Case 1

A 33-year-old farm worker is presented by the paramedics to your Resus room.  He has been squashed by a bull against one of the metal bars of its pen. The crew demonstrate a horizontal skin contusion across his chest at nipple level. Suspecting a tension pneumothorax, they have performed needle thoracocentesis on the left side with no effect.

His observations are P 70, BP not recordable, saturations not recordable, RR 30 and GCS 15. He has decreased breath sounds at the right base, pale lips, palpable brachial pulses, a sore belly generally and normal pelvic examination.

What is the most likely cause of his raised respiratory rate?

What does his CXR (image below left) and FAST RUQ (image below right) demonstrate? Click the images to see larger versions.

Aside from fluid/blood resuscitation, what urgent intervention does he require?

What additional tasks would you consider?