Evaluation and Management of Severe Thoracic Injuries

Initial Evaluation and Management

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  Airway

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    Assessment for definitive airway.

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    Endotracheal (ET) intubation/surgical airway if indicated

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  Breathing and Ventilation

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    Chest tube thoracostomy if indicated

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    Mechanical ventilators if indicated

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  Circulation

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    Venous access or intraosseous access

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    Infusion of Crystalloid solution

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    Assessment for massive transfusion protocol

Imaging

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  Chest x-rays may reveal:

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    pneumothorax.

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    hemothorax.

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    pneumomediastinum.

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      Causes

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        Pharyngeal injury

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        Tracheal and bronchial injury

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        Esophageal injury

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    mediastinal hematoma.

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      Causes

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        Mediastinal vascular injuries

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        Sternal fracture

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  Bedside ultrasound

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    Evaluation of hemopericardium

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    Evaluation of pneumothorax

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  Computerized tomography (CT) scan

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    Detailed evaluation of thoracic injuries in stable patients

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  Computed tomographic angiography (CTA) chest

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    Detailed evaluation of vascular injuries in stable patients

Esophageal Endoscopy

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  For the evaluation of esophageal injury if indicated

Bronchoscopy

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  For the evaluation of tracheobronchial injury if indicated

Mechanisms of Thoracic Injuries

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  Penetrating injury

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  Blunt injury

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  Crush injury

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  Deceleration injury

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  Blast injury

Twelve Life-threatening Chest Injuries: The Deadly Dozen

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  Six lethal injuries

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    Acute airway obstruction including airway rupture

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    Tension pneumothorax

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    Open pneumothorax

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    Flail chest

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    Massive hemothorax

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    Cardiac tamponade

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  Six hidden injuries (easily missed, potentially life-threatening)

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    Tracheobronchial injury

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    Aortic injury

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    Myocardial contusion

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    Pulmonary contusion

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    Diaphragmatic rupture

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    Esophageal rupture

AAST Grading of Chest Wall Injuries

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  Grade I

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    Chest wall contusion of any size

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    Laceration of skin and subcutaneous tissue of any size

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    Closed fractures of <3 ribs

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    Closed nondisplaced clavicle fracture

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  Grade II

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    Laceration of skin, subcutaneous tissue, and muscle

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    Closed fractures of >3 adjacent ribs

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    Open and displaced clavicle fracture

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    Closed, nondisplaced sternal fracture

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    Closed or open scapular body fracture

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  Grade III

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    Full-thickness laceration, including pleural penetration

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    Open or displaced sternal fracture

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    Flail sternum

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    Unilateral flail segment (<3 ribs)

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  Grade IV

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    Avulsion of chest wall tissue with underlying ribs fracture

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    Unilateral flail segment (>3 ribs)

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  Grade V

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    Bilateral flail chest (>3 ribs on both sides)

RIB Fractures

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  Most common thoracic injuries in blunt trauma

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  Severe force required for fractures of ribs 1–3 and sternal fractures

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  Complications of ribs fracture

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    Associated injuries

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      Fractures of ribs 1–3 have high association with:

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        subclavian artery and vein injury.

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        brachial plexus injury.

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      Fractures of ribs 4–9 have high association with:

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        pulmonary contusion.

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        pneumothorax.

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      Fractures of ribs 10–12 have high association with abdominal injuries such as spleen, kidneys, and liver.

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    Pulmonary lacerations complicated with:

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      hemothorax.

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      pneumothorax.

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    Pulmonary hematoma

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    Hypoxia due to:

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      pulmonary contusion.

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      atelectasis.

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    Pneumonia

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    Impaired ventilation due to:

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      splinting from pain.

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      flail chest.

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        Two or more fractures per rib involving two or more adjacent ribs

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        Paradoxical breathing due to discontinuity of flail chest wall segment with the rest of the thoracic cage

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        Paradoxical breathing is characterized by inward chest wall movement during inspiration and outward chest wall movement during expiration.

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        Posterior chest wall flail is usually stable due to overlying muscles and the scapula and does not cause severe ventilation problems.

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        Anterior and lateral flail segments are usually associated with impaired ventilation.

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        Frequently associated with pulmonary contusions

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  Treatment of rib fractures

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    Nonoperative treatment

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      Pain management modalities

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        Oral medications: narcotics/nonnarcotics

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        Parenteral narcotics

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        Patient-controlled analgesia (PCA) pump using narcotics

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        Intercostal nerve blocks

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        Continuous epidural anesthesia

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      Deep breathing exercises

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    Operative treatment: Internal fixation of ribs

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      Benefits

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        Restores chest wall dynamics

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        Decreases pain

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        Decreases incidence of pneumonia

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        Decreases incidence of tracheostomy

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        Decreases need for mechanical ventilation

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      Indications

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        Strongly recommended

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          ≥5 ribs flail chest on ventilatory support

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          Symptomatic nonunion

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          Severe displacement found during thoracotomy for other indications

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        May consider

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          ≥3 ribs flail chest without mechanical ventilation

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          ≥3 ribs with severely displaced fractures

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          ≥3 ribs with mild to moderate displacement and 50% reduction of expected forced vital capacity despite optimal pain management

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          Pain not relieved with medical treatment with associated respiratory compromise (e.g., deficiency in pulmonary function tests)

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          Chest wall deformity

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          Thoracotomy for other indications, such as lung laceration or open pneumothorax

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      Most commonly ribs 4–10 are fixed because these are the most mobile ribs and produce significant pain.

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      For patients with multiple fractured ribs, severely displaced and accessible ribs should be fixed.

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      Fixation of fractures of ribs 1–3 is not recommended as these ribs are difficult to access and no benefit has been shown.

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      Contraindications

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        Absolute: Contaminated field

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        Relative

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          Severe lung contusion requiring prolonged mechanical ventilation

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          High cervical spine injury requiring mechanical ventilation

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          Severe traumatic brain injury (TBI)

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          Unstable spine fractures

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      Surgical steps:

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        Position of the patient

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          Supine for anterior ribs fracture

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          Lateral decubitus for lateral or posterior ribs fracture

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        Access the fracture with:

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          muscle sparing anterior, posterior or posterolateral approach.

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          muscle splitting or cutting limited-exposure approach.

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        Plates and fixation devices

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          Synthes plates

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          RibLoc U-shaped plates

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          Intramedullary devices

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          Absorbable plates

Sternal fractures

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  Most sternal fractures involve the upper or middle part of the sternum.

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  May have associated:

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    pulmonary injuries.

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    myocardial injuries.

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    thoracic spine fractures.

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    sternoclavicular dislocations:

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      Anterior dislocations

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        More common

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        Mostly treated non operatively

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      Posterior dislocations

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        Associated with:

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          injury to mediastinal blood vessels.

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          injury to trachea.

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          injury to esophagus.

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        Usually require closed or surgical reduction

AAST grading of lung injuries

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  Grade I

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    Lung contusion, unilateral <1 lobe

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  Grade II

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    Lung contusion, unilateral single lobe

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  Grade III

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    Simple pneumothorax

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    Persistent (>72 hours) air leak from distal airway

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    Lung contusion, unilateral >1 lobe

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  Grade IV

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    Nonexpanding intraparenchymal hematoma

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    Major (segmental or lobar) air leak

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  Grade V

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    Hilar vessel disruption

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  Grade VI

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    Total uncontained transection of pulmonary hilum

Advance one grade for bilateral injuries up to Grade III .

Tension Pneumothorax

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  Air enters the pleural space and is captured during the process of exhalation.

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  Causes collapse of the ipsilateral lung with subsequent compression of the mediastinum and the contralateral lung

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  Clinical signs

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    Respiratory distress

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    Shock

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    Distended jugular veins

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    Tissue emphysema

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    Unilateral decrease in breath sounds

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    Hyperresonance

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  Treatment

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    Surgical emergency: Immediate needle thoracostomy followed by chest tube placement (tube thoracostomy)