Case: A 18-year-old male with no medical history presents to the emergency department (ED) complaining of “feeling like I am having a heart attack” which started suddenly 1 hour ago. The patient ate from a food truck the night before and developed several episodes of forceful vomiting prior to arrival in the ED. What finding in this supine chest radiograph aids in the diagnosis? Click on image for a larger view.

Poll Results

Deep Sulcus Sign

Explanation

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The deep sulcus sign was first described by Gordon in 1980 as a deep lateral costophrenic angle on the involved side.1 In this example, it is on the patient’s left side (arrow). It is an important radiograph finding to be aware of in making the diagnosis of pneumothorax, because it may often be the only abnormal finding.2 The cause of the sign is air tracking anteriorly and caudally along the pleural space and can be found on supine films. Which makes this finding particularly important for SUPINE critically ill patients. Air appears as a hyperlucency on radiographs which leads to the appearance of a deep lateral costophrenic angle on the side with the pneumothorax.

Wrong Answers

Wrong Answer Description Associations Air Fluid Level 3 Intrapulmonary cavitary with line that separates air from fluid Cavitary lesions, lung abscess, tuberculosis Kerley B Lines 4 Short horizontal lines, usually found in the lower zone periphery Congestive heart failure, interstitial lung disease, pulmonary edema Widened mediastinum 5 Mediastinum measuring a width >6 cm on upright PA chest xray, or >8 cm on supine AP chest xray Aortic aneurysm / dissection, anthrax inhalation, esophageal rupture, mediastinal mass

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1. Radiology. 1980;136(1):25-27. PubMed] Gordon R. The deep sulcus sign.. 1980;136(1):25-27. 2. Ann Emerg Med. 2007;49(5):717, 725. PubMed] Smally A, Suozzi J. Images in emergency medicine. Deep sulcus sign.. 2007;49(5):717, 725. 3. Lung India. 2014;31(2):179-181. PubMed] Bhardwaj B, Bhardwaj H. Air-fluid level in the right lung.. 2014;31(2):179-181. 4. N Engl J Med. 2009;360(15):1539. PubMed] Koga T, Fujimoto K. Images in clinical medicine. Kerley’s A, B, and C lines.. 2009;360(15):1539. 5. Emerg Radiol. 2012;19(4):309-315. PubMed] Lai V, Tsang W, Chan W, Yeung T. Diagnostic accuracy of mediastinal width measurement on posteroanterior and anteroposterior chest radiographs in the depiction of acute nontraumatic thoracic aortic dissection.. 2012;19(4):309-315.