A 27-year-old man is brought to the emergency department 45 minutes after being involved in a motor vehicle collision. He is agitated. He has pain in his upper right arm, which he is cradling in his left arm. His temperature is 36.7°C (98°F), pulse is 135/min, respirations are 25/min, and blood pressure is 145/90 mm Hg. His breathing is shallow. Pulse oximetry on 100% oxygen via a non-rebreather face mask shows an oxygen saturation of 83%. He is confused and oriented only to person. Examination shows multiple bruises on the right anterior thoracic wall. The pupils are equal and reactive to light. On inspiration, his right chest wall demonstrates paradoxical inward movement while his left chest wall is expanding. There is pain to palpation and crepitus over his right anterior ribs. The remainder of the examination shows no abnormalities. An x-ray of the chest is shown. Two large-bore IVs are placed. After fluid resuscitation and analgesia, which of the following is the most appropriate next step in management?

Intubation with positive pressure ventilation

Surgical fixation of right third to sixth ribs

A 50-year-old man presents with severe chest pain for a week. His pain increases with breathing and is localized to the right. He has tried over-the-counter medications at home, but they did not help. The patient has a 20-pack-year smoking history and currently smokes 2 packs of cigarettes daily, and he drinks 3 to 4 cans of beer daily before dinner. His temperature is 39.1°C (102.3°F), blood pressure is 127/85 mm Hg, pulse is 109/min, and respirations are 20/min. Respiratory examination shows dullness to percussion from the 7th rib inferiorly at the right midaxillary line, decreased vocal tactile fremitus, and diminished breath sounds in the same area. Chest radiograph is shown in the image. The patient is prepared for thoracocentesis. Which of the following locations would be the most appropriate for insertion of a chest tube?

Above the superior border of the 8th rib in the midaxillary line

Below the inferior border of the 7th rib in the midaxillary line

Above the superior border of the 5th rib in the midclavicular line

Below the inferior border of the 5th rib in the midaxillary line

Above the superior border of the 7th rib in the midclavicular line

A 28-year-old woman is brought to the emergency department 1 hour after being involved in a motor vehicle collision. She was riding a bike when she lost control and hit a car on the opposite side of the road. On arrival, she is unconscious. She has a history of intravenous heroin use. Her pulse is 56/min, respirations are 8/min and irregular, and blood pressure is 196/102 mm Hg. Examination shows a 2-cm laceration over the left cheek and a 3-cm laceration over the left chest. There are multiple abrasions over her face and chest. She opens her eyes and flexes her extremities to painful stimuli. The pupils are dilated and react sluggishly to light. There are decreased breath sounds over the left lung. The trachea is central. There is no jugular venous distention. Cardiac examination shows no abnormalities. The abdomen is soft and nontender. The left knee and right ankle are swollen; range of motion is limited. Two large-bore peripheral intravenous catheters are inserted. She is intubated and mechanical ventilation is initiated. A focused assessment with sonography in trauma is negative. An occlusive dressing is applied over the left chest wound. She is scheduled for a noncontrast CT scan of the brain. Which of the following is the underlying cause of this patient's hypertension?

Increased intrathoracic pressure

Reduced parasympathetic response

A 56-year-old man is brought to the emergency department after falling 16 feet from a ladder. He has severe pain in both his legs and his right arm. He appears pale and diaphoretic. His temperature is 37.5°C (99.5°F), pulse is 120/min and weak, respirations are 26/min, and blood pressure is 80/50 mm Hg. He opens his eyes and withdraws in response to painful stimuli and makes incomprehensible sounds. The abdomen is soft and nontender. All extremities are cold, with 1+ pulses distally. Arterial blood gas analysis on room air shows: pH 7.29 PCO2 33 mm Hg PO2 65 mm Hg HCO3- 15 mEq/L A CT scan shows displaced fractures of the pelvic ring, as well as fractures of both tibiae, the right distal radius, and right proximal humerus. The patient undergoes emergent open reduction and is admitted to the intensive care unit. Which of the following best indicates inadequate fluid resuscitation?

Urine output of 25 mL in 3 hours

Capillary refill time of 3 seconds

A 35-year-old woman is brought to the emergency department 45 minutes after being rescued from a house fire. On arrival, she appears confused and has shortness of breath. The patient is 165 cm (5 ft 5 in) tall and weighs 55 kg (121 lb); BMI is 20 kg/m2. Her pulse is 125/min, respirations are 29/min, and blood pressure is 105/65 mm Hg. Pulse oximetry on room air shows an oxygen saturation of 97%. Examination shows second and third-degree burns over the anterior surfaces of the chest and abdomen, and the anterior surface of the upper extremities. There is black debris in the mouth and nose. There are coarse breath sounds over the lung bases. Cardiac examination shows no murmurs, rubs, or gallop. Femoral and pedal pulses are palpable bilaterally. Which of the following is the most appropriate fluid regimen for this patient according to the Parkland formula?

Administer 6 liters of intravenous crystalloids over the next 24 hours

Administer 4 liters of intravenous colloids over the next 8 hours

Administer 5 liters of intravenous colloids over the next 6 hours

Administer 5 liters of intravenous crystalloids over the next 6 hours

Administer 8 liters of intravenous colloids over the next 12 hours

A 27-year-old soldier stationed in Libya sustains a shrapnel injury during an attack, causing a traumatic above-elbow amputation. The resulting arterial bleed is managed with a tourniquet prior to transport to the military treatment facility. On arrival, he is alert and oriented to person, place, and time. His armor and clothing are removed. His pulse is 145/min, respirations are 28/min, and blood pressure is 95/52 mm Hg. Pulmonary examination shows symmetric chest rise. The lungs are clear to auscultation. Abdominal examination shows no abnormalities. There are multiple shrapnel wounds over the upper and lower extremities. A tourniquet is in place around the right upper extremity; the right proximal forearm has been amputated. One large-bore intravenous catheter is placed in the left antecubital fossa. Despite multiple attempts, medical staff is unable to establish additional intravenous access. Which of the following is the most appropriate next step in management?

Perform endotracheal intubation

Establish central venous access

Replace the tourniquet with a pressure dressing

A 35-year-old man is brought to the emergency department from a kitchen fire. The patient was cooking when boiling oil splashed on his exposed skin. His temperature is 99.7°F (37.6°C), blood pressure is 127/82 mmHg, pulse is 120/min, respirations are 12/min, and oxygen saturation is 98% on room air. He has dry, nontender, and circumferential burns over his arms bilaterally, burns over the anterior portion of his chest and abdomen, and tender spot burns with blisters on his shins. A 1L bolus of normal saline is administered and the patient is given morphine and his pulse is subsequently 80/min. A Foley catheter is placed which drains 10 mL of urine. What is the best next step in management?

Additional fluids and escharotomy

Additional fluids and admission to the ICU

Resuscitative thoracotomy for USMLE Step 2 CK: High-Yield Surgery Lessons

Indications & Contraindications - The 'Go or No-Go' Code

Decisions hinge on injury mechanism and signs of life (SOL).

Primary Indications (Penetrating > Blunt):
- Penetrating Thoracic Trauma: Witnessed arrest with prehospital CPR < 15 min.
- Blunt Trauma: Witnessed arrest with prehospital CPR < 10 min & PEA.
- Persistent post-injury hypotension (SBP < 60 mmHg) despite aggressive resuscitation.
Absolute Contraindications:
- No SOL in the field.
- Asystole as presenting rhythm (unless tamponade is suspected).
- Severe, non-survivable brain injury.
- CPR duration exceeding time limits.

⭐ Exam Favorite: The highest survival rates are seen in patients with isolated penetrating cardiac injuries (e.g., stab wounds) who lose pulses in the emergency department.

Anterolateral thoracotomy incision landmarks

Procedure Steps - The Thoracotomy Tango

Incision & Entry:
- Anterolateral thoracotomy in the 4th or 5th intercostal space (inframammary crease).
- Use scalpel, then bluntly dissect with fingers or clamps through intercostal muscles.
- Divide the pleura to enter the chest.

Anterolateral thoracotomy incision landmarks

The Dance Floor:
- Insert rib spreaders (Finochietto) with the handle down.
- Retract the lung posteriorly.

Core Moves:
- Pericardiotomy: Incise pericardium anterior to the phrenic nerve.
- Cardiac Repair: Use finger pressure, sutures, or staples.
- Aortic Cross-Clamping: Occlude descending aorta to redirect blood flow to coronaries/brain.

⭐ High-Yield: Cross-clamp the descending thoracic aorta just distal to the origin of the left subclavian artery to preserve cerebral and coronary perfusion without compromising spinal cord blood flow unnecessarily.

Anatomy & Key Maneuvers - Navigating the Red Sea

Incision: Left anterolateral thoracotomy in the 5th intercostal space (ICS), from sternum to posterior axillary line.
Pericardiotomy: Open pericardial sac anterior to the phrenic nerve to release tamponade.
Maneuvers:
- Aortic Cross-Clamping: Controls infra-diaphragmatic bleeding; improves coronary perfusion.
- Hilar Control: Twist or clamp hilum for massive pulmonary hemorrhage.
- Internal Cardiac Massage: Direct manual compression of the heart.

Anatomy for Resuscitative Thoracotomy

⭐ To avoid paralysis of the hemidiaphragm, the pericardiotomy incision must be made anterior to the phrenic nerve.

Outcomes & Complications - The Final Tally

Survival Rates: Highly dependent on mechanism and location of injury.
- Penetrating Thoracic Trauma: ~10-15%
- Blunt Trauma: <2%
Neurologic Sequelae: Anoxic brain injury is the most feared complication in survivors; many have significant permanent deficits.
Common Complications:
- Infection (empyema, mediastinitis)
- Coagulopathic bleeding
- Phrenic nerve injury
- Iatrogenic organ damage

⭐ Survival is exceedingly rare in blunt trauma patients who have had no signs of life in the field.

Resuscitative thoracotomy is a last-resort procedure for patients in extremis from penetrating chest trauma.

Primary goals are to relieve cardiac tamponade, control intrathoracic hemorrhage, and perform open cardiac massage.

A left anterolateral thoracotomy in the 5th intercostal space is the standard approach.

Cross-clamping the descending aorta is crucial to redirecting blood flow to the brain and heart.

Survival is extremely low, especially following blunt trauma (<2%).

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