Case scenario

Mr Kit Lee, a 28-year-old unrestrained driver of a utility, was travelling on a highway at 100kph and swerved to miss road debris. He lost control and struck a tree on the median strip. He had been drinking at the local pub with friends for the last 5 hours. He was found face down 4 metres from his car. There were no passengers. The windshield was broken. Mr Lee was found conscious and in pain. He was taken to the emergency department of a large metropolitan hospital.

On arrival a primary survey reveals:

A.  Patent. No stridor. Tracheal deviation to the right and tracheal tug noted. Cervical spine: upper midline tenderness (hard collar in place).

B.  RR 35 breaths/min. Laboured breathing, speaking in single words only. States he "can't breathe." Decreased air entry on left side and asymmetrical chest wall movement. SpO2 90% on a non-rebreather mask at 15L/min.

C.  BP 74/40 mmHg (MAP 51 mmHg). Apical pulse 120 beats/min but no radial or brachial pulses palpable. Carotid pulse present but weak. ECG monitor shows sinus tachycardia.

D.  GCS 14 (E4, V4, M6) on arrival. PEARL.

E.   Core temperature 35.8°C

A secondary survey finds the abdomen slightly distended and he cries out when it is palpated. A focused assessment with sonography for trauma (FAST) exam is positive for free fluid in the abdomen. A chest X-ray shows a haemopneumothorax and multiple rib fractures on the left side. Blood results show a haematocrit of 0.24.

A left-sided chest tube is inserted in the ED, which drains bright red blood. His oxygen saturation improves to 97% on NRB at 15L/min and respiratory rate decreases to 26 per minute. Other vital signs remain unchanged. He continues to report severe pain.  

Mr Lee presents with hypovolaemic shock and theatre is organised for an emergency laparotomy.

QUESTION 1: 

From the case scenario above, identify four (4) key pieces of assessment data that support a diagnosis of hypovolaemic shock. Using current literature, explain the pathophysiology of each piece of data selected.

QUESTION 2:

Using current literature, explain the pathophysiology of Mr Lee's haemopneumothorax and how the intercostal catheter and underwater sealed drain inserted will help resolve this problem.

QUESTION 3: 

Using the primary survey as a framework to prioritise, select two (2) priority interventions (excluding preoperative preparation and transfer to the operating theatre) to implement for Mr Lee before surgical intervention. Using current literature, justify these priority interventions. Note: monitoring/observations/further tests will NOT be accepted as an intervention.

QUESTION 4:

For each intervention you have selected, outline two (2) specific evaluation criteria that would indicate to you that this intervention is having the desired effect.