135.The answer is e.(Rosen, pp 388-390.)A PTX can be divided into
three classifications: simple, communicating, and tension. A PTX is con-
sidered simple when there is no communication with the atmosphere or
any shift of the mediastinum or hemidiaphragm resulting from the accu-
mulation of air within the pleural cavity. A communicating PTX is associ-
ated with a defect in the chest wall and is sometimes referred to as a
“sucking chest wound.” A tension PTX occurs when air enters the pleural
cavity on inspiration, but cannot exit, which leads to compression of the
vena cava and subsequent decreased cardiac output and hypotension. The
progressive accumulation of air under pressure in the pleural cavity may
lead to a shift of the mediastinum to the contralateral hemithorax.
Patients with a traumatic PTX typically present with shortness of breath,
chest pain, and tachypnea. The physical examination may reveal decreased
or absent breath sounds over the involved side, as well as subcutaneous
emphysema. Any patient with respiratory symptoms in the setting of a PTX
should be treated with a tube thoracostomy (chest tube).The preferred site
for insertion is the fourth or fifth intercostal space at the anterior or mid-
axillary line. The tube should be positioned posteriorly and toward the apex
so that it can effectively remove both air and fluid.
(a)A chest radiograph may be helpful in diagnosing a PTX, however,
the patient is unstable in the setting of blunt trauma and intervention
should not wait for a chest radiograph. If the patient was stable, then a
chest radiograph could be used to confirm the presence of a PTX prior to
chest tube insertion. (b)A pericardiocentesis is a procedure used to remove
fluid from the pericardial sac, such as in the case of pericardial tamponade.
It is more likely to occur after a penetrating trauma to the chest rather than
a blunt trauma. (c)A DPL is used to diagnose fluid in the peritoneum.
Although this may be necessary for this patient, it is important to follow the
ABCs of resuscitation. In this patient, airway and breathing needs to be
addressed first. (d)ED thoracotomy is used in select circumstances, such
as in blunt or penetrating trauma patients who lose their vital signs in
transport to or in the ED.
136.The answer is d.(Rosen, p 349.)Brown-Séquard syndrome or
hemisectionof the spinal cord, typically results from penetrating trauma,
such as a gunshot or knife wound. Patients with this lesion have ipsilateral
motor paralysis and contralateral loss of pain and temperaturedistal to
the level of the injury. This syndrome has the best prognosis for recovery of
all of the incomplete spinal cord lesions.
154 Emergency Medicine