Confusing hypoxia in a 21-year-old intubated multiple trauma patient

ABSTRACT

A 21-year-old man was brought to the emergency department due to multiple trauma [MT] caused by a motor-car accident [MCA]. On arrival, the patient was intubated by prehospital emergency medical services [EMS] and had a Glasgow coma scale [GCS] score of 6 on 10 [Due to intubation, verbal score was omitted]. Physical examination revealed blood pressure of 150/70 mmHg, oxygen saturation [O2sat] of 60%, and pulse rate of 110/min. Examination of the tracheal tube site revealed incorrect esophageal placement. The patient was intubated again and his O2sat improved and reached approximately 96%. His pupils were reactive and of the same size. The Doll's eye was normal, and plantar reflex was neuter in both sides. Neither expanding hematoma nor emphysema was observed in his neck. Laceration was noted on his left ear, but otorrhagia and tympanic perforation were not found. The lung sounds were normal in both sides. Extended focused abdominal sonography for trauma [e-FAST] examination revealed the absence of free fluid in the abdomen and pericardial space. No deformity of limbs was noted and the distal pulses were palpable. The patient's O2sat decreased during his admission to the emergency department, and further examination indicated obvious de-creased sound in his right lung that could not be reversed by needle thoracostomy. On reviewing his previous chest computed tomography, an obvious questionable pathology was detected in his right side