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Needle decompression in the second intercostal space
Placement of a chest tube
Sputum culture followed by IV antibiotics
Intercostal nerve block
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This patient is presenting after a motor vehicle accident with poor oxygen saturation several hours after the incident, which suggests a diagnosis of a pulmonary contusion. Most pulmonary contusions self-resolve, and supportive therapy is all that is needed.
Pulmonary contusion typically occurs in the setting of major blunt trauma to the chest and abdomen. Typically, symptoms of pulmonary contusion will not present until hours to days later when pulmonary edema and inflammation begin to take place. Patients will present with shortness of breath, poor oxygen saturation, and an arterial blood gas that demonstrates a respiratory alkalosis. Pulmonary contusions self-resolve and all that is needed is supportive therapy.
Figure A is a chest radiograph demonstrating faint consolidation several hours after the trauma, suggesting a diagnosis of pulmonary contusion.
Answer 1: Needle decompression in the second intercostal space is the best initial step in management of a tension pneumothorax which presents with shortness of breath, hypotension, jugular venous distension, and an absence of lung markings on chest radiograph.
Answer 2: Placement of a chest tube is the best next step in management of a tension pneumothorax after large needle decompression. It is also the best next step in management of a spontaneous pneumothorax.
Answer 3: Sputum culture followed by intravenous antibiotics is the best initial step in management of a suspected bacterial pneumonia. This would present with cough, fever, and consolidation on chest radiograph.
Answer 4: Intercostal nerve block is necessary in patients (typically elderly patients) who present with broken ribs. By reducing the pain associated with breathing, these patients can take deep breaths and avoid other complications such as bacterial pneumonia.
Pulmonary contusion presents with shortness of breath, respiratory alkalosis on ABG, and self-resolves with supportive measures.
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