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Difficulty: MediumTrauma and Burns

Emergency medical personnel bring a 35-year-old female to the trauma center after she was struck by a fast-moving delivery van while riding her bicycle. She is in severe distress and gasping for air.

Vital signs on arrival are:
Temperature: 36.4°C (97.5°F)
Blood pressure: 78/42 mmHg
Pulse: 142/min
Respirations: 34/min
Oxygen saturation: 86% on room air

Initial evaluation reveals an intact and patent airway. Examination of the chest shows asymmetrical expansion, with absent breath sounds and hyperresonance to percussion over the right hemithorax. The trachea appears deviated toward the left side, and the jugular veins are significantly distended. The abdomen is diffusely tender and distended. A focused assessment with sonography for trauma (FAST) demonstrates a substantial accumulation of free fluid in the hepatorenal recess.

Which of the following is the most appropriate immediate next step in the management of this patient?

  1. Needle thoracostomy of the right hemithoraxAnswer
  2. B
    Immediate exploratory laparotomy
  3. C
    Multidetector computed tomography of the torso
  4. D
    Endotracheal intubation with positive pressure ventilation
  5. E
    Bedside echocardiography and pericardiocentesis

Answer

Needle thoracostomy of the right hemithorax
The correct answer is decompression of the right hemithorax via needle thoracostomy. This patient presents with multiple life-threatening injuries: a right-sided tension pneumothorax (indicated by severe respiratory distress, absent breath sounds, hyperresonance to percussion, tracheal deviation, and jugular venous distension) and intra-abdominal hemorrhage (indicated by a distended, tender abdomen with a positive FAST examination). Both conditions contribute to her severe hemodynamic instability (hypotension and tachycardia). The Advanced Trauma Life Support (ATLS) primary survey dictates a strict ABCDE sequential order: Airway, Breathing, Circulation, Disability, and Exposure. Because 'Breathing' precedes 'Circulation', the tension pneumothorax must be treated immediately with needle or tube thoracostomy before the intra-abdominal hemorrhage is addressed with an exploratory laparotomy. Furthermore, if this patient were intubated and given positive pressure ventilation for surgery before decompressing the chest, the increased intrathoracic pressure would drastically reduce venous return and rapidly precipitate complete cardiovascular collapse.

Step-by-Step Solution

1
Evaluate the primary survey findings to identify all life-threatening injuries.
The patient has signs of a tension pneumothorax (absent right breath sounds, hyperresonance, tracheal deviation, jugular venous distension) and intra-abdominal hemorrhage (positive FAST, tender abdomen, hypotension).
Identifying all acute threats is necessary to properly prioritize subsequent interventions.
2
Apply the Advanced Trauma Life Support (ATLS) ABCDE algorithm to prioritize management.
Airway (A) is intact. Breathing (B) is compromised by a tension pneumothorax. Circulation (C) is compromised by hemorrhagic shock from the intra-abdominal injury.
ATLS protocols dictate that injuries must be addressed in sequential order: Airway, then Breathing, then Circulation.
3
Select the most appropriate immediate intervention based on the established ATLS priority.
The tension pneumothorax (Breathing abnormality) must be decompressed via needle or tube thoracostomy before performing an exploratory laparotomy (Circulation abnormality).
Failing to decompress a tension pneumothorax before proceeding to surgery or initiating positive pressure ventilation will lead to immediate and fatal cardiovascular collapse.

Key Concept

In polytrauma patients, the ATLS algorithm requires securing the Airway and Breathing (e.g., decompressing a tension pneumothorax) before addressing Circulation (e.g., performing an exploratory laparotomy for hemoperitoneum).
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Topics

Trauma and Burns

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