trauama/tension pneumothorax

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Question 1 / 4

683b964d31242d93219d2c17

Emergency

trauama

tension pneumothorax

Case History

A 35-year-old female presents to the emergency department after being the unrestrained driver in a high-speed motor vehicle collision. She is severely dyspneic, agitated, and complaining of excruciating left-sided chest pain. On primary survey, her vital signs are: heart rate 120 bpm, blood pressure 90/60 mmHg, respiratory rate 30 breaths/min, and oxygen saturation 88% on room air. Physical examination reveals an obvious jagged penetrating wound on her left anterior chest wall, from which there is an audible "sucking" sound during inspiration and frothy bloody discharge. Breath sounds are markedly diminished over the left hemithorax with hyper-resonance to percussion. There is no significant jugular venous distention, and her trachea is midline. Considering her clinical presentation, what is the most likely diagnosis, and what initial therapeutic intervention is immediately indicated to prevent a critical complication?

Lab Parameter	Value	Reference Range
White Blood Cell Count (WBC)	14.5 x 10^9/L	4.0-10.0 x 10^9/L
Hemoglobin (Hgb)	11.2 g/dL	12.0-16.0 g/dL
Hematocrit (Hct)	34%	37-47%
Arterial pH	7.28	7.35-7.45
PaCO2	55 mmHg	35-45 mmHg
PaO2	60 mmHg	80-100 mmHg
Lactate	3.5 mmol/L	0.5-2.2 mmol/L

A ) Severe Acute Respiratory Distress Syndrome (ARDS) with indication for immediate rapid sequence intubation for airway protection.

B ) Contusion with underlying atelectasis, requiring non-invasive positive pressure ventilation to improve oxygenation.

C ) Open pneumothorax, requiring immediate application of a three-sided occlusive dressing to the wound to prevent tension pneumothorax.

D ) Suspected tension pneumothorax, necessitating immediate needle decompression at the second intercostal space, mid-clavicular line, followed by tube thoracostomy.

E ) Massive hemothorax, requiring large bore chest tube insertion followed by autotransfusion if possible.

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Question 2 / 4

683b964d31242d93219d2c22

Emergency

trauama

tension pneumothorax

Case History

A 42-year-old man is brought to a rural trauma center after a high-speed frontal impact motor vehicle collision. He is gasping for breath, appears acutely distressed, and his lips are cyanotic with pronounced nasal flaring. Inspection reveals significant bruising across both sides of his chest, and palpation elicits tenderness consistent with multiple rib fractures. His vital signs are: blood pressure 65/40 mm Hg, pulse 150 beats/min and thready, and central venous pressure estimated at 28 cm H2O. His neck veins are markedly distended, and a subtle hint of subcutaneous emphysema is noted in his lower neck and upper chest. On physical examination, the entire left hemithorax is silent to auscultation and profoundly hyperresonant to percussion. The trachea is palpably deviated to the right, and heart sounds are shifted accordingly. Given these findings, what is the most likely diagnosis and the most immediate life-saving intervention required for this patient?

Lab Parameter	Value	Reference Range
pH	7.18	7.35-7.45
PaCO2	60 mmHg	35-45 mmHg
PaO2	55 mmHg	75-100 mmHg
HCO3	24 mEq/L	22-28 mEq/L
WBC count	15,000 /µL	4,500-11,000 /µL

A ) Air embolism from tracheobronchial injuries with immediate initiation of hyperbaric oxygen therapy.

B ) Tension pneumothorax caused by lung puncture with immediate needle thoracostomy at the 2nd intercostal space, midclavicular line.

C ) Flail chest due to multiple rib fractures requiring immediate intubation and mechanical ventilation.

D ) Massive hemothorax from torn intercostal vessels requiring immediate chest tube insertion for drainage and blood transfusion.

E ) Ruptured aorta causing massive mediastinal bleeding with emergent operative repair.

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Question 3 / 4

683b964d31242d93219d2c13

Emergency

trauama

tension pneumothorax

Case History

A 45-year-old woman in the Intensive Care Unit, recovering from severe blunt chest trauma sustained in a motor vehicle collision, suddenly develops profound respiratory distress and hypotension. Her vital signs are BP 78/50 mmHg, pulse 140/min, respiratory rate 38/min, and SpO2 82% on 100% O2 via non-rebreather mask. Physical examination reveals marked jugular venous distension, tracheal deviation to the left, absent breath sounds over the entire right hemithorax, and dullness to percussion on the right. Peripheral pulses are thready. Considering the patient's acute respiratory and hemodynamic compromise, what is the most likely underlying pathology, and what is the immediate, life-saving intervention and its appropriate anatomical site?

Lab Parameter	Value	Reference Range
Hemoglobin	10.5 g/dL	12-16 g/dL
White Blood Cell Count	18.5 x 10^9/L	4.0-11.0 x 10^9/L
Arterial pH	7.20	7.35-7.45
PaCO2	60 mmHg	35-45 mmHg
PaO2	55 mmHg	80-100 mmHg

A ) Tension pneumothorax, requiring emergent needle decompression at the right second intercostal space, midclavicular line.

B ) Tension pneumothorax, requiring emergent needle decompression at the right third intercostal space, midclavicular line.

C ) Massive hemothorax, requiring emergent tube thoracostomy at the right fifth intercostal space, anterior axillary line.

D ) Cardiac tamponade, requiring emergent pericardiocentesis via subxiphoid approach.

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Question 4 / 4

683b964d31242d93219d2c37

Emergency

trauama

tension pneumothorax

Case History

A 45-year-old female construction worker is brought to the trauma bay after a severe fall, landing on her right side, with reports of a steel beam impacting near her chest. She is in acute respiratory distress and appears unresponsive, though she moans to painful stimuli. On rapid assessment, her right hemithorax shows paradoxical movement, with palpable crepitus and absent breath sounds. Her neck veins are markedly distended, and the trachea is noticeably deviated to the left. Vital signs are critically unstable: blood pressure is 80/40 mm Hg, pulse is 130/min and thready, respiratory rate is 30/min and shallow, and oxygen saturation is 85% on a non-rebreather mask. Given these critical findings, what is the most likely diagnosis and the immediate, life-saving intervention indicated, followed by the definitive management approach?

Lab Parameter	Value	Reference Range
White Blood Cell Count	18.5 x 10^9/L	4.5-11.0 x 10^9/L
Hemoglobin	13.2 g/dL	12.0-15.5 g/dL
pH	7.28	7.35-7.45
PaCO2	55 mmHg	35-45 mmHg
PaO2	60 mmHg	75-100 mmHg
Bicarbonate (HCO3)	24 mEq/L	22-26 mEq/L

A ) Diagnosis: Tension pneumothorax; Intervention: Immediate needle decompression at the second intercostal space in the right midclavicular line, followed by definitive tube thoracostomy.

B ) Diagnosis: Pericardial tamponade; Intervention: Emergent pericardiocentesis via subxiphoid approach, with continuous electrocardiographic monitoring.

C ) Diagnosis: Massive hemothorax; Intervention: Rapid intravenous fluid resuscitation and immediate preparation for exploratory thoracotomy.

D ) Diagnosis: Severe acute respiratory distress syndrome (ARDS); Intervention: Urgent endotracheal intubation with initiation of lung-protective mechanical ventilation strategies.

E ) Diagnosis: Neurogenic shock from cervical spine injury; Intervention: Spinal immobilization, vasopressor support, and urgent imaging of the cervical spine.

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