intercostal space) and the lateral Buehlau (4.-6. In a prospective study our group showed that both approaches, the ventral Monaldi (2.-3. Considering the ventral approach injury to the heart, to the oesophagus, mediastinum, induction of a contralateral pneumothorax, injury to the phrenic nerve, and an arteriovenous fistula have been described. For the lateral approach, injury to an intercostalartery, stenosis of the subclavian artery, injury to the vena cava inferior, perforation of a lung, perforation of the right atrium, of the right or left ventricle, Horner's syndrome and intraabdominal malposition have been reported. Failure rate due to malposition is reported to be 11.2%. However it can result in complications such as injury of the lung, heart and abdominal organs. After opening the thorax it could be seen that the chest drain with the connected Heimlich flutter valve had been placed correctly in the pleural space.Ĭhest tube insertion is considered an effective method to decompress tension pneumothorax. A left side resuscitative thoracotomy was performed for direct cardiac massage and thoracic aortic occlusion. Focused assessment with ultrasound in trauma (FAST) revealed neither pericardial effusion nor massive free abdominal fluid. An immediate chest film was taken the moment, when the patient was placed on the radiotranslucent trauma room table. Prior auscultation of the breath sounds was not possible due to the massive emphysema. Assuming a contralateral tension pneumothorax, a chest tube was placed on the right side while still on the gurney. Inspection of the tube and valve showed no obstruction through bending or clotted blood. At 12:25 the patient was admitted to our trauma room undergoing manual external chest compressions with a massive subcutaneous emphysema despite the pre-hospital inserted chest tube, which had been inserted on the left side. At 12:10, during transport, the patient suffered from cardiorespiratory arrest with asystole. The patient was transferred in a critical condition 150 miles by helicopter from the rural district to the next level I trauma centre. Epinephrine and dopamine were then given as the response to fluid resuscitation was not sufficient. Fluid resuscitation with cristalloids and colloids was initiated. Emergency endotracheal intubation was performed and as the breathsounds over the left side were impaired, a tube thoracostomy was performed via a Monaldi approach in the 3 rd intercostal space midclavicular line and connected to a Heimlich flatter valve. Initial ECG monitoring showed ST elevations in the aVR lead. He was able to communicate and to respond to given commands but had no measurable blood pressure. Initially, the patient was in severe respiratory distress due to flail chest. 10 minutes after the accident, an advanced life support team arrived on scene. At 10:45 the 68 year old, male patient got injured after being attacked by a bull while working at a rural slaughterhouse.
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