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  #1  
Old 03-30-2012
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ER Trauma victim; Next step in management

A 3-year-old boy is brought by ambulance to the emergency department after he and his mother are in a motor vehicle accident. The mother is not available to speak, but the paramedics tell you that the boy was awake but lethargic when they arrived, sitting on the floor of the car in front of the front seat on the passenger-side, with his head leaning back against the seat. They say that when he was moved, he appeared to cry but did not make any sound and was breathing rapidly. At that time, oxygen saturation was 94% by pulse oximetry.
On physical examination you note a 3-year-old boy strapped to a backboard with an oxygen mask secured to his face. He has a superficial laceration over the right eye and a bloody lip. Pupils are equal and reactive. He is awake but does not speak. He is forming tears but not sobbing or vocalizing in any way. He is taking 34 shallow breaths per minute. His mouth and nose are free of blood or trauma. He has no obvious facial fractures or deformities. His left collarbone is obviously fractured, and he has a large bruise developing over the upper left thorax in the front, from the midaxillary line to just left of midline. The trachea is deviated to the left. On palpation, the chest is extremely tender, and you feel a fracture in the third rib around the midclavicular line on the left. No breath sounds are heard on the left. Chest wall motion is not appreciated on the left. Percussion is not attempted due to the swelling accompanying the hematoma. No murmurs or abnormal heart sounds are auscultated, but tachycardia is present. No spinal trauma is appreciated on palpation. A focused abdominal sonography for trauma (FAST) scan shows no gross intra-abdominal or pelvic fluid collection. A Foley catheter is successfully placed with no gross hematuria. No pelvic fractures are appreciated, and extremities show no signs of edema. There is tenderness to palpation over the right radius 6 cm proximal to the wrist. Peripheral pulses are present, strong and equal in all extremities. On arrival, vital signs are: blood pressure 92/64 mm Hg, heart rate 145 beats/minute, respiratory rate 32 breaths/minute, and Spo2 91%. After 10 minutes, vital signs are: blood pressure 94/69 mm Hg, heart rate 152 beats/minute, respiratory rate 38 breaths/minute, and Spo2 82%. Which of the following represents the best next steps to take, in sequence, to manage the child’s injuries?

A. Computed tomography of the head and thorax; placement of a chest tube; radiograph of the right arm; lateral cervical spine radiograph (child is on backboard)
B. Placement of a chest tube; chest radiograph; radiograph of right arm; computed tomography of the head, thorax, and pelvis
C. Placement of a chest tube; preparation to intubate; computed tomography of the head, thorax, abdomen, and pelvis
D. Placement of a left chest tube; computed tomography of the head, thorax, abdomen, and pelvis; preparation to intubate
E. Portable chest radiograph and lateral cervical spine radiograph (child is on backboard); placement of a left chest tube; preparation to intubate; computed tomography of the head, thorax, abdomen, and pelvis
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Old 03-30-2012
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I think it's E .
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Old 03-31-2012
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any expln for the same? i am confused what to do first...CXR or tube?
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Old 03-31-2012
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Quote:
Originally Posted by tyagee View Post
any expln for the same? i am confused what to do first...CXR or tube?

cxr first,for confirmation&extention(mild,modert,massiv)
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Old 04-01-2012
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Well, I think the answer should be E.
Why?
From examination the signs are pretty clear for Left Collapsed lung due to puncture wound by the 3rd rib on the left. You have trachea deviated to the left, absent breath sound on the left, progressively decreasing SaO2- an obvious clinical Dx of collapsed lung. So your first step should be a portable CXR and then placing a chest tube . Then, because we have deterioration of SaO2, we should prepare to intubate followed by CT of Head/thorax/ abdomen and pelvis.

My question though: Is Tension Pneumothorax a clinical Dx or a CXR is a must?

Hope someone will answer.
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Old 04-01-2012
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Quote:
Originally Posted by robinssmc View Post
Well, I think the answer should be E.
Why?
From examination the signs are pretty clear for Left Collapsed lung due to puncture wound by the 3rd rib on the left. You have trachea deviated to the left, absent breath sound on the left, progressively decreasing SaO2- an obvious clinical Dx of collapsed lung. So your first step should be a portable CXR and then placing a chest tube . Then, because we have deterioration of SaO2, we should prepare to intubate followed by CT of Head/thorax/ abdomen and pelvis.

My question though: Is Tension Pneumothorax a clinical Dx or a CXR is a must?

Hope someone will answer.
Tension pneumothorax is a clinical dx...because next step in unstable TP is needle decompression.
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Old 04-02-2012
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anybody think its 'C' ??
The child is not maintaining vitals and a chest tube hasn't been placed despite a tension pneumothorax... also hes not maintaining his SpO2...so shudnt we intubate the child first? I suppose all Ix should be done after ABC in a trauma pt...
any suggestions???
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Old 04-03-2012
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Originally Posted by tyagee View Post
Tension pneumothorax is a clinical dx...because next step in unstable TP is needle decompression.
hi tyagee,ithink the diagnosis is haemothorx(trachea pulled to left),in TP(trachea bushed to contralater side).
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