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Difficulty: Very hardInitial Stabilization and Triage

Emergency medical services arrive at the trauma bay with a 27-year-old male warehouse worker who was crushed between a loading dock and a reversing forklift. On arrival, the patient is obtunded, extremely pale, and diaphoretic. Vital signs include a temperature of 36.1°C (97.0°F), blood pressure of 62/30 mm Hg, heart rate of 152/min, respiratory rate of 38/min, and oxygen saturation of 82% on a 15-L non-rebreather mask. Physical examination reveals tracheal deviation to the left and severely distended neck veins. There are absent breath sounds and hyperresonance to percussion over the right hemithorax. The abdomen is grossly distended, rigid, and diffusely tender to palpation. The pelvis is mechanically stable. Two large-bore intravenous lines are rapidly established. Which TWO of the following are the most appropriate immediate next steps in the stabilization of this patient?

  1. A
    Endotracheal intubation with positive pressure ventilation
  2. Right-sided needle thoracostomyAnswer
  3. Initiation of a massive transfusion protocolAnswer
  4. D
    Urgent computed tomography of the chest, abdomen, and pelvis
  5. E
    Continuous intravenous infusion of norepinephrine

Answer

The most appropriate simultaneous immediate steps are performing a right-sided needle thoracostomy and initiating a massive transfusion protocol.
This patient presents with a rapidly fatal combination of obstructive and hemorrhagic shock following a crush injury. The combination of profound hypotension, tracheal deviation, distended neck veins, and unilateral absent breath sounds is diagnostic of a tension pneumothorax. This represents a critical impairment of breathing and circulation (obstructive shock) that must be treated instantly with a needle or finger thoracostomy to relieve pleural pressure and restore venous return. Simultaneously, the patient's rigid, distended abdomen in the setting of severe hypotension strongly suggests massive intra-abdominal hemorrhage. Immediate resuscitation with a massive transfusion protocol (utilizing uncrossmatched blood products) is required to restore intravascular volume and oxygen-carrying capacity while preparing for emergent laparotomy.

Step-by-Step Solution

1
Analyze the patient's vital signs and physical examination to identify immediate life threats.
The patient exhibits signs of profound shock (BP 62/30 mm Hg, HR 152/min). The right-sided hyperresonance, absent breath sounds, tracheal deviation, and distended neck veins definitively diagnose a right tension pneumothorax (obstructive shock). Simultaneously, the rigid, distended abdomen following a crush injury indicates massive intra-abdominal hemorrhage (hypovolemic shock).
In acute polytrauma, the primary survey must rapidly identify and intervene on life-threatening airway, breathing, and circulation compromises.
2
Determine the necessary life-saving intervention for the identified breathing and obstructive shock emergency.
Right-sided needle thoracostomy or finger thoracostomy must be performed.
Tension pneumothorax prevents venous return to the heart. Immediate mechanical decompression is required to restore cardiac preload.
3
Determine the necessary life-saving intervention for the identified hypovolemic/hemorrhagic shock emergency.
Initiation of a massive transfusion protocol (MTP).
Profound hemorrhagic shock from an acute rigid abdomen requires immediate volume resuscitation with balanced, uncrossmatched blood products to restore oxygen-carrying capacity.

Key Concept

Simultaneous management of concurrent obstructive shock (tension pneumothorax requiring immediate decompression) and hypovolemic shock (intra-abdominal hemorrhage requiring massive transfusion) during the primary trauma survey.
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Topics

Initial Stabilization and Triage

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