Page 673 - Clinical Application of Mechanical Ventilation

Case Studies 639

Complications
Tension pneumothorax
was probably caused by exces-
sive airway and pulmonary During the course of mechanical ventilation, a left-sided tension pneumothorax
pressures.
occurred and this led to decreased lung compliance, decreased O saturation, and
2
decreased breath sounds on the left side. Chest radiography showed a shift of the
mediatinum to the right side. The tension pneumothorax gradually resolved with
To prevent self-extubation,
neuromuscular blocking agents the placement of a chest tube.
and sedatives may be used to At one point during weaning the patient became very combative and he self-
provide comfort. An alternative
is to use active restraints extubated. He was reintubated without delay. Cloth restraints were then used to
with frequent assessment for secure his extremities.
continuing use.

CASE 7: TENSION HEMOPNEUMOTHORAX

INTRODuCTION

P.S. was a 50-year-old, 96-Kg male transferred from another hospital with a
A chest tube is used to complicated, right lower lobe pneumonia and hemothorax. At the onset, a small
remove air, blood, or fluid
accumulated in the pleural right pleural effusion was found that required drainage of 600 mL exudates material
space. via a needle thoracentesis. This effusion again re-accumulated and a second
thoracentesis was performed that was productive of over 400 mL of thin, cloudy
fluid. A chest tube was placed following the procedure, which continued to drain
Hypotension and tachy- thin, cloudy fluid followed by frank blood. This output continued throughout the
cardia are two common signs day, requiring massive transfusions to maintain his blood pressure; subsequently, he
of inadequate blood volume.
was transferred to a tertiary care facility for definitive therapy. Prior to air transport,
the patient was volume-resuscitated with both blood and fluid, nasally intubated, and
noted to have inadequate drainage of the right hemothorax.
Tension pneumothorax
or hemopneumothorax shifts Upon arrival at the ICU, the patient developed further hemodynamic instabil-
the mediastinum to the unaf- ity with a systolic pressure of 70 mm Hg (normal 120 mm Hg) and a heart rate
fected (opposite) side.
of 120/min (normal 60 to 100/min). He had weak peripheral pulses, dullness
to percussion of the right thorax, expiratory wheezes, and coarse rhonchi, with
the left being greater than the right. The chest tube drained about 950 mL of
Colloids are used to
enhance fluid balance in bloody fluid. The patient was resuscitated with colloids followed by more blood
the early phase of volume transfusions. A chest radiograph revealed a complete opacification on the right
replacement.
with concurrent mediastinal shift to the left side (Figure 19-4).

Indications

The patient was electively intubated prior to transport, to establish and maintain an
adequate airway. Mechanical ventilation was established to secure an airway prior

Copyright 2013 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s).
Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.