Emergency Nursing Case Study: Management of a 6-Year-Old with Suspected Haemothorax and Chest Trauma

Introduction: Emergency Nursing Case Study

Ryan should be in triage 2. This is because patients in this cadre are critically ill and therefore demand medical attention within 10 minutes, or else their situation will degenerate into more complicated forms (Berman and Kozier 2008, p.22). In most cases, these patients are normally brought to medical facilities by emergency ambulances. In Ryan’s case, he is complaining of chest pains and has become notably shorter of breath and distressed on route. From these observations, among others, it can be suspected that Ryan may be having a right-sided haemothorax (Eastman and Minei 2009). Also, Ryan should be in this triage because of the mere fact that he got retrieved from the accident scene by the Emergency Ambulance team half an hour after the accident had occurred, and from this, he could be in deep pain, hence necessitating the need for immediate medical; attention without fail.

Priority of Care for Ryan

Kragh, Walters, and Baer (2008) observe that haemothorax can degenerate into a situation where the accumulation of blood will start to exert pressure on the mediastinum and trachea. This will strain the volume of blood that the ventricles of the heart are able to fill. Subsequently, this will further affect the trachea deviating to the unaffected part. This is what explains why Ryan should be in triage 2, where he is guaranteed medical attention at most within 10 minutes.

Immediate Care Priorities

From the information given about Ryan’s situation, the first priority will be containing the chest pain, stabilizing breathing ability, and nursing any injury sustained in the accident, both seen and unseen (O’Shea 2011, p. 21).

According to the Emergency Nurses Association (2008), chest pain and breathing inabilities could be a result of haemothorax, which is right-sided. Because of the dire dangers these conditions pose to the patient, immediate and decisive measures are needed so that they can be limited and thus save the already threatened life of the patient. First, it will be very prudent to remove the part that causes bleeding and drain any blood and air that is in the thoracic cavity and the chest area. This is accomplished through the process of inserting a thoracostomy tube into the chest cavity, resulting in the expansion of the lungs and preventing further bleeding.

Chest Tube Insertion and Management

While executing the above process, the danger of blood clogging in the tube is eminent. Therefore, to achieve effective and intended results for Ryan, better and effective drainage tubes are a necessity when draining the blood and air that might be in the chest cavity.

As earlier stated, the priority for Ryan’s treatment is to get him stable, stop any internal bleeding and drain blood and air from the bleeding and drain blood and air from the pleural cavity, and also examine his entire body to establish whether there could be other hidden injuries that can pose a danger to his healing process or at worse even his life.

Addressing Complications and Additional Procedures

A chest tube shall be inserted through the wall of the chest and made to drain the blood, which is a result of draining, as well as air that could be in this cavity. In situations where haemothorax may be complex and established that a tube alone cannot mitigate the oozing blood, thoracotomy or surgery options may be explored. This will be administered with the sole intention of controlling and deterring the bleeding that could potentially worsen the situation. Therefore, for him to regain the lost blood that is highly needed for his recovery, a proper diet, especially green vegetables and any other food that is rich in minerals, is a must.

From the description of the whole accident that Ryan got involved in, it was a grisly scenario that must have left him in shock. Therefore, Ryan also needs some professional counseling that will accompany other therapies so that he can regain his usual self. Though the time that the counseling can be done may be in contention, it is a necessity for him to receive it, and the earlier this therapy can be administered to him, the quicker.

According to Blackbourne (2008), another priority of care for Ryan shall be identifying the genesis of the haemothorax and treating it. In Ryan’s case of accident, a tube is what is needed though surgical operation can be explored in situations of further complications. Ryan’s quick recovery can also be a top priority for the nurses attending to him. This can be achieved through a careful and systematic approach that can hasten his healing process without necessarily compromising its quality.

From the observation, Ryan has also sustained bruises especially the one that could have been caused by a safety belt. Such bruises, if left unattended, could also be a source of discomfort to Ryan, who is also reeling from chest pain, breathing problems, and even shock from the accident. Therefore, an emergency way of dressing such bruises can also be another priority. Ryan also complains of nausea. This could be that when the TV flows. IV flow is higher; chances are very high that the patient will vomit. Therefore, in Ryan’s case, it would be better if the IV flow could be adjusted so that he doesn’t vomit. This will further weaken him (Emergency Nurses Association 2010).

If an operation has been carried out on Ryan or the point at which the drainage tube was inserted must be dressed. The dressing should be conducted to prevent any infection to the wound (Sinn 010, p. 17). The material chosen for such dressing should be of quality so as to promote faster healing

Also, another priority for Ryan is the dressing on the wound, which ought to be changed when the wound is not dry and intact. This situation can be attributed to symptoms of infection or any other worrying tendency like, for example, redness of the wound, swelling or discharges, or no evidence for routine wound dressing every three to seven days (O’Shea 2011). It must also be emphasized that the dressing of the wound should be done carefully and in the right way to avoid further complications from the wound, which can affect his recovery path.

Finally, the health priorities for a patient like Ryan can be many. However, compromises have to be made so as to ensure that the primary priorities for such patients are first addressed before other issues are dealt with. All these measures will be aimed at promoting his healing process while at the same time deterring the possibility of further complications from his condition.

Pathophysiological Events and Nursing Considerations:

Hamathorax is contained first by removing the part that causes bleeding and draining any blood that might be in the thoracic cavity (Hewson, Poulakis, Jarman, Kerr, McMaster, Goodge, and Silk 2011). Through the process of tube thoracostomy, blood in the cavity is drained. This is done through the insertion of a chest tube, thus subsequently affecting the lung to expand, hence stopping the bleeding. To prevent chest clogging or occlusion, which potentially can lead to further complications like crippling effective drainage of the space in the pleural cavity, better-performing chest tubes are a must.

Large diameter tubes or more than one tube are normally used with an intention of limiting clogging potentials and should clogging be detected, the patient always must transferred to a theatre with an intention of opening up the chest through a surgical process in order to get rid of pleural cavity clot.

Tambimuttu, Hawley, and Marshall (2012) state that in the event that the clot persists in the chest tube that is being used to drain the blood and any air from the chest cavity or in the pleural cavity, Thrombolytic agents are applied to break this up. Though this can be an effective way of dealing with blood clogging, it does pose a risk in that it can result in increased bleeding as a result of the thrombolytic agent that makes blood less thick, thus causing overbleeding

In the circumstances listed below, surgical operations shall be explored to reverse the trend of blood being less thick. These circumstances are;

First, if there is continued bleeding from the chest, a condition that can be explained at 150-200 ML/h for two to 4 hours

Secondly, if back-to-back blood transfusion is needed to maintain the hemodynamic stability in the body.

When draining blood and air from patients with coagulopathy, great care and attention must be paid.

This caliber of patients includes those patients who are normally administered anticoagulation therapies whenever the need arises. At this stage, it must be noted that needle aspiration are not applied in an event where clotting deficiencies are prevalent. Instead, tube thoracostomy is applied with the capability of visualizing and managing any bleeding from the chest wall. Out of necessity for patients who are in need of extended anticoagulant medication, such treatment mode can be re-continued after 8-12 hours after the thoracostomy has been done.

With the completion of tube thorascomy process, repeated chest radiographs should follow immediately. This will aid in the observation of the chest tube position hence assisting in observing how the exercise of evacuating the haemothorax from the chest cavity has been done. It may show other intrathoracic pathology that had been obstructed by the haemothorax.

Normally, a chest tube is placed to a water seal when the lung has been fully expanded through radiography. The drainage of fluid is usually less than 50ml within 4 hours and in these circumstances, residual air leak is limited.

There could be circumstances where a chest tube ought to be clamped. After the realization that air or liquid collection is absent through conducting follow up observation by use of radiography, the tube is removed. Also, it is important that radiography is done after the removal of the tube to ensure the absence of complications should drainage be incomplete, as shown by radiograph studies. After the removal of the thoracotomy chest tube, a second tube should be done through the use of video-assisted surgery. (V.A.T) and a further operation was conducted to completely drain the pleural cavity.

According to Blackbourne (2008) research has shown that 70-78% of patients with traumatic haemothorax usually get successful treatment through the use of theroscomy chest tube and therefore such patients demand no further therapies apart from one to three follow up chest radiographs within a span of 2-5 weeks to be certain of absence of intrathoracic collections that can degenerate to further complications. The prevalence of other intrathoracic pathology besides other symptoms may necessitate additional chest radiographs. The extent of other injuries will dictate extended treatment.

Research has shown that nearly 20% of the individuals who have undergone tube thorascoscomy will register amount of clot in their thoracic space (Eastman and Minei 2009). Although this is a grey area on what ought to be done, a number of opinions have been fronted on the best way of addressing this. These opinions do range from the follow ups after the initial process to evacuations through surgical methods.

Video-aided surgery (VAT) has tended to be the modern trend of addressing this medical malady. According to Manlulu, Lee, Thung, Wong, Yim (2012, p. 14), in some cases, it is administered within 7 to 8 days after the initial injury whereas others perform it within 2-3 days after retained clot has been noted in the chest cavity.

In situations where VAT is applied, one-lung ventilation is not a necessity. Instead, one-lumen tube is used to aid in ventilation during the whole process of operating the chest cavity.

Should the cardiac injury be noted, the thoracotomy process should be reverted to and with speed so that further complications can be avoided.

The decision to employ VAT when dealing with retained clots is performed by the need to reduce the number of individuals who develop empyema and prothorax.

This process besides adding operative way of managing a patient, it does also provide an almost occurrence treatment mechanisms and decreasing the number of days that a patient needs to stay in the hospital unlike other methods.

Manlulu et al, (2012) further note that after thorascomy or VAT on those patients that generally like other patients because of diminished risks chest tubes is removed when drainage is about 25-50 ml.

After the removal of the chest tube, chest radiographs are taken to be sure that the healing process is on course as intended and no further complications are noted and if any, adequate measures are taken. Additionally, chest x-ray films can be obtained to enhance proper view and understanding of the whole healing process.

Haemothorax as a result of injury to the chest can be very tricky when handling it. It is therefore important that patients suffering from haemothorax when being treated are handled with utmost care.

This is what calls for the utmost pathophysiological process and nursing consideration so that they can be treated and healed in a timely manner, where more than one treatment is needed. However, in some situations, like retained clotting, where more than one treatment option exists, there ought to be an open approach to such an issue. This can be addressed through a more researched and well-versed option instead of applying options whose efficacy has not been tasted. In a way, this will be a necessity since the issue at hand is the life of a human being that is hanging on balance and must be treated at all costs with utmost care.

Nursing management program for Ryan comprising relevant ED pathways and pharmacological management in ED:

It is apparent that Ryan is in a sorry health state and thus in dire need of emergency nursing measures. These measures will be directed to cardiopulmonary stabilization with an intention of limiting ventilator time and deterring sit upright unless other injuries hampers this position. Oxygen will be administered in order to give the patient breathing stability and air way should be released together with the breathing (Australasian College of Emergency Medicine 2011).

Because of Ryan’s conditions like, chest pain notably breath shortness, chest pain among conditions, there will be urgent need for his upright chest radiographs to be obtained so as to ascertain the extent of injuries to the chest and any other vital organs of the body. The aim of this is to establish the extent of the injuries and the most appropriate treatment to be adopted when treating the patient (Curtis and Ramsden 2011).

An extensive evaluation of the chest ought to be done to establish whether tension pneumothorax is prevalent and, if so, appropriate measures adopted. To be sure of this, needle decompression of tension pneumothorax shall be used. If it is confirmed, emergency measures shall be undertaken to diffuse it; otherwise, it can lead to worse oxygen shortages and very low pressure of the blood, subsequently resulting in sequelae ( a condition that is a result of trauma or injury) which can actually cause death (Tambimuttu, Hawle, and Marshall 2012).

Given that Ryan has exhibited respiratory complications, a thoracotomy will be needed. As explained earlier, thoracotomy involves the insertion of the chest into the chest cavity so as to drain any blood that might be in the thoracic cavity. The tube inserted will cause the lungs to expand, thus preventing further bleeding.

If it is established that Ryan has sustained bruises, especially the one caused by a seat belt, measures like the application of liniment shall be undertaken so as to alleviate any pain caused by such bruises that result from an accident. If needed, strong painkillers can be administered so as to mitigate discomfort to Ryan, who is also suffering from haemothorax (Australasian College of Emergency Medicine 2011).

Ryan is in pain mostly from the chest and needs emergency pharmacological management in the emergency department as to alienate this, significant pain management aspects have been derived to assist patients like Ryan who are in dire need of them. Some tests must be done on Ryan to establish the extent of the injury to his chest haemothorax (Eastman and Minei 2009). These tests include chest X-rays, Chest X-rays CT scans, pleural fluid analysis, and thoracentesis

Emergency measures must, therefore, be undertaken upon realizing that Ryan is suffering from the already suspected haemothorax. The major target for such treatment will be to make him (Ryan) stable, hinder further internal bleeding, and also get rid of the blood and air that might be in the pleural cavity. A chest tube will have to be inserted into the chest cavity through the wall with the sole purpose of draining blood and air in this space.

If it is found out that the haemothorax is advanced, a surgical method (thorascomy) will have to be applied so as to aid in controlling further bleeding. There is a likelihood of blood in the chest cavity thickening because of the activation of the clotting cascade. Blood thickening will lead to clots in the pleural cavity resulting to chest tube occlusion. Subsequently, this will effect inhibition of proper drainage of the pleural fluid. Therefore, effective working chest tubes are needed in order to limit the clogging potential and its related complications.

Ryan must be administered with 100% oxygen through a non-rebreathing mask. This will aid him in breathing, as he has been noted to have breathing complications (Curtis and Ramsden 2011). Another emergency response that Ryan desperately née is the completed examination of his body to be sure that all injuries sustained in the accident are attended.

It appeared that Ryan is only complaining of chest pain and that there are no other physical injuries, But a thorough examination of his entire body is a necessity; otherwise if this is overlooked, a serious health issue could be underway that can greatly affect his healing process or even his health

Another emergency that might be needed for Ryan is the use of thrombolytic agents. These are used in situations where there are blood clots. They are, therefore, used to diffuse clots in tubes or when such clots emerge in the pleural cavity. However, such procedure in risky because of the potential of leading to increased bleeding

In case bleeding persists, surgical operation will be a necessity especially if it has been caused by aorta rapture.

Final Summary

In summary, pneumothorax is a bit common in trauma patients, and therefore, being able to promptly recognize the clinical aspect and also being able to aggressively care for the patient is of utmost importance. Therefore, emergency departments (EDs) must have the necessary manpower with the best equipment so as to be able to fix such life-threatening issues; otherwise, if left unattended, the life of a patient can be lost.

References

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