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olhamada · 04-24-2009, 08:46

Thanks SS. Great case. Knives scare me. Reminds me of a case I saw about 10 years ago. I had just started my ER shift and took turnover from the doc covering the earlier shift. She said, "I've only got one patient to turn over to you. Nothing bad. He's been here about 4 hours. He can probably go home."

Story was: 22 yo athletic BM stabbed in the R trapezius with a pair of scissors. Right after I got settled and the other doc had left, I went in to see him to get a better picture of his condition. He was sitting up in bed with a nasal cannula running 2L O2. He was splinting his right side, leaning forward supporting himself with his left arm, breathing through his mouth. When I walked in he immediately said, "I can't breathe". I quickly evaluated the situation, looked at the vitals monitor and saw he was breathing 22/min, HR was 130, BP was 108/72. He didn't have any JVD, tracheal shift, or visible injury other than two small puncture wounds in his right trapezius consistent with the history I received. At this point I was cussing the previous doctor. I quickly listened to his chest and heard no breath sounds on the right. He was moving air fairly well on the left and CV was normal other than being tachycardic. I asked for a stat CXR and the nurse said one was done about 2 hours prior. I asked her to still call for XR but asked her to bring me the films. Within 30 seconds I was holding it up to the overhead light and saw a completely collapsed R lung with minimal mediastinal shift. I also saw the broken tips of the scissors deep in the trap and quickly guessed that both had most probably penetrated the pleura. (Good guess, huh?) Remember, this film was 2 hours old. Now, why the heck, didn't the first doc look at this? Or if she did, why didn't she act on it?

I quickly placed an angiocath in the 2nd IC space and he began to show some improvement.

XR was slow, so I went ahead and put a chest tube in and covered the posterior wounds with an occlusive dressing. Immediately, the chest tube began draining blood, and his breathing eased, his color returned, and he became visibly more comfortable. As I watched the pleurevac I saw the level of blood rise - 200 cc, 250, 300, 350, 400, 450, 500, 550...... I began to get nervous again. As he passed 850 cc, I reviewed my procedure. I was sure I didn't puncture his liver, thought there is no way I'm in the IVC, aorta, heart, etc....... His vitals were holding stable, but he began to get a bit anxious and I wondered if this was because he was about to crash, or I thought he may be reading my anxiety though I thought I was covering it well.

One thing I didn't say, is that this was an outlying hospital with no good surgical backup, and it would take at least an hour to get him to a trauma center even with LifeFlight. I didn't have an hour. I had a few minutes at most.

We had two large bore IVs going, O2 BFM, and I started running through my game plan in my head. I asked the nurse to bring in a chest cart.

What would you have done?

04-24-2009, 08:46	#9
olhamada Guerrilla Join Date: Sep 2007 Location: Nashville Posts: 310	Thanks SS. Great case. Knives scare me. Reminds me of a case I saw about 10 years ago. I had just started my ER shift and took turnover from the doc covering the earlier shift. She said, "I've only got one patient to turn over to you. Nothing bad. He's been here about 4 hours. He can probably go home." Story was: 22 yo athletic BM stabbed in the R trapezius with a pair of scissors. Right after I got settled and the other doc had left, I went in to see him to get a better picture of his condition. He was sitting up in bed with a nasal cannula running 2L O2. He was splinting his right side, leaning forward supporting himself with his left arm, breathing through his mouth. When I walked in he immediately said, "I can't breathe". I quickly evaluated the situation, looked at the vitals monitor and saw he was breathing 22/min, HR was 130, BP was 108/72. He didn't have any JVD, tracheal shift, or visible injury other than two small puncture wounds in his right trapezius consistent with the history I received. At this point I was cussing the previous doctor. I quickly listened to his chest and heard no breath sounds on the right. He was moving air fairly well on the left and CV was normal other than being tachycardic. I asked for a stat CXR and the nurse said one was done about 2 hours prior. I asked her to still call for XR but asked her to bring me the films. Within 30 seconds I was holding it up to the overhead light and saw a completely collapsed R lung with minimal mediastinal shift. I also saw the broken tips of the scissors deep in the trap and quickly guessed that both had most probably penetrated the pleura. (Good guess, huh?) Remember, this film was 2 hours old. Now, why the heck, didn't the first doc look at this? Or if she did, why didn't she act on it? I quickly placed an angiocath in the 2nd IC space and he began to show some improvement. XR was slow, so I went ahead and put a chest tube in and covered the posterior wounds with an occlusive dressing. Immediately, the chest tube began draining blood, and his breathing eased, his color returned, and he became visibly more comfortable. As I watched the pleurevac I saw the level of blood rise - 200 cc, 250, 300, 350, 400, 450, 500, 550...... I began to get nervous again. As he passed 850 cc, I reviewed my procedure. I was sure I didn't puncture his liver, thought there is no way I'm in the IVC, aorta, heart, etc....... His vitals were holding stable, but he began to get a bit anxious and I wondered if this was because he was about to crash, or I thought he may be reading my anxiety though I thought I was covering it well. One thing I didn't say, is that this was an outlying hospital with no good surgical backup, and it would take at least an hour to get him to a trauma center even with LifeFlight. I didn't have an hour. I had a few minutes at most. We had two large bore IVs going, O2 BFM, and I started running through my game plan in my head. I asked the nurse to bring in a chest cart. What would you have done? __________________ "And dying in your beds many years from now, would you be willing to trade all the days from this day to that for one chance, just one chance to come back here and tell our enemies that they may take our lives, but they'll never take our freedom?"- Braveheart *de Oppresso Liber* Last edited by olhamada; 04-24-2009 at 08:49.
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