Stabbed with a knife at Lt chest ,2cm below the Lt nipple ,20min ago,40-yr old man was tranferrred to the hospital with consciousness. At arrival, his blood pressure 90/60 mmHg, pulse 100/min, RR 20 /min. After rapidly infuse 2000 cc of balanced salt solution intravenously, his blood pressure was 110/70 mmHg however, he complained more chest tightness.

1.Cause of low BP at arrival? External hemorrhage from stab wound Internal hemorrhage :

- blood in the pleural cavity 1, lung laceration bleeding.- vascular or thoracic intercostal broken blood vessel

damage- damage to the heart and large blood vessels rupture

- Hemopericardium

2.What cause of progressive chest tightness Continue bleeding increase intrathoracic& intrapericardium

pressure Esophagus rupture

Assessment Massive hemothorax

Tension pneumothorax

Cardiac tamponade

Hx Parenchymal : BluntAnother : penetrate

M/c : Blunt M/c : Penetrate

Pulse Rapid Rapid Rapid

Blood pressure Low Low Low

Pulsus paradoxus No Yes Possibly

Heart sounds Audible Audible Muffled

Neck vein Flat Distended Distended

Percussion Dull Hyperresonance Normal

Trachea Midline/deviated Deviated Midline

Chest symmetry Normal/Asymmetry Asymmetrical Normal

Breath sounds Absent/rhonchi/rales

Absent Present

Investigation Thoracentesis : if non massive should CXR

Thoracentesis Fast

4.If you have detected fresh blood from the left chest, what would your next action ?

เบื้��องต้�นใส่� ICD ถ้�าพบื้ว่�ามี�เลื�อด ลืมี หรื�ออ��น ๆ อยู่��ในช่�องปอด

Suture at wound Investigation ต้�อ เช่�น CXR, Fast เป�นต้�น

5. If you put in a chest tube in and fresh blood came out about 800 cc, what is your plan?

Moderate(500 – 1000cc)Chest tube

○ Bleeding stops Clearing and no further treatmentPersistent hemothorax requires thoracotomy

○ Continued bleeding requires thoracotomy

6. If you put in a chest tube in and fresh blood came out more than 2000cc and there was no detecable vital signs after that, what is your response to this situation?

อ�นด�บื้แรืก clamp ส่ายู่ ICD แลืะส่�ง emergency thoracotomy