04-14-2007, 02:00 PM
A 47-year-old man is brought into the emergency department by ambulance after a motor vehicle accident. He is conscious, alert and, besides the lacerations on his scalp, he seems to be otherwise well. His neck is stabilized by a brace and he asks you to remove it. You assess his neurologic exam to be non-focal, but you obtain cervical neck films anyway. No cervical spine abnormalities are noted and you remove the cervical collar. Suddenly, the patient's pulse rises to 130/min, his blood pressure drops to 80/50 mm Hg, and his respiratory rate increases to 35/min. His physical examination reveals jugular venous distension, peripheral and perioral cyanosis, absent breath sounds on the left side of his chest, a tachycardic but otherwise normal cardiac examination, and a tender abdomen in the left upper quadrant. The most appropriate initial step is to
A. insert a needle thoracostomy into the second intercostal space
B. insert a tube thoracostomy into the pleural space
C. intubate the patient for hypoxemic respiratory failure
D. order a portable chest x-ray
E. perform a diagnostic peritoneal lavage for a splenic rupture
A. insert a needle thoracostomy into the second intercostal space
B. insert a tube thoracostomy into the pleural space
C. intubate the patient for hypoxemic respiratory failure
D. order a portable chest x-ray
E. perform a diagnostic peritoneal lavage for a splenic rupture