This is a very good teaching case.

A young male was admitted as a trauma patient after he was involved in a motor vehicle accident. The patient sustained right-sided hemopneumothorax and a severe head injury. Right-sided chest tube was placed in the ER and he was taken to the operating room for subdural hematoma evacuation.

Left-sided subclavian central venous catheter was placed in the operating room. A Chest XR immediately after the procedure was “Ok”. The patient was transferred to the ICU after the surgery.

Several hours after the admission to the ICU the patient started having problems on the ventilator. A follow-up Chest XR revealed large left-sided pneumothorax (see upper image above). The chest tube was inserted on the left.

In hindsight, the patient developed a small pneumothorax immediately after the central line placement. The pneumothorax was barely noticeable on the initial Chest XR (see arrow on the bottom image. Click on the image to see a larger version.) Given that the patient was placed on a positive pressure ventilation the pneumothorax had gotten significantly bigger.

The teaching point – we have got to be more careful when looking for pneumothorax after a central line placement. It can easily be missed.