Mr. Smith is a 36-year-old motor vehicle accident victim presenting with massive head and chest…

Mr. Smith is a 36-year-old motor vehicle accident victim
presenting with massive head and chest trauma. He is immediately intubated in
the emergency department and mechanically ventilated in the volume control
mode. He has received sedation and paralysis and is ventilated with the
following settings. Tidal volume 500 ml (6 ml/kg PBW), rate 22/ min, peak flow
40 liters/min, inspiratory time 0.66 sec. He has 10 cm H2O PEEP and
an FIO2 of 60%. At these settings his SpO2 is 95%, pulse
is 78/min, and arterial blood pressure is 110/70. His peak airway pressure is
24 cm H2O and his plateau pressure is 18 cm H2O. He has
received a total of 4 liters of fluid.

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As you are standing at the bedside you observe a breath-by
breath increase in his peak airway pressure and the high pressure alarm sounds
at 50 cm H2O. His SpO2 has decreased to 88% and appears
to be decreasing breath by breath. His pulse is 140/min and blood pressure is
80/50. You observe that his trachea is deviated to the left, and on
auscultation note an absence of breath sounds on the left. His percussion note
is hyperresonant on the left side and on palpitation you note a rise only of
the right chest. What should you do?

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