When using a chest x-ray to look for a pneumothorax, positioning of the patient is everything.  The first chest x-ray below is an upright chest x-ray from an OSH of a patient that fell 30 feet from deer stand and was found to have a right pneumothorax.  The OSH didn’t do any other imaging and didn’t even send the patient with a c-collar.

When the patient arrived we laid him down and placed a c-collar and assumed that his spines weren’t cleared yet.  When we shot the portable, supine chest x-ray in our ED we couldn’t see a pneumothorax and our radiologist actually read it as no pneumothorax.

Using the US, an EFAST was performed and showed a pneumothorax and the subsequent Chest CT verified it.  Therefore the next time you get an ED, supine chest xray on someone, remember that just because you don’t see a pneumothorax on a supine CXR, doesn’t mean they don’t have one.  The optimal xray is an upright chest xray (expiratory if possible)!

Upright Chest x-ray from OSH

Portable, supine Chest X-ray in our ED

CT showing the Right Pneumothorax