Diagnosis And Treatment Of Pneumothorax In A Motor Vehicle Trauma Patient

Background

Motor vehicles traumas (MVT) are complex trauma injuries that occurs because of fatal injuries sustained due to motor vehicle accidents. MVT patients may come in emergency department with various types of serious injuries like spinal injury, hemothorax, pneumothorax, pelvic fractures and many others. This paper provides an insight into the clinical presentation of a MVT patient diagnosed with pneumothorax by developing a case study and it also provides a critique on one treatment option for the condition.

Mr. William, a 29 year old electrical engineer was driving back home from work at night when a truck suddenly came in front of his car at a turning point. As the truck carried heavy luggage, the influence of the collision was huge and William’s car fell 5 metres away towards a concrete barrier. The influence of the trauma was such that he sustained serious injuries on his chest. Paramedics and rescue staffs arrived at the scene 15 minutes later and he was transferred to the emergency department with several bruises in head and hands.

During the admission of the client in the emergency department, the patient was experiencing severe chest pain and he was experiencing difficulty in breathing. There were many injuries and cuts too. William was in panic state. No breath sound was heard when the physician placed the stethoscope over his chest. Vital stats assessment, chest-x-ray and arterial blood gas analysis revealed was ordered. A comprehensive A-E assessment was also done. Diagnosis And Treatment Of Pneumothorax In A Motor Vehicle Trauma Patient Essay Paper The chest x-ray result revealed a diagnosis of pneumothorax because of darkened area in the left-side of the lungs. This condition is indicative of pneumothorax because darkening of the lungs occurs because of air leakage from the chest cavity. The initial vital sign assessment results for William were as follows:

Blood pressure: 150/90

Respiratory rate: 28 (12-20 breaths per minute)

Heart rate: 102 beats per minute (Normal 72-80 beats/min)

Arterial blood gas results were as follows:

SaO2: 75% (Normal value is 98-100%)

PaCO2: 50mmHg (normal 40)

PaO2: 55 mm Hg (normal value is 80-100)

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Past medical/surgical history:

The patient was in a critical condition and his wife was called up. Before deciding on optimal treatment for pneumothorax, details related to patient’s past medical or surgical history was obtained from his wife. Although William had no past surgical history, however his medical history revealed that he is a patient with chronic obstructive pulmonary disease (COPD). This might also be a reason for developing pneumothorax. This can be said because COPD is one clinical condition that results in pneumothorax for COPD patient even without any history of trauma. Further assessment was necessary to confirm whether pneumothorax occurred because of the COPD or because of the effect of blunt trauma caused due to motor vehicle accident.

Reason For Admission And Type Of Injury

Airway assessment: Airway assessment was done first to identify signs of hypoxia and end-organ damage after the motor vehicle trauma. This was done by evaluation of vital signs, mental status, airway patency and ventilation status in patient (Thim et al., 2012)

The airways assessment results for William were as follows:

RR: 28 breaths per minute

O2:75% oxygen saturation value indicating need for oxygen support

Mental status: Patient was in painful and restless state

Airway patency: Upper airway obstruction found

Ventilation status: No wheezing sound observed

Breathing assessment: Breathing assessment was done by evaluation of respiratory rate, chest wall movement, chest auscultation and palpation details for patient. Proper examination of the chest wall is necessary because of the laceration of the lungs by fracture. This may help to identify changes in breathing patterns of patients (Thim et al., 2012).

The breathing assessment results included the following:

Inspection of breathing and chest wall movement: Decreased chest wall movement

Chest auscultation: rapid breath sounds

Palpation: Injuries found in the chest wall.

Circulation assessment: Skin colour, pulse rate and heart auscultation can give indication regarding any impairment in circulation. The main rational for skin colour assessment is that it can give clues about circulatory problems in patient. Heart auscultation can also help to detect circulation issues in patient (Smith & Bowden, 2017). Circulation related issues in William were judged by means of:

Skin colour: Pale skin colour

Capillary refill: Delayed capillary refill less than 3 seconds

Urine output: Decreased urine output

BP: 155/90

Heart rate:  102 breaths per minute (Tachycardia)

Disability assessment:  The AVPU method was used to assess and grade patients on parameters of alertness, voice responsiveness, pain responsiveness or unresponsiveness. The Glasgow coma scale also defines conscious level. This form of assessment is necessary to determine the best treatment to manage airway, breathing and circulation issues. Decreases level of consciousness can be corrected by providing oral or infused glucose (Thim et al., 2012).   Disability assessment results for William were as follows:

Pupillary examination: No dilation of the pupil found

Glasgow coma scale score: 13

Alertness scale:

Exposure assessment: The main purpose of exposure is to identify other signs of injury in patient. This is mainly done by observation method by looking for signs of trauma, bruises, injury or lacerations on the body. This is done by cutting off clothing and conducting assessment of the entire body. The advantage of this form of assessment is that it can help to identify the mechanism of injury (Raja et al., 2012). The exposure assessment results for William are as follows:

A-E Assessment Details For Patient

Mechanism: Motor vehicle accident

Injury: Blunt injuries to the chest wall

Signs: High respiratory rate and pulse rate

Treatment: Oxygen therapy

As pneumothorax is a condition leading to abnormal collection of air in the pleural space between the lung and chest wall, the main treatment goal for pneumothorax is to eliminate air from the pleural space and the decrease the likelihood of recurrence (Kaneda et al., 2013). Diagnosis And Treatment Of Pneumothorax In A Motor Vehicle Trauma Patient Essay Paper One of the treatment options for eliminating air and treating respiratory dysfunction includes catheter drainage. Air elimination is the main goal of catheter drainage. It is one of the common procedures in which chest tubes or catheters are used for the purpose of draining accumulated air in the pleural cavity (Huang et al., 2014). The process chest tube insertion and placement differs based on the size of catheters. For example, small bore chest tubes are inserted using the Seldinger technique whereas the large chest tubes are inserted using the blunt dissection technique (Porcel, 2018).

Although chest tube drainage is a conventional treatment option for patient with pneumothorax, it is also associated with operative trauma, incision infection and significant pain in patient. Due to this issue, catheter drainage is considered as a safe and convenient alternative to chest tube drainage. The advantage of catheter drainage is that it induces less pain compared to tube-based drainage. The evidence by Han, Li & Wang (2018) reported about the effectiveness of central venous catheter drainage compared to conventional chest tube drainage by conducting a meta-analysis of research literature. The outcome of patients with pneumothorax in the emergency department was evaluated by analysis of length of hospital stay and rate of complication incidence after treatment. Length of stay and complication rate was found lower for catheter treatment group compared to chest tube treatment group. The study reported about getting several research evidences that reported about high success rate of catheter drainage. Hence, low complication rate, no trauma and short indwelling time are some features that depicts the effectiveness of catheter drainage as a good treatment option for management and quick recovery of patients with pneumothorax.

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Despite the above advantages, research evidence also points out to challenges in the use of catheter drainage for the management of pneumothorax. The evidence by Parienti et al. (2015) reveals that central venous catheterization can lead to intravascular complications by insertion site. One of the issues associated with the use of central venous catheterization is the risk of infection and thrombotic complications in patient. Complications may differ based on site of insertion. As the study revealed overall risk of mechanical infection in all three insertion sites, it can be said that there is no idea site for insertion. However, complications can be avoided by considering the duration of catheterization.

Critique Of One Treatment For Pneumothorax

Catheter drainage has been regarded as a first line treatment options for the management of catheterization. It is regarded as optimal treatment option above needle aspiration because of unsatisfactory results for large patients (Tsai et al., 2017). To ensure safety of patients like William while initiating catheter drainage, it is necessary that physicians take the responsibility to insert the catheter using aseptic technique. Nurses should also pay extra attention to monitor for suction level, content and quantity of drainage, follow-up of patient and providing support to the patient. Daily inspection for signs of infection and daily dressing changes can promote recovery for patient (Tarhan et al., 2016).

Conclusion:

The assignment gave an insight into the clinical presentation and complications found in patient after sustaining motor vehicle trauma. The case study related to William gave indication about the occurrence of pneumothorax and respiratory complication in patient after motor vehicle accident. The critique of one treatment for pneumothorax revealed that catheter drainage is an effective first line treatment to manage patients with pneumothorax.

References:

Han, M., Li, C., & Wang, Z. (2018). Comparison of central venous catheter drainage and conventional chest tube drainage for pneumothorax treatment: a meta-analysis. INTERNATIONAL JOURNAL OF CLINICAL AND EXPERIMENTAL MEDICINE, 11(6), 5492-5500.

Huang, Y., Huang, H., Li, Q., Browning, R. F., Parrish, S., Turner, J. F., … Zarogoulidis, P. (2014). Approach of the treatment for pneumothorax. Journal of Thoracic Disease, 6(Suppl 4), S416–S420. https://doi.org/10.3978/j.issn.2072-1439.2014.08.24

Kaneda, H., Nakano, T., Taniguchi, Y., Saito, T., Konobu, T., & Saito, Y. (2013). Three-step management of pneumothorax: time for a re-think on initial management. Interactive Cardiovascular and Thoracic Surgery, 16(2), 186–192. https://doi.org/10.1093/icvts/ivs445

Parienti, J. J., Mongardon, N., Mégarbane, B., Mira, J. P., Kalfon, P., Gros, A., … & Savary, B. (2015). Intravascular complications of central venous catheterization by insertion site. New England Journal of Medicine, 373(13), 1220-1229.

Porcel, J. M. (2018). Chest Tube Drainage of the Pleural Space: A Concise Review for Pulmonologists. Tuberculosis and Respiratory Diseases, 81(2), 106–115. https://doi.org/10.4046/trd.2017.0107

Raja, A., Zane, R. D., Moreira, M. E., & Grayzel, J. (2012). Initial management of trauma in adults. Retrieved from: https://www.medicos.cr/web/documentos/EMC%202014/presentacionesdelseminariodetrauma/Initial%20management%20of%20trauma%20in%20adults.pdf

Smith, D., & Bowden, T. (2017). Using the ABCDE approach to assess the deteriorating patient. Nursing Standard (2014+), 32(14), 51.  Diagnosis And Treatment Of Pneumothorax In A Motor Vehicle Trauma Patient Essay Paper