HISTORY. Establish a history of the injury. If the patient has been shot, ask the paramedics for ballistic information, including the caliber of the weapon and the range at which the person was shot. If the patient was in an MVC, determine the type of vehicle (truck, motorcycle, car), the speed of the vehicle, the victim's location in the car (driver or passenger), and the use, if any, of safety restraints. Determine if the patient has had recent tetanus immunization. If the patient can communicate, determine the location of chest pain and whether the patient is experiencing shortness of breath. If there is no chest trauma, establish a history of other risk factors. Determine if the patient has undergone thoracic surgery or anticoagulant therapy. Establish a history of pulmonary infarction, dissecting thoracic aneurysm, or tumor.

PHYSICAL EXAMINATION. The initial evaluation focuses on assessing the adequacy of the patient's airway, breathing, and circulation, as well as neurological status. The patient should be completely undressed for a thorough visual assessment. The initial evaluation, or primary survey, is completed by the trauma resuscitation team and may occur simultaneously with life-saving interventions as needed.

The secondary survey, completed after life-threatening conditions are stabilized, includes serial vital signs and a complete head-to-toe assessment. Assess the patient for a patent airway. Note respiratory rate, breathing pattern, and lung sounds on an hourly basis. Observe the patient's breathing; the affected side of the chest may expand and stiffen while the unaffected side rises. Auscultate for lung sounds; the loss of breath sounds is evidence of a collapsed lung. Percuss the lungs; blood in the pleural space yields a dullness. Note signs of respiratory failure; the patient may appear anxious, restless, even stuporous, and cyanotic. If the patient has a chest tube, monitor its functioning, the amount of blood loss, the integrity of the system, and the presence of air leaks.

Examine the thorax area, including the anterior chest, posterior chest, and axillae, for contusions, abrasions, hematomas, and penetrating wounds. Note that even small penetrating wounds can be life threatening if vital structures are perforated. Observe carefully for pallor, blood pressure, and pulse rate, noting the early signs of shock or massive bleeding such as a falling pulse pressure, a rising pulse rate, and delayed capillary refill.

PSYCHOSOCIAL. The patient may be fearful or panic-stricken because of difficulties in breathing and intense pain. Ongoing assessment of coping strategies of patient and family assists in planning and evaluating interventions. Note that approximately half of all traumatic injuries

408 Hemothorax are associated with alcohol and other drugs of abuse. Assess the patient's drinking and drug-taking patterns.

Diagnostic Highlights

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