Reference no: EM133423253

UNRESTRAINED DRIVER AND PNEUMOTHORAX

A 26-year-old man with an unknown past medical history arrives to the emergency department (ED) by ambulance. He had been driving his car while unrestrained and was involved in a high-speed motor vehicle collision. There was airbag deployment and significant front-end damage to the vehicle, with intrusion into the passenger compartment of the car. The patient was extricated from the vehicle and placed on a backboard, and a cervical collar was placed by EMS. A non-rebreather facemask and 1 peripheral intravenous (IV) line were placed in the field. On arrival to the hospital, the patient is ill-appearing and combative. His initial vital signs are:

? Heart rate of 117 bpm ? Blood pressure of 85/50 mm Hg ? Respiratory rate of 32 breaths/min ? Oxygen saturation of 91% on the non-rebreather mask On primary survey, his oropharynx is clear, his airway is patent, and his trachea appears to be shifted to the right of midline. On auscultation, the patient's breath sounds are decreased over the left chest. Percussion of the left chest demonstrates hyper-resonance. His carotid pulse is weakly palpable, and his jugular venous pulse is elevated. The patient's clothing is removed, revealing no obvious deformities or areas of bleeding. The patient's abdomen is soft, without any tenderness to palpation. His pelvis is stable. Standard trauma x-rays, including an antero-posterior (AP) chest and pelvis scan, are performed after the primary survey. The chest radiograph (see Figure 1) confirms the suspected clinical diagnosis of a tension pneumothorax. A complete secondary survey is postponed because of the patient's poor clinical condition. A large-bore peripheral intravenous line is placed, and the patient begins to receive a bolus of 1000 cc of normal saline under pressure. A needle thoracostomy was performed to quickly decompress the pleural space. A rush of air was noted as the needle entered the pleural space. Subsequent to the needle thoracostomy, the patient's vital signs are: ? Pulse of 105 bpm, ? Blood pressure of 95/60 mm Hg, ? Respiratory rate of 22 breaths/min, ? Oxygen saturation of 98% on the non-rebreather mask. The resident then prepared the left chest and placed a chest tube in the fifth intercostal space, midaxillary line. There was immediate drainage of 1600 mL of bloody fluid through the chest tube. Un-crossmatched blood was administered, and the surgical team was consulted for the massive hemothorax. The patient was intubated and transported to the operating room (OR). In the OR, the surgery team performed a thoracotomy, repaired the injured lung parenchyma, and ligated several small arteries that were actively bleeding. The patient was transported to the surgical intensive care unit (ICU) and extubated the following day. The chest tube was removed 48 hours later, and the patient was discharged on hospital day 4 in stable condition. Immediately after the procedure is performed, the patient is noted to have a dramatic clinical improvement.

1. Explain the reason for the change in all of the patient's vital signs before and after the needle thoracostomy Figure

2. How is the patient's weak carotid pulse and elevated jugular venous pulse related to his tension pneumothorax?

3. In this case was the tension pneumothorax the only thing causing the compression (remember pneumo means air)? Use signs and or symptoms to justify your answer.