A patient is admitted to the emergency department following an assault.

You note a penetrating wound on the

anterior chest wall. On examination, his blood pressure is 80/65 mmHg, pulse is thready and respiratory rate is
38 breaths/min. His jugular venous pulse is unrecognizable as the neck veins are grossly distended. Breath
sounds are equal bilaterally. During your evaluation the patient’s output becomes undetectable. The next course
of action should be:
A. Thoracocentesis
B. Plain chest radiograph
C. Pericardiocentesis
D. Resuscitative thoracotomy
E. Echocardiogram

Beck’s triad consists of venous pressure elevation, reduced arterial blood

pressure and muffled heart sounds. These three features are the classic
identifying features of cardiac tamponade. In addition, an exaggerated
pulsus paradoxus (a fall in arterial blood pressure >10 mmHg on
spontaneous inspiration) and Kussmaul’s sign (rising venous pressure on
spontaneous inspiration) are also signs of tamponade. Knowing this,
candidates can correctly identify tamponade as the likely diagnosis in this
scenario.
The next thing to recognize is that this patient is peri-mortem. There are
two methods used to confirm the diagnosis of tamponade:
echocardiography in the form of a FAST (focused assessment with
sonography for trauma) scanner is less invasive but has a false negative
rate of 10 per cent even in experienced hands. In a patient as
compromised as the scenario suggests, with a convincing history of
penetrating chest injury, pericardiocentesis is both diagnostic and
therapeutic, and should not be delayed by other diagnostic adjuncts.
Resuscitative thoracotomy may be required but is the reserve of surgeons
experienced enough to perform such a procedure. Pericardiocentesis
should be attempted first to allow time for a more controlled surgical
management. Thoracotomy or a pericardial window procedure should be
reserved for cases where pericardiocentesis fails.

Flail chest is a term used to describe an injury to the chest wall which
results in a section losing continuity with the remainder. This loose
segment is therefore sucked in by the negative pressures implicit in
inspiration, preventing effective respiration and causing significant
damage to the underlying lung parenchyma. These two factors combined
result in significant impairment of gas exchange and respiratory failure.
Analgesia will improve the patient’s pain but since the respiratory failure
is not due to pain restricting breathing it will not save this patient’s life.
Fluid resuscitation is a complicated issue in these patients; a careful
balance must be struck as the injured lung is vulnerable to fluid overload,
which only exacerbates the poor gas exchange. High-flow oxygen will
partially reverse the hypoxia but is only a holding measure and will not
affect the carbon dioxide retention. This patient requires mechanical
ventilation and therefore the placement of a definitive airway. Both
endotracheal intubation and cricothyroidotomy will provide this, but
surgical airways are reserved for cases in which intubation fails or is
impossible due to severe facial injury. Therefore, endotracheal intubation
is the best option for this case.

Aortic rupture is a common cause of sudden death following

suddendeceleration
injuries occurring in traffic collisions or after falls from
height. The point of disruption in the wall of the aorta is at the
ligamentum arteriosum, across which the aorta may kink or twist, causing
dissection or rupture.
Rupture into the left side of the chest is nearly universally fatal, unless it
occurs in the emergency department itself. In those who survive, the
haematoma is retained either within the adventitia or within the
mediastinum. Features on a chest radiograph include:
• widening of the mediastinum
• loss of the aortic knuckle
• deviation of the trachea to the right
• obliteration of the space between the aorta and pulmonary artery
(the AP window)
• depression of the left main bronchus
• left-sided haemothorax.
Rarely, in 1–2 per cent of cases, following great vessel disruption there
will be no signs evident on plain radiographs.