A 29-year-old female, G1P0 at 34 weeks gestation, is brought to the emergency department b… — USMLE Step 3

A 29-year-old female, G1P0 at 34 weeks gestation, is brought to the emergency department by paramedics after being the unrestrained driver in a high-speed motor vehicle collision. The patient was extricated with a rigid cervical collar and is immobilized supine on a backboard. On arrival, she is lethargic and pale. Vital signs are temperature $36.8^\circ \text{C}$ ( $98.2^\circ \text{F}$ ), blood pressure $68/40\text{ mmHg}$ , heart rate $145\text{/min}$ , and respiratory rate $28\text{/min}$ . Oxygen saturation is $88\%$ on a non-rebreather mask. Physical examination reveals a gravid uterus consistent with a third-trimester pregnancy. There is severe ecchymosis over the anterior chest wall. The trachea is deviated to the left. Auscultation reveals absent breath sounds over the right hemithorax and markedly distended neck veins. Her Glasgow Coma Scale score is 11. Which of the following are the most appropriate simultaneous initial steps in the management of this patient? (Select 2 options)

Perform a right-sided needle thoracostomyCevap
Apply manual left lateral uterine displacementCevap
C
Transfer the patient to the radiology suite for a computed tomography scan of the chest and abdomen
D
Perform a focused assessment with sonography for trauma (FAST) examination prior to chest decompression
E
Initiate an intravenous norepinephrine infusion

Cevap

The most appropriate simultaneous initial steps are to perform a right-sided needle thoracostomy and apply manual left lateral uterine displacement.

The patient is presenting with profound obstructive shock caused by two simultaneous, compounding physiological emergencies: a tension pneumothorax and aortocaval compression. The trauma history, combined with absent right-sided breath sounds, tracheal deviation, jugular venous distension, and severe hypotension, clinically confirms a right-sided tension pneumothorax. The massively elevated intrathoracic pressure compresses the superior and inferior vena cava, severely impeding venous return. This requires immediate decompression via a needle or finger thoracostomy. Concurrently, because the patient is 34 weeks pregnant and immobilized in a supine position on a backboard, the heavy gravid uterus is physically compressing the inferior vena cava against the spine. This aortocaval compression drastically reduces preload in pregnant patients. Manual left lateral uterine displacement must be performed immediately (while maintaining spinal precautions) to relieve this obstruction. Addressing only one of these mechanical obstructions may not sufficiently restore cardiac output.

Adım Adım Çözüm

Assess the patient's primary survey (Airway, Breathing, Circulation) and vital signs.

The patient is in profound shock (BP 68/40 mmHg) and hypoxia with tracheal deviation to the left, absent breath sounds on the right, and distended neck veins.

These findings represent the classic triad of a right-sided tension pneumothorax, causing severe obstructive shock.

Identify compounding physiological factors specific to this patient's demographics.

The patient is in her third trimester of pregnancy (34 weeks) and is immobilized supine on a rigid backboard.

In late pregnancy, the heavy gravid uterus compresses the inferior vena cava against the spine when supine, severely reducing venous return (aortocaval compression).

Determine the necessary simultaneous stabilizing interventions to restore cardiac output.

Immediate right-sided needle thoracostomy (or finger thoracostomy) combined with manual left lateral uterine displacement.

Decompressing the chest relieves the intrathoracic obstruction, while displacing the uterus relieves the intra-abdominal vascular obstruction. Both must be addressed immediately to restore venous return and prevent cardiac arrest.

Anahtar Kavram

In a pregnant trauma patient presenting with obstructive shock from a tension pneumothorax, simultaneous management of both the intrathoracic mechanical obstruction (via needle or finger thoracostomy) and the aortocaval compression (via manual left lateral uterine displacement) is critical for initial stabilization.

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