When I was a young house officer...

....I would have been hauled over the coals if my boss ever saw this CT. 

Actually I wouldn't, as back then a CT would require me getting my consultant out of bed, to get the radiology consultant out of bed, to warm up the scanner.....much more trouble than it was worth!  But even ordering the XRay would have been considered poor practice.

So what is the diagnosis, and what has changed?

So it's a pneumothorax in a trauma patient.  Best seen by pressing 2 or sometimes 3 on the numberpad on the department computers to get the lung windows (it's different on different machines.....Dan?).  For those of you with an especial eye for detail, there is distortion of the anterior mediastinal line (from the heart to the sternum) indicating a degree of tension.

So why would I have been in trouble?  Well the old teaching was that tension was a clinical diagnosis, so severe that even getting the CXR was a negligent failure to recognise and treat.  And yes, all you Ultrasound Geeks: Supine CXR isn't that brilliant for them anyway, and your little toys on wheels are much better.

Our systems are so different now here, with CXR usually performed in the middle of the primary survey, and so sometimes available as the doctor completes their assessment of B, that we will inevitable see some.  But a CT?  Surely we should have put in a needle first at least?

Well perhaps not.  Certainly in spontaneously ventilating patients it seems to be a very different entity - have a read of this one if you want to know it all.  Bottom line, if spontaneously ventilating, its  hypoxia that is the problem presenting with progressive dyspnoea, tachypnoea and dropping sats, so you have time to decompress it properly (and if you think needles in chests are harmless, just ask me for the video!)  Ventilated patients are a whole different problem - and here the BP can drop very fast without much warning and you need to act NOW!  I'd prefer to do a finger thoracostomy given they're asleep anyway.  If you do use a needle, use a big enough one, and for those military guys taught to "think laterally" in generously proportioned people, think again.