A 27-year-old man with multiple stab wounds to the chest.

A 27-year-old man presented to a community emergency department (ED) after sustaining multiple stab wounds to the anterior and posterior chest and posterior neck after an altercation at a local bar. Shortly after arrival at the ED, the patient's mental status altered, and he increasingly became combative and confused. When the patient was assessed in the ED, staff found the patient hypoxic with oxygen saturations noted to be in the low 90s. He was tachypneic and tachycardic, although there was no evidence of hypotension. The ED staff quickly intubated him using standard weight-based dosing of succinylcholine and etomidate for airway protection. Once his airway was controlled, he was placed on propofol for sedation and was pharmacologically paralyzed with pancuronium. His initial chest x-ray demonstrated bilateral pneumothoraces. Bilateral chest tubes were placed and arrangements made for transport by helicopter emergency medical services (EMS) to the nearest level 1 trauma center for continued management (Figure 1).