Demetri LeBlanc, a 24 year old Caucasian male was brought to Dade Hospital ER, a large metropolitan, 850 bed facility, with a gunshot wound to the anterior right chest. He is approximately 6ft 1in. and 250lbs. The penetrating injury was sustained during a drive by shooting at his home at approximately 3:30am. An exit wound was not identified. He is complaining of sharp chest pain. Emergency crew, at the scene, sealed the wound and put the patient on a non-rebreather. He has no previous medical history on file, but his doctor has been notified. His family is on their way. A chest x-ray was ordered with results pending. Upon admission he was A&O x 3.
Physical Exam (7/13/2011) 3: 45am- Upon admission to the ER, Demetri was conscious, diaphoretic, pale, and in respiratory distress. . Breath sounds were diminished on the right side with coarse crackles throughout. PERRLA. At this time, gag reflex is present with a patent airway. Trachea is midline with no jugular vein distention. Tactile fremitus is decreased upon palpation. Dull percussion is noted in the right lower lobe.Vocal resonance is decreased. Slow capillary refill in the extremities, but no edema present. Accessory muscle use and bilateral reduction in chest expansion observed. He was using accessory muscles to breathe shallow and rapid. NKDA. No history of disease and patient takes no medications at home. The patient has a sucking chest wound that has been sealed. Abdomen is soft and tender in the upper right quadrant. No obvious trauma of the extremities. Vital signs showed: BP – 150/88, HR– 118, RR 34 Temperature 38.9 degrees Celsius,and, SpO2 – 88% on a non-rebreather at admission. Blood gasses, drawn on admission show: pH – 7.49, CO2 – 28, Bicarb – 24, PaO2 – 73. A CBC was obtained with the following results – Hgb – 7.2, Hct – 29 %, WBC –12,000. 4:00am- Chest xray showed a hemothorax on the right side. Thoracentesis was performed and a chest tube was inserted in the upper border of the ninth rib. 400cc of blood was drained from the right lung.
S- Pt stated, "I was shot at home in the right side of my chest". NKDA. CC- chest pain. Patient rated pain a “10” on a scale of 1-10. Patient rated dyspnea a 9 on a scale of 10. O- Awake, anxious, oriented to time and place. PERRLA. Gag reflex is present with patent airway. Breath sounds were diminished on the right side with coarse crackles throughout. Tactile fremitus is decreased upon palpation. Dull percussion is noted in the right lower lobe. Vocal resonance is decreased. Slow capillary refill in the extremities, but no edema present. Accessory muscle use and bilateral reduction in chest expansion observed. Pt. is diaphoretic, pale and in respiratory distress. Temperature 38.9 degrees Celsius. O2 @ 15 LPM non-rebreather. Vital signs showed: BP –150/88, HR – 118, RR – 34 and shallow, SpO2 – 88% on non-rebreather. Blood Gasses, drawn left radial artery on admission show: pH – 7.49, CO2 – 28, Bicarb – 24, PaO2 – 73. CBC was obtained with the following results – Hgb – 7.2, Hct – 29 %, WBC –12,000. A- Pt has a gunshot wound to the right anterior chest area. Increased work of breathing AEB use of accessory muscles, and uncompensated respiratory alkalosis.
Possible hemothorax.
Hyperventilation with mild hypoxemia on 15LPM non-rebreather
P- Oxygen per protocol to keep SpO2 >90%. Prepare for possible intubation with S&S of shock. Possible surgery to remove bullet once exact location identified. Thoracentesis preparation upon results of chest x-ray.
Q1 – What is a hemothorax?
Q2- What is a trauma score and how is it used in an emergency situation?
Q3- What type of chest trauma is a gunshot wound classified as?
Chest Trauma
Group Members:
CHEST TRAUMA
Admitting History
Demetri LeBlanc, a 24 year old Caucasian male was brought to Dade Hospital ER, a large metropolitan, 850 bed facility, with a gunshot wound to the anterior right chest. He is approximately 6ft 1in. and 250lbs. The penetrating injury was sustained during a drive by shooting at his home at approximately 3:30am. An exit wound was not identified. He is complaining of sharp chest pain. Emergency crew, at the scene, sealed the wound and put the patient on a non-rebreather. He has no previous medical history on file, but his doctor has been notified. His family is on their way. A chest x-ray was ordered with results pending. Upon admission he was A&O x 3.Physical Exam (7/13/2011)
3: 45am- Upon admission to the ER, Demetri was conscious, diaphoretic, pale, and in respiratory distress. . Breath sounds were diminished on the right side with coarse crackles throughout. PERRLA. At this time, gag reflex is present with a patent airway. Trachea is midline with no jugular vein distention. Tactile fremitus is decreased upon palpation. Dull percussion is noted in the right lower lobe.Vocal resonance is decreased. Slow capillary refill in the extremities, but no edema present. Accessory muscle use and bilateral reduction in chest expansion observed. He was using accessory muscles to breathe shallow and rapid. NKDA. No history of disease and patient takes no medications at home. The patient has a sucking chest wound that has been sealed. Abdomen is soft and tender in the upper right quadrant. No obvious trauma of the extremities. Vital signs showed: BP – 150/88, HR– 118, RR 34 Temperature 38.9 degrees Celsius,and, SpO2 – 88% on a non-rebreather at admission. Blood gasses, drawn on admission show: pH – 7.49, CO2 – 28, Bicarb – 24, PaO2 – 73. A CBC was obtained with the following results – Hgb – 7.2, Hct – 29 %, WBC –12,000.
4:00am- Chest xray showed a hemothorax on the right side. Thoracentesis was performed and a chest tube was inserted in the upper border of the ninth rib. 400cc of blood was drained from the right lung.
S-
Pt stated, "I was shot at home in the right side of my chest". NKDA. CC- chest pain. Patient rated pain a “10” on a scale of 1-10. Patient rated dyspnea a 9 on a scale of 10.
O-
Awake, anxious, oriented to time and place. PERRLA. Gag reflex is present with patent airway. Breath sounds were diminished on the right side with coarse crackles throughout. Tactile fremitus is decreased upon palpation. Dull percussion is noted in the right lower lobe. Vocal resonance is decreased. Slow capillary refill in the extremities, but no edema present. Accessory muscle use and bilateral reduction in chest expansion observed. Pt. is diaphoretic, pale and in respiratory distress. Temperature 38.9 degrees Celsius. O2 @ 15 LPM non-rebreather. Vital signs showed: BP –150/88, HR – 118, RR – 34 and shallow, SpO2 – 88% on non-rebreather. Blood Gasses, drawn left radial artery on admission show: pH – 7.49, CO2 – 28, Bicarb – 24, PaO2 – 73. CBC was obtained with the following results – Hgb – 7.2, Hct – 29 %, WBC –12,000.
A-
Pt has a gunshot wound to the right anterior chest area. Increased work of breathing AEB use of accessory muscles, and uncompensated respiratory alkalosis.
P-
Oxygen per protocol to keep SpO2 >90%. Prepare for possible intubation with S&S of shock. Possible surgery to remove bullet once exact location identified. Thoracentesis preparation upon results of chest x-ray.
Q1 – What is a hemothorax?
Q2- What is a trauma score and how is it used in an emergency situation?
Q3- What type of chest trauma is a gunshot wound classified as?
Q4- What are the signs and symptoms of shock?
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