Correct!
4. Hemothorax due to intercostal artery laceration
Given the patients recent traumatic chest injury with rib fractures and the fact that he is anticoagulated, and new large left pleural effusion in a patient with hemorrhagic shock most likely is the result of intercostal artery laceration producing a large hemothorax. Sepsis is a consideration given the evidence of urinary traction infection and clinical suspicion for infective endocarditis, but the patient was afebrile, his decompensation was sudden, and his infection had been well-controlled. Cardiac tamponade could produce his hypotension, but would not explain the new large left pleural effusion, and the repeat bedside echocardiogram showed only a tiny pericardial effusion. Cardiogenic shock due to myocardial infarction merits consideration, but the patient’s left ventricular function was normal-to-hyperdynamic, rather than showing regional wall motion abnormalities that typically result from myocardial ischemia. Furthermore, transesophageal echocardiography failed to reveal any vegetations. Finally, cardiogenic shock is a possibility give that the repeat bedside echocardiogram showed new moderate right ventricular systolic dysfunction and the patient’s decompensation was acute; however, the pleural effusion is atypically large for effusions associated with thromboembolic disease and, while the echocardiogram showed new systolic dysfunction, it did not show leftward bowing of the interventricular septum or new right ventricular enlargement, both of which are typically encountered with large pulmonary emboli producing systemic hypotension.
Which of the following choices is most appropriate for the management of this patient? (Click on the correct answer to proceed to the fifth of eight pages)