our former practice of indiscriminately
administering large volumes of IV fluid to
all trauma patients.
Lastly, the patient initially had a systolic
BP of 108, but then rapidly decompensated,
demonstrated by worsening hypotension
and increasing tachycardia and tachypnea.
The astute medic realized that, with a possible chest wound, this patient may be manifesting a tension pneumothorax. In this
condition, the pneumothorax enlarges progressively, increasing pressure in the chest to
the point that the return of blood to the heart
is compromised, resulting in decreased SV,
and a shock state ensues. The immediate and
lifesaving treatment is to decompress the
tension pneumothorax by placing a large-bore IV catheter in the second intercostal
space in the mid-clavicular line.
This results in an immediate decrease in
the intrathoracic pressure and improvement
in venous blood refilling the heart, restoring SV and cardiac output. Our medics recognized and treated this patient with chest
decompression followed by a calibrated 500
cc bolus of crytalloid, with improved vital
signs found on reassessment. These medics
prevented the onset of irreversible shock and
saved this patient’s life with their prompt and
New concepts in trauma management differentiate between controllable hemorrhage
from extremities and uncontrollable internal
hemorrhage from truncal injuries. The goal
of trauma management is the prevention of
uncompensated and irreversible shock.
Prompt control of blood loss from
extremities with a pressure dressing or a
tourniquet is an immediate priority and
should be implemented during the primary
survey of the trauma patient. Internal bleeding control from truncal injuries is facilitated
by “not popping the clot.” These patients
may be managed in their compensated shock
state (BP above 80–90 mm/Hg) by avoiding
excess prehospital IV fluids. Judicious and
calibrated IV boluses are used to support the
BP below this level.
Last, remember that a penetrating chest
injury in the face of shock may represent a
tension pneumothorax and require immediate needle thoracostomy to restore cardiac
Peter P. Taillac, MD, FACEP, is an associate clinical professor
in the University of Utah Division of Emergency Medicine.
He serves as the medical director for the Utah Bureau of
EMS, the Utah Department of Health, and West Valley City
Fire and EMS. Contact him at firstname.lastname@example.org.
Chad Brocato, DHSC, CFO, JD, is the Deerfield Beach
(Fla.) district fire chief for the Broward Sheriff’s Office
Department of Fire Rescue & Emergency Services in South
Florida. He’s also an adjunct professor at Kaplan University
as well as the coordinator for the JEMS Games. Contact him
This clinical education feature appears as part of
the JEMS Integrated Clinical Training & Simulation
(ICTS) project sponsored by Laerdal Medical
Corp.’s Discover Simulation program,
with support from
JEMS and the