A 6-year-old female was struck by a car and thrown about 10 feet. Vital signs are BP 60/P, P 140, R 10 and labored. She has subcutaneous emphysema and absent breath sounds on the left. What should you suspect?

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This scenario points to a tension pneumothorax. After blunt chest trauma, the combination of air leaking into the chest (evidenced by subcutaneous emphysema) and no breath sounds on one side means the lung on that side is collapsed and air is under pressure. That pressure not only collapses the affected lung but also compresses the heart and great vessels, drastically reducing venous return to the heart. The result is rapid shock manifested by a very low blood pressure and a fast, labored pulse.

Subcutaneous emphysema supports the idea of an air leak from the lung. While a hemothorax can cause diminished breath sounds, it doesn’t typically produce air in the tissues. Cardiac tamponade can cause shock as well but usually presents with muffled heart sounds and pressure on the great vessels rather than unilateral absent breath sounds with an air leak. A simple pneumothorax can cause decreased breath sounds, but it rarely causes the severe hemodynamic collapse seen with a tension pneumothorax.

This is an emergency requiring immediate decompression of the chest to relieve the pressure and restore circulation.