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Difficulty: HardInitial Stabilization and Triage

A 31-year-old woman is brought to the emergency department after sustaining a stab wound to the left lower chest. On arrival, she is pale, diaphoretic, and confused. Her blood pressure is 72/40 mm Hg, pulse is 142/min, and respirations are 32/min. Oxygen saturation is 92% on 15 L/min of oxygen via a non-rebreather mask. Primary survey reveals a 3-cm penetrating wound in the left sixth intercostal space at the midaxillary line. Breath sounds are markedly decreased on the left. The trachea is midline, and the jugular veins are flat. Bedside extended focused assessment with sonography for trauma (eFAST) reveals a large accumulation of fluid in the left hemithorax, with no pericardial effusion or free intraperitoneal fluid. Two large-bore peripheral intravenous lines are established.

Which of the following are the most appropriate simultaneous next steps in the initial stabilization of this patient? (Select 2)

  1. Activation of the massive transfusion protocolAnswer
  2. Insertion of a left-sided thoracostomy tubeAnswer
  3. C
    Computed tomography angiography of the chest
  4. D
    Administration of a 2-liter intravenous crystalloid bolus
  5. E
    Placement of a central venous catheter for hemodynamic monitoring

Answer

The most appropriate simultaneous next steps are activation of the massive transfusion protocol and insertion of a left-sided thoracostomy tube.
This patient presents with a massive hemothorax and Class IV hemorrhagic shock following a penetrating chest injury. Her confusion, severe hypotension, and profound tachycardia mandate immediate life-saving interventions. The management of an unstable massive hemothorax requires two simultaneous actions: decompression of the pleural space and volume resuscitation. Insertion of a thoracostomy tube (chest tube) serves both diagnostic and therapeutic purposes; it evacuates the accumulated blood, allowing the lung to re-expand and improve ventilation, while also providing a means to monitor the rate of ongoing hemorrhage (which dictates the need for an emergency thoracotomy). Concurrently, because the patient is in profound hemorrhagic shock, resuscitation must be initiated with a massive transfusion protocol (MTP). MTP provides packed red blood cells, fresh frozen plasma, and platelets in a balanced ratio (often 1:1:1), which restores intravascular volume and oxygen-carrying capacity while preventing the dilutional coagulopathy that occurs with crystalloid administration.

Step-by-Step Solution

1
Analyze the patient's hemodynamic status and clinical signs.
The patient is in Class IV hemorrhagic shock (confusion, pulse >140/min, severe hypotension) with a penetrating chest injury.
Identifying the severity of shock dictates the urgency and type of fluid resuscitation required.
2
Correlate physical examination findings with the eFAST results.
Decreased breath sounds on the left, flat neck veins, and fluid in the left hemithorax on ultrasound confirm a massive left hemothorax.
Establishing the source of bleeding and respiratory compromise guides the specific physical intervention.
3
Determine the necessary immediate stabilization interventions.
Simultaneous pleural decompression (tube thoracostomy) and balanced damage-control resuscitation (massive transfusion protocol) are required.
Tube thoracostomy treats the respiratory compromise and measures bleeding, while the massive transfusion protocol treats the hemorrhagic shock without causing dilutional coagulopathy.

Key Concept

In unstable patients with a massive hemothorax, initial stabilization requires simultaneous pleural decompression via tube thoracostomy and damage-control resuscitation using a massive transfusion protocol.
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Topics

Initial Stabilization and Triage

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