Just Plain Ruff Posted August 14, 2008 Posted August 14, 2008 Another scenario and educational piece from Medline CME by WebMD A 26-year-old man is involved in a high-speed motor vehicle collision. The patient’s oropharynx is clear, his airway is patent, and his trachea appears to be shifted to the right of midline. The patient’s breath sounds are decreased and percussion of the left chest demonstrates hyperresonance. Standard trauma x-rays, including an anteroposterior (AP) chest and pelvis scan, and an emergent procedure are performed. What is the underlying pathophysiology, and what procedure was performed?
ERDoc Posted August 14, 2008 Posted August 14, 2008 What is the underlying pathophysiology? Provider incompetence What procedure was performed? A lawsuit
Eydawn Posted August 14, 2008 Posted August 14, 2008 Left traumatic tension pneumothorax due to lung injury/compromise? And the emergent procedure would be a needle decompression, no? Maybe? Wendy CO EMT-B
Just Plain Ruff Posted August 14, 2008 Author Posted August 14, 2008 Wendy - bingo but let's go further. 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 a heart rate of 117 bpm, a blood pressure of 85/50 mm Hg, a respiratory rate of 32 breaths/min, and an 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 hyperresonance. His carotid pulse is weakly palpable, and his jugular venous pulse is elevated. The patient receives a Glasgow Coma Scale score of 12. 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 anteroposterior (AP) chest and pelvis scan, are performed after the primary survey. A complete secondary survey is postponed because of the patient's poor clinical condition. A second large-bore peripheral intravenous line is placed, and the patient begins to receive a bolus of 1000 cc of normal saline under pressure. A decision to perform an emergent procedure is made. Immediately after the procedure is performed, the patient is noted to have a dramatic clinical improvement. Subsequent to the procedure, the patient has a pulse of 105 bpm, a blood pressure of 95/60 mm Hg, a respiratory rate of 22 breaths/min, and an oxygen saturation of 98% on the non-rebreather mask. The secondary survey is completed, revealing no major injuries. Additionally, the chest radiograph (see Figure 1) confirms the suspected clinical diagnosis that prompted the emergent procedure.
ERDoc Posted August 14, 2008 Posted August 14, 2008 If you have signs of a tension pneumo that are this obvious, you should not be getting an xray. ABCs include putting a needle in the chest. You have lost vital time by getting an xray. I would say that in this case the dx was pretty obvious and should have been taken care of prior to the xray.
Just Plain Ruff Posted August 14, 2008 Author Posted August 14, 2008 If you have signs of a tension pneumo that are this obvious, you should not be getting an xray. ABCs include putting a needle in the chest. You have lost vital time by getting an xray. I would say that in this case the dx was pretty obvious and should have been taken care of prior to the xray. true true true and the answer to one of the questions did say that radiographs for this case were not needed due to the presentation of the guy. If anyone wants more of these types of scenarios let me know.
BushyFromOz Posted August 15, 2008 Posted August 15, 2008 i'd have decompressed him during initial assessment on the side of the road.
firedoc5 Posted August 15, 2008 Posted August 15, 2008 i'd have decompressed him during initial assessment on the side of the road. Soon as you detect it, decompress it.
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