A 20-year-old man was stabbed in the chest during a street fight. Blood pressure is 90/58 mm Hg, pulse is 124/min, and respirations are 30/min. The patient is in severe respiratory distress. Breath sounds are present on the left and absent on the right. Heart sounds are normal. The neck veins are distended. The patient becomes obtunded during examination. Which of the following is the best next step in management?

Question

A 20-year-old man was stabbed in the chest during a street fight.  Blood pressure is 90/58 mm Hg, pulse is 124/min, and respirations are 30/min.  The patient is in severe respiratory distress.  Breath sounds are present on the left and absent on the right.  Heart sounds are normal.  The neck veins are distended.  The patient becomes obtunded during examination.  Which of the following is the best next step in management?

Quizplus · Accepted Answer

11ec25c8_d855_a198_bc81_978f083e1b36_MD0003_00 This patient who was stabbed in the chest has respiratory distress and right-sided absent breath sounds accompanied by hypotension and distended neck veins. This is concerning for tension pneumothorax (TP). TP develops when accumulated air (due to injured lung tissue) causes high intrathoracic pressure that compresses the vena cava and impedes cardiac venous return, resulting in decreased cardiac output and hypotension. This occurs when a one-way valve has formed, allowing air to flow into the pleural space during inspiration but trapping it during expiration. When TP is suspected, decompression (eg, needle thoracostomy) should be performed immediately to prevent cardiovascular collapse. Needle thoracostomy can be performed quickly and should precede intubation. This is an important exception to the typical order of establishing the airway first (ie, airway, breathing, circulation) but is necessary because positive-pressure ventilation (eg, intubation and mechanical ventilation) rapidly increases accumulated air and intrathoracic pressure, exacerbating TP and causing cardiovascular collapse (Choice C). Following needle decompression, tube thoracostomy is required for definitive pneumothorax management. (Choice A) Needle decompression precedes establishing a means of further ventilation in the specific case of TP. In addition, although cricothyroidotomy is sometimes used to establish an emergency airway (eg, upper airway obstruction or hemorrhage), this patient can likely undergo endotracheal intubation once the TP is decompressed. (Choice B) Emergency department thoracotomy (ie, rapidly gaining intrathoracic access) is a heroic measure to resuscitate penetrating trauma patients with witnessed or imminent cardiac arrest (eg, via open cardiac massage, aortic clamping). Although this patient may be on the verge of cardiovascular collapse from TP, needle decompression is a more appropriate and less invasive next step. (Choice E) Although cardiac tamponade (which can be treated by pericardiocentesis) may cause hypotension with distended neck veins, TP is more likely given this patient's absent right-sided breath sounds and normal (rather than muffled) heart sounds. (Choice F) This patient may eventually require rapid volume resuscitation, but the TP (rather than bleeding) may be primarily responsible for his hypotension. Decompression of the TP should occur first to restore normal cardiac venous return and prevent cardiovascular collapse, after which it will be easier to determine the degree of fluid resuscitation required. Educational objective: Positive-pressure ventilation can rapidly exacerbate tension pneumothorax (TP) and cause cardiovascular collapse. Therefore, decompression (eg, needle thoracostomy) should be performed prior to intubation for patients with TP who also need airway protection-an important exception to the typical order. References: Penetrating trauma. (http://www.ncbi.nlm.nih.gov/pubmed/25337403) Pneumothorax: from definition to diagnosis and treatment. (http://www.ncbi.nlm.nih.gov/pubmed/25337391)

A 20-Year-Old Man Was Stabbed in the Chest During a Street