A 25-year-old man requires urgent assessment in the
emergency department. Recently admitted following a fall of 20mwhile climbing, he
has suddenly become hypotensive (BP 55/30 mmHg), hypoxaemic (SpO2 88% on 15 L/min O2 via a non-rebreathe mask) and tachycardic (HR 160 bpm) having been
cardiovascularly stable with good saturations on admission 60 minutes earlier. He has sustained
multiple bilateral rib fractures, a sternal fracture, bilateral fractured scapulae and
a mid-shaft femoral fracture but no pelvic fracture. Auscultation of his lung fields reveals bilateral air entry, his trachea is midline, his abdomen is soft and
non-distended and there has been no response to administration of 3000mL of crystalloid.
Which of the following is the MOST LIKELY diagnosis to explain the sudden
deterioration?
a) Blood loss secondary to multiple fractures
b) Cardiac tamponade
c) Severe, bilateral pulmonary contusions
d) Tension pneumothorax
e) Liver laceration
