar vertebrae 1 and 3 and distal dislocated forearm fractures on both sides. During radiography the systolic blood pressure of the patient dropped to 70 mm Hg, and rapid infusion was started under the suspicion of hypovolemia. Blood pressure stabilized, but rapid infusion had to be maintained. Repeated physical examination gave no additional information. Repeated chest x­ray film again showed no signs of pneumo­ or hematothorax or mediastinal widening, and due to the low suspicion of an intrathoracic pathologic condition, an empiric chest tube was not placed. Ultrasonography of the abdomen was performed, but due to intestinal gases only the lower part could be visualized. This image showed no signs of bleeding. Ultrasonography of the chest was not performed.