A 45-year-old man is involved in a high-speed automobile collision. He arrives at the ER in
coma, with fixed dilated pupils. He has multiple other injuries (extremities, etc). His blood
pressure is 70 over 50, with a feeble pulse at a rate of 130. What is the reason for the low BP and
high pulse rate?
Point of the question: It is not from neurological injury. (Not enough room in the head for enough
blood loss to cause shock). Look for answer of significant blood loss to the outside (could be
scalp laceration), or inside (abdomen, pelvic fractures).
6. – A 22-year-old gang member arrives in the E.R. with multiple guns shot wounds to the abdomen.
He is diaphoretic, pale, cold, shivering, anxious, asking for a blanket and a drink of water. His
blood pressure is 60 over 40. His pulse rate is 150, barely perceptible.
What is it? – Hypovolemic shock
Management: Several things at one: Big bore IV lines, Foley catheter and I.V. antibiotics. Ideally
exploratory lap immediately for control of bleeding, and then fluid and blood administration. If
O.R. not available, fluid resuscitation while waiting for it.
7. – A 22-year-old gang member arrives in the E.R. with multiple gun shot wounds to the chest and
abdomen. He is diaphoretic, pale, cold, shivering, anxious, asking for a blanket and a drink of
water. His blood pressure is 60 over 40. His pulse rate is 150, barely perceptible.
What is it? – Hypovolemic shock still the best bet, but the inclusion of chest wounds raises
possibility of pericardial tamponade or tension pneumothorax. As a rule if significant findings are
not included in the vignette, they are not present. Thus, as given this is still a vignette of
hypovolemic shock, but you may be offered in the answers the option of looking for the missing
clinical signs: distended neck veins (or a high measured CVP) would be common to both
tamponade and tension pneumo; and respiratory distress, tracheal deviation and absent breath
sounds on a hemithorax that is resonant to percussion would specifically identify tension
pneumothorax.
8. – A 22-year-old gang member arrives in the E.R. with multiple guns shot wounds to the chest and
abdomen. He is diaphoretic, cold, shivering, anxious, asking for a blanket and a drink of water.
His blood pressure is 60 over 40. His pule rate is 150, barely perceptible. He has big distended
veins in his neck and forehead. He is breathing OK, has bilateral breath sounds and no tracheal
deviation.
What is it? – Pericardial tamponade
Management: No X-Rays needed, this is a clinical diagnosis!. Do Pericardial window. If positive,
follow with thoracotomy, and then exploratory lap.
9. – Identical to the previous one, but with only a single gunshot wound in the precordial area: when
the location of the wound strongly suggests pericardial tamponade, emergency thoracotomy might
be done right away without prior pericardial window.
- – A 22-year-old gang member arrives in the E.R. with multiple gun shot wounds to the chest and
abdomen. He has labored breathing is cyanotic, diaphoretic, cold and shivering. His blood
pressure is 60 over 40. His pulse rate is 150, barely perceptible. He is in respiratory distress, has
big distended veins in his neck and forehead, his trachea is deviated to the left, and the right side
of his chest is tympantic, with no breath sounds.
What is it? – Tension pneumothorax.
Management: Immediate big bore IV catheter placed into the right pleural space, followed by
chest tube to the right side, right away! Watch out for trap that offers chest X-Ray as an option.
This is a clinical diagnosis, and patient needs that chest tube now. He will die if sent to X-Ray.
Exploratory lap will follow.
11. – A 72 year old man who lives alone calls 911 saying that he has severe chest pain. He cannot
give a coherent history when picked up by the EMT, and on arrival at the ER he is cold and
diaphoretic and his blood pressure is 80 over 65. He has an irregular, feeble pulse at a rate of 130.
His neck and forehead veins are distended and he is short of breath.
What is it? – Many findings similar to above cases, but no trauma, old man, chest pain: i.e.:
straightforward cardiogenic shock, from massive MI.
Management: verify high CVP. EKG, enzymes, coronary care unit etc. Do not drown him with
enthusiastic fluid “resuscitation”, but use thrombolytic therapy if offered.
12. – A 17 year old girl is stun by a swarm of bees…or a man of whatever age breaks out with hives
after a penicillin infection…or a patient undergoing surgery under spinal anesthetic…eventually
develop BP of 75 over 25, pulse rate of 150, but they look warm and flush rather than pale and
cold. CVP is low.
What is it? – Vasomotor shock (massive vasodilation, loss of vascular tone)
Management: Vasoconstrictors. Volume replacement would not hurt.
13. – A 25-year-old man is stabbed in the right chest. He is moderately short of breath, has stable
vital signs. No breath sounds on the right. Resonant to percussion.
What is it? – Plain pneumothorax.
How is diagnosis verified? There is time to get a chest X-Ray if the option if offered.
Treatment: Chest tube to underwater seal and suction. If given option for location, high in the
pleural cavity.
14. – A 25-year-old man is stabbed in the right chest. He is moderately short of breath, has stable
vital signs. No breath sounds on at the base on the right chest, faint distant breath sounds at the
apex. Dull to percussion.
What is it? – Sounds more like hemothorax.
How do we find out? - Chest X-Ray
If confirmed, treatment is chest tube on the right, at the base of the pleural cavity.
15. – A 25-year-old man is stabbed in the right chest. He is moderately short of breath, has stable
vital signs. No breath sounds on at the base on the right chest, faint distant breath sounds at the
apex. Dull to percussion. A chest tube placed at the right pleural base recovers 120 cc of blood,
drains another 20 c in the next hour.
Further treatment: The point of this one is that most hemothoraxes do not need exploratory
surgery. Bleeding is from lung parenchyma (low pressure), stops by itself. Chest tube is all that
is needed. Key clue: little blood retrieved, even less afterwards.
16. – A 25-year-old man is stabbed in the right chest. He is moderately short of breath, has blood
pressure is 95 over 70, pulse rate of 100. No breath sounds on at the base on the right chest, faint
distant breath sounds at the apex. Dull to percussion. A chest tube placed at the right pleural base
recovers 1250 cc of blood…(or it could be only 450 cc at the outset, but followed by another 420
cc in the next hour and so on).
Further treatment: The rare exception who is bleeding from a systemic vessel (almost invariably
intercostal). Will need thoracotomy to ligate the vessel.
17. – A 25-year-old man is stabbed in the right chest. He is moderately short of breath, has stable
vital signs. No breath sounds on the right. Resonant to percussion at the apex of the right chest,
dull at the base. Chest X-Ray shows one single, large air-fluid level.
What is it? – Hemo-pneumothorax. Chest tube, surgery only if bleeding a lot.
18. – A 33-year-old lady is involved in a high-speed automobile collision. She arrives at the E.R.
gasping for breath, cyanotic at the lips, with flaring nostrils. There are bruises over both sides of
the chest, and tenderness suggestive of multiple fractured ribs. Blood pressure is 60 over 45.
Pulse rate 160, feeble. She has distended neck and forehead veins, is diaphoretic. Left hemithorax
has no breath sounds, is tympanitic to percussion.
What is it? – A variation on an old theme: classic picture for tension pneumothorax…but Where is
the penetrating trauma? : The fractured rubs can act as a penetrating weapon.
Management: chest tube to the left right away! Do not fall for the option of getting X-Rays first,
but you need them later to rule out wide mediastinum (aortic rupture).
19. – A 54-year-old lady crashes her car against a telephone pole at high speed. On arrival at the E.R.
she is in moderate respiratory distress. She has multiple bruises over the chest, and multiple site
of point tenderness over the ribs. X-Rays show multiple rib fractures on both sides. On closer
observation it is noted that a segment of the chest wall on the left side caves in when she inhales,
and bulges out when she exhales.
What is it? – Classical physical diagnosis finding of paradoxical breathing, leading to classical
diagnosis of flail chest. She is at high risk for other injuries.
Management: Rule out other injuries (aortic rupture, abdominal injuries) The real problem is flail
chest is the underlying pulmonary-contusion, for which the treatment is controversial, including
fluid restriction, diuretics, use of colloid rather than crystalloid fluids when needed, and
respiratory support. The probable wrong alternatives will revolve around various ways of
mechanically stabilizing the part of the chest wall that moves the wrong way…because that used
to be what was believed in the past.
Further management: if other injuries require that she go to the OR, prophylactic bilateral chest
tubes because she is at high risk to develop tension pneumothorax when under the positive
pressure breathing of the anesthetic.
20. – A 54-year-old lady crashes her car against a telephone pole at high speed. On arrival at the E.R.
she is breathing well. She has multiple bruises over the chest and multiple sites of point
tenderness over the ribs. X-Rays show multiple rib fractures on both sides, but the lung
parenchyma is clear and both lungs are expanded. Two days later her lungs “white out” on XRays and she is in respiratory distress.
What is it? – Pulmonary contusion. It does not always show up right away, may become evident
one or two days after the trauma.
Management: Fluid restriction (using colloid), diuretics, respiratory support. The latter is key,
with intubation, mechanical ventilation and PEEP if needed.
21. – A 54-year-old lady crashes her car against a telephone pole at high speed. On arrival at the E.R.
she is breathing well. She has multiple bruises over the chest, and is exquisitely tender over the
sternum at a point where there is a crunching feeling of crepitation elicited by palpation.
What is it? – Obviously a sternal fracture…but the point is that she is at high risk for myocardial
contusion and for traumatic rupture of the aorta.
Further tests: as you would do for a MI : EKG, cardiac enzymes, but the real important ones
would be CT scan, transesophageal echo or arteriogram looking for aortic rupture.
22. – A 53-year-old man is involved in a high-speed automobile collision. He has moderate
respiratory distress. Physical exam shows no breath sounds over the entire left chest. Percussion
is unremarkable. Chest X-Ray shows air fluid levels in the left chest.
What is it? – Classical for traumatic diaphragmatic rupture. It is always on the left.
Further test? Not really needed. A nasogastric tube curling up into the left chest might be an
added tid bit.
Management: Surgical repair.
23. – A motorcycle daredevil attempts to jump over the 12 fountains in front of Caesar’s Palace Hotel
in Las Vegas. As he leaves the ramp at very high speed his motorcycle turns sideways and he hits
the retaining wall at the other end, literally like a rag doll. At the Er. he is found to be remarkably
stable, although he has multiple extremity fractures. A chest X-Ray shows fracture of the left first
rib and widened mediastinum.
What is it? – Actually a real case. Classical for traumatic rupture of the aorta: King size trauma,
fracture of a hard-to-break bone (it could first rib, scapula or sternum) and the tell-tale hint of
widened mediastinum
How is the diagnosis made? – Arteriogram (aortogram).
Treatment: Emergency surgical repair.
24. – A 34-year-old lady suffers severe blunt trauma in a car accident. She has multiple injuries to her
extremities, has head trauma and has a pneumothorax on the left. Shortly after initial examination
it is noted that she is developing progressive subcutaneous emphysema all over her upper chest
and lower neck.
What is it? – Traumatic rupture of the trachea or major bronchus.
Additional findings: Chest X-Ray would confirm the presence of air in the tissues.
Management: Fiberoptic bronchoscopy to confirm diagnosis and level of injury and to secure an
airway. Surgical repair after that.