Chest trauma: Clinical

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Chest trauma: Clinical

USMLE® Step 2 questions

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USMLE® Step 2 style questions USMLE

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A 55-year-old male presents to the emergency department after falling from a ladder. The patient was standing on a six-foot ladder when he suddenly lost balance, fell, and landed on his right side. He currently reports pain in the shoulder and over the right rib cage. He does not take any medications and does not have other medical conditions. Temperature is 37.0°C (98.6°F), pulse is 101/min, and blood pressure is 132/63 mmHg. Respiratory rate is 20/min and oxygen saturation is 92% on room air. Physical examination reveals decreased breath sounds at the right lung base, as well as a 5 cm x 5 cm area of ecchymosis over the lateral rib cage. A chest CT is obtained, and the results are shown below:

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Which of the following best describes the correct anatomic space for emergent intervention to manage this patient's condition?


Content Reviewers


The chest wall houses a number of vital structures in the body - the heart and the pericardium, the lungs and the pleura, the aorta, and the esophagus - all protected within the rib cage and sternum.

And trauma to the chest wall is responsible for over one-fourth of trauma deaths.

Chest trauma can be blunt, such as from motor vehicle accidents, or penetrating, such as from a stab or gunshot wound.

Chest trauma evaluation starts with the primary survey, which includes the ABCDEs: airway, breathing, circulation, disability, and exposure, and the goal is to quickly assess and treat life-threatening injuries.

It starts with checking the patency of the airway and whether the individual requires endotracheal intubation.

As for breathing, you can look, listen, and feel.

So look at the respiratory rate, oxygen saturation, and breathing pattern.

If the person is hypoxemic, a 100% oxygen non-rebreather mask should be given.

Also if there’s asymmetric breathing it could indicate a weak chest segment due to rib fractures.

Next, listen for breath sounds for signs like decreased air entry in tension pneumothorax or hemothorax, or muffled heart sounds in cardiac tamponade.

After that feel for tenderness along the chest wall, which can occur with rib fractures.

In circulation, check the blood pressure and heart rate.

If there are signs of shock it could be due to a number of causes like bleeding into the pleura or pericardium, obstruction of cardiac output in the setting of a tension pneumothorax, or inadequate cardiac output in the setting of myocardial injury.


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