Having problems with message search?
Sorry for the delay, for some reason I did not receive Sam’s
email from the yahoo group. First, good question (and answer..thank you
laurel). I just want to elaborate on a few thing that were mentioned.
First, there are several causes of pneumothorax, but I did not
want to elaborate on all of the them in one case especially with my last
email being as long as it was. I think Laurel said it best that you may
not always see signs of trauma in a pneumothorax. She made an excellent
point that you can have a pneumothorax without ANY signs of trauma and that any
sign of trauma does not necessarily mean pneumothorax. What does indicate
a pneumothorax is the clinical presentation of the patient, i.e. absent breath
sounds, deterioration of the patient, etc.
Laurel had also mentioned a pleural bleb. This is something to
certainly keep in mind. This is often the cause of a Spontaneous
pneumothorax where there would be NO sign of trauma. A typical patient would
be a white skinny, tall, male. They have a higher risk of a pleural bleb
that spontaneously ruptures leading to a pneumothorax.
So, as laurel said, trauma neither rules in or out a
pneumothorax.
I also wanted to take the opportunity and elaborate on the “ABCs”
that laurel mentioned. This is the governing principle on treating patients
and stands for “Airway, Breathing, Circulation, Disability and Expose.”
Without going into too much detail, you start with A (clever enough) and evaluate
the airway, if they have one, if it is obstructed etc. Than Breathing,
which was what was deficient in this patient with absent breath sounds.
As Laurel had said, you HAVE to treat each of these as you go BEFORE proceeding
on (A before B, B before C, etc). In this case, his breathing was
compromised so we treat it.
I hope that clears a few things up. Keep the emails going J
Glenn
From:
Sackler911@yahoogroups.com [mailto:Sackler911@yahoogroups.com] On Behalf Of Laurel
Mohrmann
Sent: Saturday, March 01, 2008 10:05 AM
To: Sackler911@yahoogroups.com
Subject: Re: [Sackler911] Answer to our first case
What's most important in this case is that there was a clinically
significant deterioration (hypotension) that required intervention.
Whether or not you see signs of trauma on the chest is not. There could
have been an emphysematous bleb that ruptured with impact. In this case,
there would be no external indication of pleural rupture. On the other
hand, flail chest does not necessarily indicate pneumothorax. Chest
bruising/broken ribs does not automatically equal a need to insert a chest
tube. A non-traumatic appearing chest does not rule out pneumothorax.
The bottom line is that if you have a high index of suspicion with clinical
deterioration, you need to intervene before continuing.
Remember, ABC. Never move onto the next item until the previous has been
secured.
Laurel
Sam Weisblatt <samweisblatt@...> wrote:
I just wanted to thank you Glenn for a great presentation of the case and the answer choices.
I recognize that the given data about the patient might be enough to warrant a chest tube insertion, but I'm curious if other information might have been neglected. Specifically, it's my understanding that this injury being a trauma injury, you would see evidence to confirm that the pleural cavity has been punctured, whether it was from a foreign object, or something internal, like a broken rib. I guess my question is whether or not you will always be able to confirm this diagnosis by just looking at the patient, and if this is necessary before your perform the procedure?
Thanks,
Sam----- Original Message ----
From: Glenn Skow <glennskow@...>
To: Sackler911@yahoogroups.com
Sent: Thursday, February 28, 2008 5:53:29 PM
Subject: [Sackler911] Answer to our first caseI 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.
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
Be a better friend, newshound, and know-it-all with Yahoo! Mobile. Try it now.
Never miss a thing. Make Yahoo
your homepage.
Offline 
Send Email