Lim
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a 22-year old man is stabbed in the right chest with a 5 cm-long knife blade. On arrival at the emergency department, he is wide awake and alert. He is speaking with a normal tone of voice but complaining of shortness of breath. The right hemithorax is hyperresonant to percussion and has no breath sounds;the rest of the initial survey is negative. His blood pressure is 110/75 mm Hg, pulse is 86/min, and venous pressure is 3 cm H2O. Pulse oximetry shows a saturation of 85%. Which of the following is the most appropriate next step in patient care?
A. infusion of 2 L ringer's lactate
B. securing an airway by orotracheal intubation
C. immediate insertion of a needle into the right pleural space
D. Chest x-ray and insertion of a chest tube
E. sonographically guided evacuation of the pericaridal sac
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| DrVirgo
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The dx sounds like PTX but could also be Hemothorax. He is not in shock so there is time to do CXR and then place a chest tube. Answer: D.
However IF he was hemodynamically unstable (shock) with Tension PTX -showing deviation of the midline, then C -insertion of a tube would be right. -usually this is a clinical diagnosis and there is no time to do CXR -if you waste time going to Xray, he could die so treatment is urgent.
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| Ivonne
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(D) Nice explanation Dr Virgo
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| Lim
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DrVirgo, great explanations.
(also considering about hemothorax, your idea is great.)
can you explain about SpO2 85% of him?
what about thinking of airway? like intubation?
i got this q right, but what about SpO2? isn't it somehow low enough approaching with airway first?
Doesn't lots of pt low spO2 with stable vital signs cause much problems? that's the reason?
thanks in adavnce.
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| sandra
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hi guys,
a doubt....its mentioned that the rt hemithorax is hyperresonant. doesnt that point towards tension pneumothorax?.if it was hemothorax, wouldnt it be dull? and is the cvp 3 here? assuming its tension pneumothorax, how can this be explained?
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| Lim
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sandra
he's stale,so it could't be a tension pneumothorax,i guess.
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| DrVirgo
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Lim wrote:
DrVirgo, great explanations.
what about thinking of airway? like intubation?
"he is wide awake and alert. He is speaking with a normal tone of voice"
so no intubation is necessary.
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| DrVirgo
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by the way: What is the range for NORMAL CVP???
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| neuroblastoma
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Normal CVP is 2-6 mm Hg.
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| neuroblastoma
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Lim wrote:
DrVirgo, great explanations.
(also considering about hemothorax, your idea is great.)
can you explain about SpO2 85% of him?
what about thinking of airway? like intubation?
i got this q right, but what about SpO2? isn't it somehow low enough approaching with airway first?
Doesn't lots of pt low spO2 with stable vital signs cause much problems? that's the reason?
thanks in adavnce.
HE IS SPEAKING NORMALLL---airway intact.. o2 saturatiow Below a level of 80% cells do not receive enough oxygen to continue to function normally
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| Lim
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thanks..
If CVP is 0, it counts low,isn't?
i remember some reference said normal value of CVP is 0~8. it's wrong. i guess
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| sandra
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Lim,
I still dont get it. how does hyperresonace co-relate with hemothorax ?
normal value of cvp is 2-6, which implies, its normal in this cae.
whts the anticipated change associated with cvp in case of hemothorax?
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| darkhorse
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i agree with D...its definitely pneumothorax...and its unlikely to be under tension...as JVP is not raised...there is no mention of trachea....there is no clue for a hemothorax as you would expect percussion to be dull in hemothorax contrary to hyperresonant in pneumothorax...in case of a hemopneumothorax.....blood being heavier than air ...it goes to base in standing and posteriorly in lying down...the bases or posteriorly it should be dull...and air being lighter ...antiriorly it should be hyperresonant....in this case ...you would expect him to be lying down...anterior percussion would yield a hyperresonant note...even if there is some amount of hemothorax
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| gr8doc
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D.
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