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CASE PRESENTATION
Jennifer Gardner, a 16-year-old 54 kg (120 lb) white female, is brought to the emergency department by
She is awake, alert, and oriented to person, place, and time when admitted via spinal board with cervical collar intact, on 2 L/min nasal cannula, with 16-guage intravenous (IV) lactated ringers at 100 cc/hr. She is complaining of midsternal chest pain nonradiating of 2 to 3 on pain scale
SaO: 97%-98%
Routine lab values reveal normal hemoglobin and hematocrit. Chest X-ray (CXR) was completed and reveals sinus tachycardia
ADMISSION TO ICU
The patient is awake, alert, and oriented, pain level is now a 1 with vital signs as noted: >BP: 110/70 mm Hg >HR: 118 bpm >Respirations: 20 breaths/min >Temperature: 98.6 F >SaO: 97%
When assessing heart sounds the nurse notes distant, muffled heart sound with the PMI slightly shifted to the left.
cardiac tamponade.
QUESTIONS:
1. Define blunt cardiac trauma (BCT). State the etiology and pathophysiology of BCT.
Blunt cardiac trauma is defined as a blunt trauma injury to the chest/heart that causes either ecchymosis or petechiae to develop on the myocardium (heart muscle).
Blunt cardiac trauma is most often caused an acceleration/deceleration injury that is sustained during a motor vehicle collision (MVC). Usual mechanism of injury is either the seat belt or from striking an object inside the vehicle (usually the steering wheel or dashboard). Other common mechanisms for sustaining a blunt cardiac trauma include: Motor vehicle accident Being kicked by a large animal (a horse for example) Being assaulted with a blunt instrument Industrial crushing injuries (explosions for example) Rigorous cardiopulmonary resuscitation
Crush injury
Fall
Pedestrian accident
Explosion
Shearing (stretching forces to areas of the chest causing tears, ruptures, or dissections Compression (direct blow to the chest)
Acceleration injury (moving object hitting the chest or patient being thrown into an object
Flail chest
Sternal fractures Esophageal injuries
Penetrating Cardiac Trauma is defined as anything that causes the myocardium to sustain a puncture wound from a sharp object. ETIOLOGY: Fractures (rib most commonly) Force inflicted injuries (knife, gunshot, ice pick) Industrial injury (usually falling on a sharp object) Motor vehicle collision that causes some sort of impalement Sports injuries Crushing injuries
Tracheal deviation
Audible air escaping from chest wound Decreased breath sounds on side of injury Decreased O saturation Frothy secretions
Dysrhythmias
Decreased BP Narrowed pulse pressure Asymetric BP values in arms Crunching sound synchronous with heart sounds
Subcutaneous emphysema
Open chest wound
8. Discuss appropriate nursing diagnosis for a patient with PCT. Decreased cardiac output secondary to decreased contractility or hypovolemia
PCT.
Provide adequate analgesia to promote breathing, coughing and movement Intercostal nerve blocks or continuous epidural analgesia may be employed to manage pain assoc. with flail chest
Control hemorrhage (apply direct pressure if bleeding from the wound). DO NOT REMOVE the impaled object (controlled surgical intervention will be required). Stabilize impaled object with IV bags and dressings Chest tube for hemothorax or pneumothorax will more then likely be required. Pericardiocentesis for cardiac tamponade
11. Define cardiac tamponade. State the etiology and pathophysiology of cardiac tamponade.
Cardiac tamponade is defined as the accumulation of blood, effusion fluid and or pus into the pericardial space. This fluid accumulation compromises cardiac filling and cardiac output as a result of increasing pressure on the
myocardium.
ETIOLOGY
Blunt or penetrating trauma Pericarditis Cardiac rupture Post CPR Rupture of the great vessels Renal failure Hepatic failure Infections (viral, bacterial or fungal) Drugs (Procainamide, Methyldopa, Hydralazine for example)
Electrical cardioversion
Malignancy Radiation therapy Connective tissue disease Metabolic disorders
Rheumatic fever
Viral infection
Aortic aneurysm
Release of inflammatory mediators Inflammatory response WBCs amass the site of injury Formation of exudates (fibrinous, semi-fibrinous, or purulent Collection of exudates in the pericardial sac
Pericardial effusion
Chest trauma
Heart compression
12. What clinical presentation will the patient with a diagnosis of cardiac tamponade display?
Complaints of pericardial fullness Complaints regarding feelings of doom Pain Dyspnea Tachycardia Pulseless Electrical Activity (PEA) in severe cases Becks Triad (hypotension, distended neck veins and muffled heart sounds) Increased right atrial pressure Increased Pulmonary artery diastolic pressure Decreased cardiac output and cardiac index
13. Discuss appropriate nursing diagnoses for a patient with cardiac tamponade.
Decreased cardiac output secondary to decreased contractility or hypovolemia Fluid volume deficit secondary to hemorrhage Pain Anxiety Knowledge Deficit
14. Outline Ms. Gardners collaborative plan of care related to a diagnosis of cardiac tamponade.
Intubation and mechanical ventilation (in most cases) Replacement of circulating volume (Normal Saline or Albumin) Inotropes as necessary
15. How should the nurse prepare Ms. Gardner for pericardiocentesis?
Performing a Pericardiocentesis is often a life saving measure for the patient who has developed cardiac tamponade. If Pericardiocentesis is required, the nurse can assist with the following preparations: Place patient in semi-Fowlers position ECG pads should be placed on limbs and away from the chest wall if possible Monitoring of ST-segment elevation is required and will be seen when the needle touches the epicardium. Pain medication and sedation should be given when possible. Monitoring for other complications (pneumothorax, cardiac rupture or cardiac laceration).
Crush injury
Fall
Pedestrian accident
Explosion
Direct blow to the rib/ rib cage Muscles and ribs cannot stand the force of the impact Chest trauma
Rib fracture
Flail chest
Flail Chest frequently a complication of blunt chest trauma from a steering wheel injury; occurs when two or more
Dyspnea Medical Management Rapid, shallow breathing Initial therapy Tachycardia Airway management Unequal chest expansion Adequate ventilation Palpable crepitus Diminished breath sounds
Supplemental O therapy Careful IV solution administration Pain control Mechanical ventilation may be necessary
Definitive therapy
Reexpansion of the lung Ensure adequate oxygenation
References
Marini, J., J. & Wheeler, A., P. (2006). Critical care medicine: the essentials. (3rd ed.). Lippencott, Williams and Wilkes. Philadelphia American Lung Association. (November 2003). Fact Sheet: Adult Respiratory Distress Syndrome. Retrieved on January 10, 2006 at: www.lungusa.org/diseases.ards_factsheet.html Cohen, S., S. (2003). Trauma nursing secrets. Questions and answers reveal secrets to safe and effective trauma nursing. Hanley & Belfus. Philadelphia. Critical Care Medicine Tutorials. (2003). Key points of acute lung injury. Retrieved on January 10, 2006 at: http://www.ccmtutorials.com/rs/ali/09_alikp.htm Melander, S., D. (2004). Case studies in critical care nursing: A guide to application and review. (3rd ed.). Saunders. Philadelphia