Examkin

Question

Difficulty: MediumCardiothoracic and Vascular Surgery

A 28-year-old male is brought to the emergency department via ambulance after being struck by a motor vehicle. He is confused and complains of severe right-sided chest pain and difficulty breathing. His blood pressure is 75/4575/45 mm Hg, heart rate is 135135/min, and respiratory rate is 2828/min. Oxygen saturation is 88%88\% on room air. Physical examination reveals large abrasions and severe bruising over the right lateral chest wall. The trachea is deviated to the left. Examination of the right hemithorax demonstrates decreased tactile fremitus, dullness to percussion, and absent breath sounds. The jugular veins are flat. Which of the following is the most appropriate next step in management?

  1. Tube thoracostomyAnswer
  2. B
    Computed tomography angiography of the chest
  3. C
    Needle thoracostomy in the right second intercostal space
  4. D
    Ultrasound-guided pericardiocentesis
  5. E
    Observation with continuous cardiopulmonary monitoring and packed red blood cell transfusion

Answer

Tube thoracostomy
The correct answer is tube thoracostomy. This patient presents with a classic massive hemothorax following blunt chest trauma. The hallmark signs include hemodynamic instability, respiratory distress, absent breath sounds on the affected side, and dullness to percussion due to the accumulation of blood in the pleural space. The flat jugular veins confirm that the shock is hypovolemic (hemorrhagic) rather than obstructive. The immediate next step in management is the placement of a large-bore chest tube (tube thoracostomy) to drain the blood, re-expand the lung, and monitor the rate of ongoing hemorrhage, alongside aggressive volume resuscitation.

Step-by-Step Solution

1
Analyze the vital signs and primary survey.
The patient is in shock (hypotension, tachycardia) and acute respiratory distress following blunt trauma.
To determine if the patient requires immediate life-saving procedural intervention versus further diagnostic imaging.
2
Evaluate the specific physical examination findings of the chest.
There is tracheal deviation to the left, dullness to percussion, and absent breath sounds on the right, accompanied by flat jugular veins.
To differentiate between major causes of thoracic trauma. Dullness indicates fluid (blood), while hyperresonance would indicate air (pneumothorax).
3
Synthesize the findings to establish the diagnosis and next step.
The combination of hypovolemic shock, flat neck veins, and a dull right hemithorax indicates a massive hemothorax. The appropriate definitive next step is tube thoracostomy.
A chest tube will immediately drain the blood, re-expand the lung, correct the mediastinal shift, and allow the trauma team to quantify the bleeding.

Key Concept

Massive hemothorax presents with hemorrhagic shock, flat neck veins, absent breath sounds, and dullness to percussion. The immediate treatment is tube thoracostomy.
Estimated Time:1m 15s
Rate this question

Topics

Cardiothoracic and Vascular Surgery

More questions from this topic