Group 4B

Luceno, Beatricia Alyssandra

Lumactud, Deanna Lisette
Macatangay, James Mawell
Maderazo, Don Gilson
Maglalang, Harold
Malazo, John Philip
Malimban, Oliver
Maloles, Shane

Case #3

24y/o male stab wound 5th ICS R MCL brought to the ER

Able to communicate
Dyspneic RR 30/ min
BP 70/50 PR 120/min
Able to speak, neck veins distended, no subcutaneous emphysema neck trachea deviated to
the left
Lag on the right on chest expansion
Decrease breath sounds on the right
Crepitation on the right no chest deformities

What is your diagnosis? Explain.

Tension Pneumothorax on the basis of the following
 Patient had a stab wound on the 5th ICS MCL
 Patient is dyspneic
 RR = 30 (Tachypneic)
 PR = 120/ min (Tachycardic)
 BP = 70/50 (Hypotensive)
 Presence of neck vein distention
 Trachea was deviated to the left
 There is lag on chest expansion
 Decrease breath sounds and crepitations on the right

What are the steps to be taken next? Explain.

1. Empiric treatment with pleural decompression

2. Chest Xray>> for visualization
3. Immediate tube thoracotomy >> for decompression??
 The diagnosis of tension pneumothorax should be made on clinical examination. The classic
findings include respiratory distress (in an awake patient), hypotension, diminished
breath sounds over one hemithorax, hyperresonance to percussion, jugular venous distention,
and shift of mediastinal structures to the unaffected side with tracheal deviation. In most
instances, empiric treatment with pleural decompression is indicated rather than delaying
to wait for radiographic confirmation. When a chest tube cannot be immediately inserted,
such as in the prehospital setting, the pleural space can be decompressed with a large-caliber
needle.
Immediate return of air should be encountered with rapid resolution of hypotension.
Unfortunately, not all of the clinical manifestations of tension pneumothorax may be evident on
physical examination. Hyperresonance may be difficult to appreciate in a noisy resuscitation
area. Jugular venous distention may be absent in a hypovolemic patient. Tracheal deviation is a
late finding and often is not apparent on clinical examination. Practically, three findings are
sufficient to make the diagnosis of tension pneumothorax: respiratory distress or
hypotension, decreased lung sounds, and hypertympany to percussion. Chest x-ray
findings that may be visualized include deviation of mediastinal structures, depression of the
hemidiaphragm, and hypo-opacification with absent lung markings. As discussed earlier,
definitive treatment of a tension pneumothorax is immediate tube thoracostomy. The chest
tube should be inserted rapidly, but carefully, and should be large enough to evacuate any
blood that may be present in the pleural space.
Most recommend placement in the fourth intercostal space (nipple level) at the anterior axillary
line.

What is the Definitive plan? Explain.

Chest tube insertion – this is done to decompress/remove the air within the affected
site. This procedure will provide immediate relief to the patient. The procedure will address the
positive intrapleural pressure that depresses the ipsilateral hemidiaphragm which shifts the
mediastinal structures in the contralateral chest and compress the heart and superior and
inferior vena cava.
Case #5

24y/o male motor vehicular accident brought to the ER

Able to communicate severe chest pain right
Dyspneic RR 30/ min
BP 100/60 PR 96/min
Able to speak, neck veins not distended, no subcutaneous emphysema neck
Lag on the right on chest expansion
Contusion hematoma, ecchymosis right level of 3rd ICS to 7th ICS
Decrease breath sounds on the right
No crepitation on the right with chest deformities right

What is your diagnosis? Explain.

Diagnosis: MASSIVE HEMOTHORAX
Basis:
No neck vein distention
Decreased breath sounds on the right
Lag on the right chest expansion
No crepitation or chest deformities

What are the steps to be taken next? Explain.

In any situation of trauma, a primary survey of the patient must be done.

A- Airway must be secured.

B- Breathing must be checked. Especially since chest trauma and respiration is
compromised- oxygen should be given due to tachypnea.
C- Circulation of the patient should be intact.
D- Disabilities should be checked. (Decreased breath sounds on the right speaks of a
collapsed lung.
E- Environmental factors should be taken into account.

When the patient is stabilized a secondary survey may be conducted. Doctors consulting
with trauma should be able to prioritize life over limb, In this case that the patient has trauma to
the chest- respiration and the respiratory centers should be secured.
What is the Definitive plan? Explain.

 No surgery is requires as it has the tendency to coaptate.

 Adequate oxygenation (patient is tachypneic)

 Pain management

 IV hydration, should it be needed since the patient is not yet hypotensive (normal blood
pressure)