Snapshot A 19-year-old male is brought to the emergency department with several gunshot wounds to the chest. EMT reports the man was found unresponsive and intubated in the field. Large bore IV access is available. Introduction Defined as rapid accumulation of more than 1000mL of blood into the thoracic cavity Most commonly caused by penetrating trauma involving the great or hilar vessels Be highly suspicious of penetrating trauma that is medial to the nipple line or posterior wounds medial to the scapula Presentation Symptoms patients are usually unresponsive or unconscious Physical exam decreased NOT absent breath sounds in the affected area(s) dullness to percussion hypotension collapsed neck veins tachycardia hemorrhagic shock Evaluation CXR shows large fluid collection in thoracic cavity usually associated collapsed lung on the affected side may demonstrate other injury-related pathology Differential Pneumothorax, pleural effusion, pneumonia Treatment/Management Non-operative aggressive fluid resuscitation with large-bore IV access before placing chest tube supplemental oxygen Operative chest tube placement to decompress chest cavity following fluid resuscitation inserted at level of nipple and anterior to midaxillary line CXR or CT scan post-chest tube placement to assess for remaining blood/pathology emergent thoracotomy if >1500ml removed from chest tube or if bleeding does not stop Prognosis, Prevention, and Complications Prognosis can range broadly depending on extent of injury and speed of intervention Prevention chest tube placement to prevent tension pneumothorax from blood build-up Complications can lead to hemorrhagic shock and death