I want to thank everyone who participated in our first case presentation.  I hope you will find these useful.  The case that was presented was as follows:

 

A 24 year-old man comes to the E.R. after being involved in an automobile collision. You clear his airway, but find absent breath sounds in the right chest. Distended neck veins are present and a blood pressure of 80/60 mm Hg (normal: 120/80) is measured. Which of the following would be your next course of action?

1)      Send the patient for a chest x-ray

2)      Continue with the patient examination before determining treatment

3)      Immediately insert a needle/chest tube into the right chest

4)      Prepare the patient for surgery

The answer to this question was choice number 3.  The patient in this case has suffered a traumatic injury to the right lung allowing air to escape into the pleural space causing a progressive increase in positive pressure.  This is known as a Pneumothorax.  As air builds up in the pleural space and the pressure continues to rise, a pneumothorax can develop into what is known as a Tension Pneumothorax, which is life-threatening.  A Tension Pneumothorax exists when the pressure has increased to the point (when it equals or exceeds venous pressure) where it can compress the structures in the chest (such as the heart and trachea) and shift them to the opposite side.  With the pressure now exceeding venous pressure, venous return, cardiac output and blood pressure will all decrease.  There is also a physical compression of these structures, such as the heart that now has to work harder to pump blood.   As a result, we see jugular venous distension in the neck. 

 

In Short, the signs of a tension pneumothorax as was described in this case are absent breath sounds over the affected lung, distended jugular veins, and hypotension.  One sign that was not listed was that of tracheal deviation.  As I said before, the structures of the chest will be shifted to the opposite side in a tension pneumothorax so you would expect that the trachea might shift to the left side in this case where the injury was on the right.

 

As this is a life-threatening, clinical suspicion is enough to treat this patient, which is accomplished by inserting a needle/chest tube to decrompress the chest.  You are basically providing a means for the trapped air in the pleural space to escape.  If your diagnosis is correct, you will see an instantaneous improvement in the patient.

 

The reason why you would not send this person for a chest x-ray (Choice A) is that this is a true emergency and your patient can die while you wait for an x-ray.  This point holds true for a lot of cases, if your patient is unstable, as was this patient being hypotensive, you stabilize before anything else.  This same reasoning can be used to justify why you would not continue with the physical exam (Choice B) before providing treatment.    As you find life-threatening ailments on a physical exam, treat them before continuing on.

 

I have posted a photo to our yahoo group.  The link is below, but am not sure it will work.  The photo is an example of a pneumothorax seen on chest x-ray. 

 

http://health.ph.groups.yahoo.com/group/Sackler911/photos/view/4aa7?b=1

 

I hope this explanation made sense.  As it was my first attempt at answering a case, a welcome any feedback.  If there are any questions do not hesitate to email me or call me (054.497.7317).  Hopefully more people will participate in our next case.  Thank you again for participating.

 

Glenn