There are many causes of severe hypotension in chest injured patients. A hemothorax of volume 2 liters or more caused by bleeding from parietal vessels (intercostal, internal mammary, great vessels) or the pulmonary vasculature or parenchyma can quickly lead to shock. Bleeding from the aorta, the hilar vessels, and the heart is massive and rapidly fatal, even with immediate surgical treatment.

Aortic rupture may occur in blunt trauma patients subjected to rapid deceleration. The intact adventitia may contain the hemorrhage temporarily, allowing time for diagnosis and surgical intervention. However, any delay may be fatal. Penetrating cardiac or great vessel trauma may cause pericardial tamponade which sometimes saves the patient from exsanguination, particularly if the pericardium is torn, allowing decompression into the pleural space. Cardiac contusion rarely causes shock and is generally self-limiting.

Air embolism is a rare but possible cause of intractable shock and cardiac arrest in the chest trauma patient. When airway and vascular injury coexist, as in penetrating trauma, embolization is possible with rapid and dramatic consequences.

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