1. Continued Scene Assessment
The driver is extricated and immobilized. Blood pressure 100/P, HR 128 bpm, RR 28/min, SaO2 90% on 100% oxygen. No other injuries are identified, but breath sounds are  on the left. ACLS arrives.
What should be done first?
Perform rapid sequence intubation
Do needle thoracentesis of the left chest
Transport to nearest hospital (5 minutes)
Transport to trauma center (15 minutes)
Key Concept: Repeat the primary assessment frequently. If a life-threatening problem is identified, institute an intervention immediately. Transport to a trauma center according to local EMS guidelines.
Discussion Points: ACLS has now arrived, and the Primary ABCD Survey is repeated. Key to optimal care is continuing assessment and immediate intervention as life-threatening problems develop.
Ask participants if indications for intubation exist.
This patient is stable, but just so. She has tachycardia, borderline hypotension, and an oxygen saturation of 90%.
Early advanced airway placement could be considered, but the indication is anticipated respiratory failure or cardiac arrest.
Ask participants if decreased breath sounds are a concern with rapid sequence intubation and positive-pressure ventilation. What is the clinical significance?
Defer the differential diagnosis for now. A pneumothorax can be converted to a tension pneumothorax with positive-pressure ventilation, a real possibility here. A pneumothorax usually requires chest tube insertion before advanced airway placement and positive-pressure ventilation. A complicated airway emergency may develop on-scene.
Ask participants what they or their EMS system would do. Many would rapidly transport the patient to a definitive trauma center with interventions as necessary en route. 10

2. ED Assessment
You confirm decreased breath sounds in the left chest and observe JVD. As you listen to the heart, a bradycardia develops, and SaO2 falls to 78%. BP is absent, RR agonal.
What should you do now?
Give atropine, then epinephrine
Place an advanced airway
Perform needle decompression of the left thorax
Perform pericardiocentesis
Key Concept: Hypotension in the trauma patient is most likely due to hypovolemia. When hypotension is persistent or recurs after volume repletion, continued bleeding or other causes are suspected and evaluated.
Discussion Points: This patient now has agonal respirations, has no blood pressure, and is hypoxemic and hypotensive. Immediate intervention is indicated.
The next action is placement of an advanced airway by the orotracheal route with cervical spine stabilization. This initiates ventilation, administration of 100% oxygen, and protection of the airway.
In a trauma team setting, assessment and multiple interventions often occur concurrently. Immediately a needle decompression or insertion of a left chest tube is indicated for presumptive tension pneumothorax. Relief of a pneumothorax is a priority because positive-pressure ventilation will worsen the clinical situation if the pneumothorax is increased. The next question illustrates this principle.
Ask participants what the clinical response should be if hypotension is due to a tension pneumothorax. The last slide is supplemental for demonstration purposes if needed. A CT scan shows air in the right chest and relation to heart and mediastinal structures. 14