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Module 6 case study:

A 65-year-old white male presents to the ED with CO dyspnea and chest pain that was a sudden
onset after he was rear ended in an automobile accident yesterday. The CNP orders a chest X Ray and 12
lead EKG. While waiting for these results, the patient becomes more dyspneic with an SPO2 of 88%.
ABGS are ordered.

1. Please interpret: pH: 7.5; PaCO2: 30; PaO2 56; HCO3; 24

Uncompensated respiratory alkalosis. The pH is 7.5 which is alkalotic . The CO2 is 30 which is
low. The patient is likely tachypneic. The PaO2 is 56, indicating hypoxia. The normal value is 70-
100. The sodium bicarbonate is 24 which is normal (Ferri, 2019, p157).
2. Is any treatment necessary for these ABGs? If so, what?
Yes. We need to determine the cause of the patient’s hypoxia but I would first give the patient
high flow oxygen or a bipap. In this case the bipap is not treating the patients CO2 but to help
alleviate the work of breathing and improve oxygenation.
3. Please interpret 12 lead EKG

The rate is about 120

The rhythm is regular

The p wave is visible and upright, the pr interval is 0.16 which is wdl. There is a p wave for every QRS

The QRS is 0.08 which is WDL. There is no Bundle branch block.

The QT interval is about .32

The rhythm is Sinus Tachycardia

There is no axis deviation.

There is no ST elevation or depression.

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Chest X Ray returns

4. Please interpret the following:

My first thought is that this is a hemothorax due to the trauma from the car accident.

This is an AP view of the chest with full inspiration. The thoracic vertebrae are present indicating good
exposure. The clavicles appear level and the thoracic spine is mostly centered between the sternum and
the clavicles.

Airway – trachea appears midline.

Bones – no obvious fractures are present. There appears to be a pin in the right shoulder

Cardiac Silhoutte is not entirely visible due to the large effusion of the left lung.

Diaphragm is not clearly visible

Effusion – A large left sided effusion is present.

Fields – The clavicles are symmetric and equidistant from the spinous processes. Bilateral lung fields
appear congested with pulmonary infiltrates. Costophrenic angles are blunted on the right and absent
on the left. There is no pneumothorax. Gastric Bubble - present

Hilar – The hilar region is not well defined on the left. There is possibly an enlarged lymph node on the
right.

Lines - There appears to be a central line crossing the right lung field in the position of the superior vena
cava. The case study makes no mention that a central line was placed. It presents as if it’s a temporary
dialysis catheter which also would not make much sense with information about the patient scenario in
the case study.
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The pulmonologist instructs the CNP to perform a thoracentesis The CNP knows the following

5. How will you position the patient?

a. The patient should lay supine with the arm secured over the ipsilateral shoulder
6. Where will you insert the chest tube?
a. The chest tube should be placed on the patient’s left side (the affected side) at the fifth
intercostal space, anterior to the mid axillary line. The nipple is a good landmark to
determine the correct location.
7. Drainage is 500 mL of Frank Red blood. Is your diagnosis still the same? Why or why not?
a. My diagnosis is still the same. According to Legome, (2023), “motor vehicle collisions are
the most common cause of major thoracic injury in adult blunt force trauma accidents”
Causes of hemothorax can include injuries to the lung parenchyma, intercostal or
mammary blood vessels. A hemothorax with >300 mLs of blood is treated with chest
tube insertion and drainage. In some cases, if the hemothorax is large enough, a surgical
thoracotomy will need to be performed to prevent infection and pulmonary fibrosis.

References

Ferri, Fred F., (2019), Ferri’s Best Test, (p.157) Fourth edition, Philadelphia: Elsevier

Legome, E. (2023, March 29). Initial Evaluation and Management of Blunt Thoracic Trauma in Adults .
UptoDate. Retrieved April 17, 2023, from
https://www-uptodate-com.eps.cc.ysu.edu/contents/initial-evaluation-and-management-of-
blunt-thoracic-trauma-in-adults