A 28-year-old man is admitted to your facility, status post a motor vehicle crash that resulted in a C5 fracture/subluxation with a spinal cord injury. He was paraplegic on presentation and was initially treated with Gardner-Wells tong traction and methylprednisolone sodium succinate according to protocol. Because of the extent of his injury, he underwent anterior and posterior cervical stabilization. Postoperatively, he was extubated and watched in the ICU. He is now on the medical-surgical floor.

The nurses page you because he has had sudden onset of respiratory distress. The patient feels that he is not able to “clear his secretions.” The nurse states that the patient was fine until 30 minutes ago, when he underwent a bedside swallowing study; his symptoms developed soon thereafter.

His oxygen saturation is 80% to 85% on 4L by nasal cannula. Nasal/oral suctioning produces thick secretions. With subsequent respiratory treatments and placement of a nonrebreather mask providing 100% oxygen, the patient’s saturation increases to 95%. However, he is still using his accessory muscles to breathe and has a weak cough.

A stat chest radiograph is obtained, and the decision is made to transfer the patient back to the ICU and reintubate him. What finding on the radiograph prompted this decision?   

Answer

The answer is, nothing. Overall, the radiograph does not show any acute findings. The patient is slightly rotated to the left, giving the appearance of the left base being somewhat blunted. 

This case demonstrates an important teaching point: Treat the patient, not the radiograph. The decision to transfer this patient back to the ICU and intubate him was purely a clinical one. The working thought was that one of two things had occurred. Either he aspirated from his swallowing study, in which case it would be too early for the radiograph to manifest any findings short of a mucus plug completely blocking a bronchus. Or, because of the nature of his injury, he was developing evolving edema of his upper cervical cord, causing him to lose his respiratory drive. Either way, lack of early, aggressive intervention can prove to be catastrophic.