PHYSIOLOGY

A 45-year-old obese woman developed dyspnea and shortness of breathing after chest trauma due to
road traffic accidents. Initial assessment shows blood pressure 132/90 mmHg, heart rate 92/min, and O2
saturation 94% on room air. Suddenly her pulse increases from 92 to 140/min; systolic Blood Pressure
drops from 132 to 90 mm Hg; jugular vein congested. On chest examination, breath sounds are absent
on the left side. What is the most likely physiological explanation that can occur with this woman?

A) Decrease right ventricular filling

B) Increase cardiac preload
C) Decrease central venous pressure
D) Increase oxygen partial pressure
E) Increase diastolic blood pressure

Answer: A
A) The history and clinical findings of this case are typical of Tension pneumothorax.
Tension pneumothorax is a possible complication of chest trauma due to RTA. The rapid collapse of the
lung and compression of the mediastinum can lead to impaired right ventricular filling.

B) Increase cardiac preload incorrect option due to mediastinal shifting away from the pressure. This
results in compression of the vena cava leading to decreased venous return and decreased cardiac
preload.

C) Decrease central venous pressure incorrect and can increase result in distended neck veins, and
hypotension.

D) Lungs have a tendency to collapse due to elastic recoil. Pneumothorax enlarges, and the lung gets
smaller due to this vital capacity and leads to oxygen partial pressure decreases.

E) Increase diastolic blood pressure is not occur and can lead to a decrease in diastolic blood pressure
due to decreased venous return and decreased cardiac preload.

Key point:

pneumothorax is a possible complication of chest trauma due to RTA. when high PEEP is used. The chest
trauma leads to the rupture of the lung parenchyma and compression of the mediastinum results in the
impaired right ventricular filling, decreased cardiac preload, increase in central venous pressure, and
oxygen partial pressure decreases.

Briel M, Meade M, Mercat A, et al. Higher, lower positive end-expiratory pressure in patients with acute
lung injury and acute respiratory distress syndrome: systematic review and meta-analysis. JAMA. 2010
Mar 3; page 865

CARDIOLOGY
A 28-year-old, healthy woman is presented to the emergency room after a stab wound to the fifth left
intercostal space in the midclavicular line. On initial examination: a pulse of 140/min, Blood pressure
80/40 mmHg, and the respiratory rate are 20/min. The o2 saturation is 91% on 8L oxygen on the pulse
oximeter. Her trachea is midline, heart sounds appear distant on auscultation, and breath sounds are
equal bilaterally. According to your diagnosis, what is the most appropriate next step in management for
this woman?

(A) Intubation and assisted ventilation

(B) Emergency department thoracotomy
(C) Pericardiocentesis
(D) Rapid infusion of an IV fluid bolus
(E) chest tube

Answer: C
C) Cardiac tamponade results from the rapid accumulation of fluid in the pericardial sac, compromising
cardiac filling and resulting in decreased cardiac output. The clinical findings of tachycardia,
hypotension, and distant heart sounds in the presence of penetrating chest trauma should alert the
physician to this diagnosis. Patients may also demonstrate JVD from a decreased venous return to the
right heart, and diminished pulse pressure. Penetrating stab trauma with an entry wound in this location
(fifth intercostal space midclavicular line) would be unlikely to injure the descending aorta.
Pericardiocentesis is the best choice for this case and should be the first step in management. Aspiration
of as little as 10–20 Ml may improve the patient’s hemodynamic status. Once stabilized, the patient
should be transferred to the operating room for definitive management of the underlying penetrating
cardiac injury.

A) Intubation and assisted ventilation is not required because this patient does not have a respiratory
compromise.

B) Emergency department thoracotomy is reserved for patients with penetrating chest trauma who
arrive in the emergency department with measurable vital signs and subsequently suffer
cardiopulmonary arrest. The thoracotomy permits open cardiac massage, and attempt at manual control
of blood loss from the site of injury, in preparation for rapid transfer to the operating room.

D) Rapid infusion of an IV fluid bolus may not respond and requires urgent pericardial decompression to
improve venous return and cardiac output.

E) Chest tube is not required because this patient does not have a respiratory compromise.

Key point:
If the patient presents with Penetrating trauma in (fifth intercostal space midclavicular line) associated
with clinical findings of tachycardia, hypotension, and distant heart sounds, the Cardiac tamponade is
the most likely diagnosis. Pericardiocentesis should be the first step in management. Aspiration of as
little as 10–20ml may improve the patient’s hemodynamic status. Then, should be transferred to the
operating room for definitive management.

Schwartz's Manual of Surgery, 8th edition, page 72-73