An automobile driver was brought into the trauma center after a high-speed car accident. There was no air bag deployment and there is a steering wheel pattern of bruising on the upper chest.
He has no palpable pulse and the following ECG rhythm in Lead II:
When you are feeling for a carotid pulse, you notice that his throat appears to be off-center, more towards the right side than it should be. You notice that he has no breath sounds over the left lung.
Question 1: What is the diagnosis?
The rhythm is consistent with Pulseless Electrical Activity (PEA). Essentially, any rhythm except ventricular fibrillation and pulseless ventricular tachycardia can be present during PEA. If you said tachycardia, you are right, but the fact that the patient does not have a pulse makes PEA the more important diagnosis.
Question 2: What is the most likely cause?
Part of ACLS management of PEA is to look for possible causes. The causes of PEA can be remembered by the H’s and T’s. We know that the driver suffered trauma to his rib cage and probably broke some ribs. He does not have breath sounds on the left and tracheal deviation to the right. He has tachycardia, hypotension, and dyspnea. This is consistent with a diagnosis of tension pneumothorax. Tension pneumothorax is one of the T’s under causes of PEA.
Question 3: Which of the following is the definitive emergent treatment?
A. Volume resuscitation
B. Tissue plasminogen activator (tPA)
C. Needle thoracostomy
The definitive treatment for tension pneumothorax is needle thoracostomy. The goal is to remove the air that is in the pleural space and pressing on the lungs, heart, great vessels, etc. This can be done with needle aspiration or tube thoracostomy (usually a needle in emergent situations).
Volume resuscitation would be given for hypovolemia, tPA would be given for pulmonary embolism (or even myocardial infarction in some centers), and pericardiocentesis would be performed for a cardiac tamponade.
We told you it was tricky.
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