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Chapter 24. Intrathoracic Diseases

A 28-year-old pregnant woman is brought emergently to the emergency department (ED) trauma bay by emergency medical services (EMS) following a head-on motor vehicle accident in which she was the sole occupant of the vehicle. The driver of the other vehicle died at the scene. Upon arrival to the trauma bay, you observe a woman in the advanced stages of pregnancy. She is immobilized in a cervical spine collar on a spinal board. She is crying, and has bilateral cubital fossa intravenous access placed by EMS. Her initial vital signs are a heart rate of 130 bpm, sinus rhythm, noninvasive blood pressure of 70/40 mm Hg, and oxygen saturation (SpO2) of 88% on a 100% oxygen non-rebreather mask. She becomes acutely diaphoretic, and you displace the uterus to the patient’s left side by placing a wedge beneath the spinal board. Her blood pressure improves to 90/65 mm Hg. She complains of severe sternal pain and has marked bruising on her right anterior chest. Auscultation reveals absence of breath sounds and dullness to percussion on the right with normal breath sounds and percussion on the left. What is the next most appropriate step in her management?

A. Obtain an urgent computed tomography (CT) scan of thorax, abdomen, and pelvis

B. Obtain an urgent obstetrics consult

C. Intubate the patient to secure the airway

D. Perform an emergency tube thoracotomy on the right side

D. The woman in this scenario is verbalizing, so her airway is patent. An endotracheal tube is not an obligation at this point. A potential distractor is the fact that she is pregnant. Caval compression has been addressed, and she remains hypotensive in the setting of obvious chest trauma. Her jugular veins are most likely very difficult to assess in the context of the cervical spine collar. The clinical findings on her chest exam are consistent with a significant hemothorax. As per advanced trauma life support (ATLS) guidelines, she is in shock and the diagnosis of a life-threatening hemothorax should be confirmed by the emergent placement of a chest tube. This diagnosis, if time permits, can be confirmed by performing an urgent chest x-ray as an adjunct to the primary survey. Urgent surgical exploration by thoracotomy is indicated if >1.500 mL of blood has accumulated and/or an ongoing production of >200 mL of blood per hour to control the source of bleeding. She is too unstable for safe transfer for more advanced diagnostic imaging.

An 83-year-old woman sustains multiple rib fractures to the right rib cage following a mechanical fall on ice. Which of the following interventions is most likely to prevent respiratory complications from her rib fractures?


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