A 70-year-old woman is brought to the emergency department by ambulance for evaluation of sudden-onset slurred speech and weakness. Initially, her vital signs were stable, and the working theory was that she might be experiencing a cerebrovascular accident.
Just prior to going to the CT scanner, she becomes acutely diaphoretic, less responsive, and bradycardic. The decision is made to urgently intubate her.
Subsequent noncontrast CT of the head does not demonstrate any acute stroke or hemorrhage. Because she is within the three-hour window of presentation, it is decided to administer tissue plasminogen activator.
While reviewing her chart, you examine her chest radiograph. What is your impression?
ANSWER
The chest radiograph shows a patient with endotracheal and nasogastric tubes present. Also of note is subcutaneous emphysema on both sides of the neck and chest, although it is greater on the left than the right side. In addition, a large amount of free air is noted in the abdomen. Since the patient has no history of recent abdominal surgery and has undergone intubation, it is important to consider the possibility of a traumatic intubation (which may have caused an esophageal perforation) or of spontaneous perforation within the bowel.
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