W. R., 33-year-old man, was involved in a motor vehicle crash in which he sustai
ID: 127641 • Letter: W
Question
W. R., 33-year-old man, was involved in a motor vehicle crash in which he sustained chest injuries. W. R., the driver, was not wearing his seat belt, and the steering wheel was bent. At the scene, W. R. was unresponsive. After placing a cervical collar to stabilize his neck, the paramedics performed endotracheal intubation and provided ventilation with 100% oxygen via a bag-valve device. Vital signs included a palpable systolic blood pressure (BP) of 60 mm Hg and a heart rate of 136 beats/min. W.R.’s skin was pale, cold, and clammy with a delay in capillary refill. Peripheral pulses were weak and thready. Two 14-gauge peripheral intravenous catheters were inserted, and lactated Ringer’s solution was infused at a wide open rate. He was transported to the emergency department on a backboard. The initial assessment in the emergency department noted that his palpable BP had increased to 90 mm Hg and heart rate was 125 beats/min. He was restless in response to pain, with no other purposeful responses. Pupils were equal and reactive to light. Chest expansion was unequal, and breath sounds were markedly diminished on the right side. A chest X-ray documented a 70% hemopneumothorax on the right side, and a 36-French chest tube was inserted at the eighth intercostal space at the right midaxillary line. Immediately, 2000 mL of blood was drained from the chest, and an additional 500 mL of drainage was recorded in the next 30 minutes.
Initial laboratory results were:
Hemoglobin: 9 g/dL
Prothrombin time: 15 seconds
Hematocrit: 31%
Partial thromboplastin time: 47 seconds
Platelets: 274,000/L
Red blood cells: 2.9 million/L
White blood cells: 5300/mm3
An indwelling urinary catheter was inserted, and 80 mL of clear, yellow urine immediately drained. Fluid resuscitation was continued to maintain a systolic BP at 90 to 100 mm Hg. W. R. was taken immediately to the operating room, where a right thoracotomy was performed, with repair of the right axillary artery. In the operating room, his vital signs remained stable with continued fluid resuscitation of crystalloids, blood, and fresh frozen plasma.
After surgery, he was admitted to the critical care unit, where his BP was 116/70 mm Hg, heart rate was 90 beats/min, and respiration rate was 24 breaths/min on the ventilator (assist/control mode with a rate of 20 breaths/min). He was responsive to commands and denied pain. He was medicated with morphine, 4 mg intravenous push every hour for pain.
Laboratory results were:
Hemoglobin: 11 g/dL
Prothrombin time: 18.7 seconds
Hematocrit: 34%
Partial thromboplastin time: 71.7 seconds
Platelets: 180,000/L
Fibrinogen: 76 mg/dL
Red blood cells: 4.8 million/L
White blood cells: 5300/mm3
Arterial blood gases (on 60% assisted ventilation):
pH: 7.30
PaCO2: 40 mm Hg
PaO2: 90 mm Hg
SaO2: 92%
HCO3: 17 mEq/L
Questions:
What type of shock did W. R. demonstrate at the scene, and what components of his assessment supported this diagnosis?
W. R.’s initial assessment indicates that he is in which stage of shock?
In the emergency department, W. R. received lactated Ringer’s solution for fluid resuscitation. Is this the appropriate solution at this time?
Explain W. R.’s arterial blood gas results. What treatment is indicated?
Describe the nursing care W. R. will receive in the first 24 hours after his surgery.
Describe the risk factors W.R. has for developing sepsis.
Explanation / Answer
1.a W.R demonstrates Hemorrhagic shock and assessment data which supports this diagnosis are
systolic blood pressure (BP) of 60 mm Hg and a heart rate of 136 beats/min, pale, cold, and clammy with a delay in capillary refill,weak and thready Peripheral pulses,BP increased to 90 mm Hg and heart rate of 125 beats/min, 70% of hemopneumothorax, Hemoglobin: 9 g/dL,Prothrombin time: 15 seconds,Hematocrit: 31%,Partial thromboplastin time: 47 seconds,Platelets: 274,000/L,Red blood cells: 2.9 million/L,White blood cells: 5300/mm3.
1.b.The initial assessment of W.R . indicates that he is in the compensatory stage of shock.
1.c In hemorrhagic shock fluid replacement is aimed toward normalization of hemodynamic parameters. Fluid treatment is aimed at restoration of radial pulse or restoration of sensorium or obtaining a blood pressure of 80 mm Hg by aliquots of 250 mL of lactated Ringer's solution .Hence it is appropriate solution to be administered at this stage.
1.d The ABG analysis reveals Primary metabolic acidosis (HCO3: 17 mEq/L less than normal) indicates need for resuscitation and sodium bicarbonate administration.
1.e Nursing care- monitoring Vitals.
Ventilator care
Fluid Resuscitation with plasma,Crystalloids,blood,plasma
Pain management
Prevention of infection and other complications.
!.f. Risk factors for Sepsis.
Chest injury,Chest tube drainage,surgical interventions.(Thoracotomy)
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