A 26-Year-Old Man Who Has Been in a Motor Vehicle Collision

Sara W. Nelson, MD; Daniel M. Lindberg, MD


August 31, 2016

Physical Examination and Workup

On arrival to the hospital, the patient is ill-appearing and combative. His initial vital signs are a heart rate of 117 beats/min, a blood pressure of 85/50 mm Hg, a respiratory rate of 32 breaths/min, and an oxygen saturation of 91% on the nonrebreather mask. Upon primary survey, his oropharynx is clear, his airway is patent, and his trachea appears to be shifted to the right of midline. Upon auscultation, the patient's breath sounds are decreased over the left chest. Percussion of the left chest demonstrates hyperresonance. His carotid pulse is weakly palpable, and his jugular venous pulse is elevated. The patient has a Glasgow Coma Scale score of 12. The patient's clothing is removed, revealing no obvious deformities or areas of bleeding. The patient's abdomen is soft, without any tenderness to palpation. His pelvis is stable. Standard trauma radiographs, including an anteroposterior chest and pelvis scan, are performed after the primary survey. A complete secondary survey is postponed because of the patient's poor clinical condition.

Figure 1.

A second large-bore peripheral intravenous line is placed, and the patient begins to receive a bolus of 1000 cc of normal saline under pressure. A decision to perform an emergent procedure is made. Immediately after the procedure is performed, the patient is noted to have a dramatic clinical improvement. Subsequent to the procedure, the patient has a pulse of 105 beats/min, a blood pressure of 95/60 mm Hg, a respiratory rate of 22 breaths/min, and an oxygen saturation of 98% on the nonrebreather mask.

The secondary survey is completed, revealing no major injuries. Additionally, the chest radiograph (Figure) confirms the suspected clinical diagnosis that prompted the emergent procedure.


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