Clinical Opal - Unresponsive following MVA
Initial assessment showed: Shallow breathing with a respiratory rate of 9, Weak pulse of 98, BP 95/40, withdraws to painful stimuli, PEARL and pinpoint.
Sam was intubated at the scene with confirmation of tube placement via direct visualisation of the tube passing through the cords, ETCO2 52 and equal rise and fall of the chest with ventilations.
Sam was transferred to the ED and primary survey performed:
Airway - Size 8 ETT in situ 22 cm at teeth
Breathing - ETCO2 48, Unequal rise and fall, air entry absent on left
Circulation - Sinus Tachycardia 134, BP 80/50
Disability - Unresponsive
What are you worried about?
There are a lot of clinical concerns to consider with a patient following trauma. Our prioritisation needs to focus on maintaining adequate oxygenation and perfusion, this can be done applying the principles of emergency care to our ABCDE approach:
- Assessment
- Intervention
- Reassessment
In our patient Sam, our initial priority will be to optimise his breathing and address the unequal rise and fall with absent breath sounds on the left. There should be 2 initial concerns to assess for here:
- Do we have intubation of the Right Main Bronchus
- Do we have a left sided haemo/pneumothorax
Reviewing Sam’s ABCDE assessment the presence of tachycardia and hypotension along with unequal rise and fall of the chest with positive pressure ventilation following previously confirmed ETT placement are indicative of a haemo/pneumothorax.
The dilemma is now how best to treat. Is there enough information to make a diagnosis and initiate an intervention? What are the risks of intervention vs no intervention?
Before you can make a decision Sam suffers a cardiac arrest. It is decided to perform an immediate Finger Thoracostomy to treat the suspected tension pneumothorax as the likely cause of arrest.
Emergency chest decompression via finger thoracostomy is a life saving procedure and is the recommended treatment for cardiac arrest likely to be caused by tension pneumothorax. Finger thoracostomy is preferred over needle decompression as it allows maximum release of air/fluid from the pleural cavity and full lung re-expansion, it is also possible to re-sweep the thoracostomy site if there is reaccumulation or deterioration.
Following finger thoracostomy, Sam has return of spontaneous circulation (ROSC). After stabilisation, an intercostal catheter is inserted and Sam is able to undergo further assessment including a Chest X-Ray and Head CT.
If you want to know more about the assessment and management of life threatening emergencies, you may be interested in:
- The ALERT Course (Acute Life-threatening Emergencies Recognition and Treatment)
- Critical Bytes: Code Crimson
References:
1. https://www.cprguidelines.eu/assets/guidelines/European-Resuscitation-Council-Guidelines-2021-Ad.pdf
2. https://trauma.reach.vic.gov.au/guidelines/thoracic-trauma/immediately-life-threatening-injuries
Susan is the Head of Nursing Education for the Medcast Group.
DipAppScNsg, BN, CritCareCert, CoronaryCareCert, TraumaNsgCareCert, CertIV(TAE), MN(Ed), and GradCert(Ldrshp & Mgt).
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