CASE STUDY 1

Case Study 1

Case Study 1

Part One-Assessment

Primary Survey

Airway

Tension pneumothorax may develop insidiously, especially in patients with positive pressure ventilation. This may happen immediately or some hours down the line. An unexplained tachycardia, hypotension and rise in airway pressure are strongly suggestive of a developing tension. (Hendley et al. 2009: 261-5) Tension pneumothorax may also persist if there is an injury to a major airway, resulting in a bronchopleural fistula. In this case a single chest tube is cannot cope with the major air leak. Two, three or occasionally more tubes may be needed to manage the air leak. In these cases thoracotom is usually indicated to repair the airway and resect damaged lung.

Breathing

Tension gastrothorax has been described and may be confused with a tension pneumothorax. There is haemodynamic compromise, tracheal & mediastinal deviation, and decreased air entry in the affected hemithorax (usually left). Tension gastrothorax occurs in spontaneously breathing patients with a large diaphragmatic tear (usually blunt trauma). This emphasises the importance of blunt dissection and examining the pleural space with a finger prior to chest tube insertion (Mayberry 2010: 239-61).

Beware also the patient with bilateral tension pneumothoraces. The trachea is central, while percussion and breath sounds are equal on both sides. These patients are usually haemodynamically compromised or in traumatic arrest. Emergent bilateral chest decompression should be part of the procedure for traumatic arrest where this is a possibility. (Cullinane 2010: 749-52)

Breath sounds and percussion note may be very difficult to appreciate and misleading in the trauma room. It should never be used just because we don't hear breath sounds on one side. In clear cut cases: shock with distended neck veins, reduced breath sounds, deviated trachea, it could be life saving.

Circulation

Progressive build-up of pressure in the pleural space pushes the mediastinum to the opposite hemithorax, and obstructs venous return to the heart. This leads to circulatory instability and may result in traumatic arrest. The classic signs of a tension pneumothorax are deviation of the trachea away from the side with the tension, a hyper-expanded chest, an increased percussion note and a hyper-expanded chest that moves little with respiration. The central venous pressure is usually raised, but will be normal or low in hypovolaemic states. (Britten 2009: 165-169)

However these classic signs are usually absent and more commonly the patient is tachycardic and tachypnoeic, and may be hypoxic. These signs are followed by circulatory collapse with hypotension and subsequent traumatic arrest with pulseless electrical activity (PEA). Breath sounds and percussion note may be very difficult to appreciate and misleading in the trauma room.

Disability

Bansidhar et al found that 93% of patients with clinical rib fractures are able to resume their daily activities without disability. As a result, the authors did not recommend routine chest radiographic follow-up in addition to physical examination except in the presence of clinical deterioration. Adequate pain control, rapid mobilization, and meticulous respiratory care can prevent respiratory complications in patients with rib fractures. An adequate oral analgesic or an intercostal nerve block plus an oral analgesic should provide ...