Examkin

Question

Difficulty: Very hardSurgical and Procedural Interventions

A 24-year-old man is brought to the emergency department 15 minutes after sustaining a gunshot wound. The entrance wound is located in the left fifth intercostal space at the midclavicular line. There is no exit wound.

Vital signs on arrival:
- Blood pressure: 76/40 mm Hg
- Heart rate: 138/min
- Respiratory rate: 32/min
- Oxygen saturation: 86% on room air

Primary survey reveals flat neck veins and a midline trachea. There are absent breath sounds and dullness to percussion over the left hemithorax. The abdomen is exquisitely tender with diffuse rigidity and involuntary guarding.

Large-bore intravenous access is established, the massive transfusion protocol is activated, and the patient is rapidly intubated for airway protection. His blood pressure remains 76/40 mm Hg following intubation.

Which of the following are REQUIRED immediate procedural interventions for this patient? (Select all that apply)

  1. Placement of a left-sided tube thoracostomyAnswer
  2. Emergent exploratory laparotomyAnswer
  3. C
    Computed tomography (CT) angiography of the chest and abdomen
  4. D
    Left anterolateral resuscitative thoracotomy in the emergency department
  5. E
    Diagnostic peritoneal lavage (DPL)

Answer

The most appropriate immediate interventions are placement of a left-sided tube thoracostomy and emergent exploratory laparotomy.
The patient has sustained a penetrating injury to the thoracoabdominal box. The combination of dullness to percussion and absent breath sounds indicates a massive hemothorax, requiring immediate placement of a tube thoracostomy. Concurrently, the presence of a rigid abdomen with involuntary guarding in a hemodynamically unstable patient represents an absolute indication for emergent exploratory laparotomy. Both procedures must be executed to achieve definitive source control and stabilize the patient.

Step-by-Step Solution

1
Analyze the wound location relative to internal anatomy.
The wound is in the 5th intercostal space. During expiration, the diaphragm can rise to the 4th intercostal space anteriorly. Therefore, this is a thoracoabdominal injury capable of affecting both thoracic and abdominal cavities.
Accurate anatomic localization determines the compartments at risk for hemorrhage.
2
Interpret the thoracic examination findings.
Absent breath sounds and dullness to percussion on the left, combined with hypoxia and flat neck veins, indicate a massive hemothorax.
Identifies the cause of respiratory failure and guides thoracic intervention.
3
Interpret the abdominal examination findings.
Diffuse rigidity, rebound tenderness, and involuntary guarding indicate acute peritonitis from an intra-abdominal injury.
Establishes an absolute indication for abdominal exploration.
4
Synthesize findings to select the immediate procedures.
The patient requires simultaneous decompression of the chest (tube thoracostomy) and surgical control of abdominal hemorrhage (exploratory laparotomy).
Definitive management of hemorrhagic shock requires immediate source control in all affected compartments.

Key Concept

Patients with penetrating trauma to the thoracoabdominal box (between the 4th intercostal space and costal margins) are at risk for both thoracic and abdominal injuries. Hemodynamically unstable patients with peritonitis require immediate exploratory laparotomy, and concurrent massive hemothorax must be treated with tube thoracostomy. Advanced imaging and resuscitative thoracotomy are contraindicated in hypotensive but non-arrested patients.
Estimated Time:1m 30s
Rate this question

Topics

Surgical and Procedural Interventions

More questions from this topic