Tension viscerothorax: an important differential for tension pneumothorax.

CASE REPORT A 70 year old male pedestrian was struck by a fast moving motor vehicle. On arrival at a local community hospital he was haemodynamically stable with blood pressure, heart rate, and respiratory rate all within normal range. Positive examination and radiological findings included a right pubic ramus fracture, and an undisplaced right fibular fracture. Ten hours later he was transferred to a trauma facility for further management of his orthopaedic injuries. During transfer the patient deteriorated and on arrival at the regional trauma facility the patients respiratory rate was 46/min, heart rate 132/min, and his blood pressure had fallen to 90/60. His left hemithorax was hyper-resonant with absent breath sounds. Auscultation detected prominent bowel sounds in the left infraclavicular region. A presumptive diagnosis with reference to his first chest radiograph (fig 1), of acute tension viscerothorax was made and confirmed with a portable chest radiograph (fig 2). The patient was given 100% oxygen, a two litre bolus of crystalloid, and a nasogastric tube inserted, which promptly relieved his respiratory distress. Repeat chest examination showed improved air entry over the left hemithorax. The patient was removed to the operating theatre where a 7 cm tear in the left hemidiaphragm was oversewn. Of note at operation, the spleen and left kidney were uninjured and there was no evidence of pneumothorax or haemothorax. The patient’s recovery was unremarkable.