Introduction

This is a blog devoted completely to the discussion of pneumothorax. Here you will find an actual case study of a patient who experienced a pneumothorax, as well as pictures, external links, and a short quiz comprised of NCLEX like questions. Please, look around and let me know if you have any questions.

The Patient
73 Year Old Male 145 lbs. NKA Full Code Admitted for: 1. Right-sided pain of the thorax and upper arm 2. Four centimeter scalp laceration

History of Present Condition

Patient sustained a 10 foot fall Diagnosed as having: 1. Right-sided pneumothorax 2. Right sided fractured ribs 3. Right-sided sternoclavicular joint dislocation 4. Four centimeter scalp laceration. Immediate Course of Action: Day #1 Patient came in to the ED following a fall. He was subject to chest x-rays, CT scan (head, chest, abdomen, pelvis, and cervical spine), as well as an MRI (lumbar, thoracic, and cervical spine). As

stated above he was diagnosed as having a right-sided pneumothorax, multiple rib fractures, and

a sternoclavicular joint dislocation.

To treat the pneumothorax he had a chest tube inserted with 20cm dry suction water-seal drainage ordered. The patient endured no complications as a result of this procedure. To treat the dislocated joint he had his arm placed in a sling to stabilize the sternoclavicular joint. The scalp laceration was closed with staples. For his pain the patient had a thoracic epidural placed (10mgDilaudid, 2mL q4min). Course of Action: Day #2 Patient received another chest x-ray to monitor the s

tatus of the chest tube placement andpneumothorax. Results showed that the right lung hadreexpanded. Patient also went in to atrial fibrillation with rapid ventricular response. He was placed on a Cardizem drip to maintain a HR of greater than 120 and SBP greater than 90. Course of Action: Day #3 Patient received another chest x-ray to monitor the status of the chest tube placement and pneumothorax.Results showed that the right lung remained fully expanded. He also converted back to normal sinus rhythm at 2200. Course of Action: Day #4 Patient received another chest x-ray to monitor the status of the chest tube placement and pneumothorax.Results showed that the right lung remained fully expanded,

however there was increased opacity of the LLL suggestive of pneumonia. Patient was placed

on Levaquin (750mg every 24 hours x 5 days). Course of Action: Day #5-10 Patient'slung remains reexpanded. Copious amounts of drainage collected in water-seal system. He also completed his round of IV antibiotics for the pneumonia. Course of Action: Day #11 Patient's chest tube removed as well as the staples from his scalp laceration. Course of Action: Day #12 Patient was dismissed home. Went home with sling for his arm to stabilize the sternoclavicular joint.

Pathophysiology

A pneumothorax occurs when air enters the pleural space between the visceral pleura and parietal pleura causing partial or complete lung collapse. Signs & Symptoms: Mediastinal shifting usuallyoccurring with distant to absent breath sounds on the affected side. Sudden onset of acute pleuritic chest pain on the affected side usually occurs with labored breathing and dyspnea. Other problems that may occur include uneven chest wall movement, tachycardia, respiratory distress (severe tachyapnea).

Past Medical History

- Hypothyroidism - History of duodenal stricture - No history of smoking or drinking

Assessment Findings
0800: VS- 97.7/100/16, BP 128/76 in left arm, O2 sat 93%. Pt. alert, oriented x3. Skin pale, warm to cool, dry, intact. Eccymosis diffuse over right lateral thorax. MM moist, pink, intact. Nail beds pale pink, <3 seconds. Radial pulse 2+ bilat., PP 2+ bilat. Lung sounds clear bilat. ant/post. Abdomen soft, flat, bowel sounds present x4. IV in right forearm, occluded. Pt. c/o pain of 7/10 in right shoulder area radiating down to his right side ribs. Oxycodone (10 mg) administered. 0900: Pt. rates pain at 1-2/10, and is more comfortable now. Pt. taught cough and deep breathing and encouraged performing this every hour. 1200: Right forearm IV dcd, catheter intact. 1300: C/o pain 5/10 Lortab (1 tablet) given. 1345: Pt. rates pain on 0/10 and is more comfortable. VS: 99.2/84/16, BP 126/58, O2 sat 93%. All other assessments remain unchanged.

Relevant Labs
WBC = 12.8 (5.0-10.0)- Related to trauma, inflammation Free T3 = 1.88 (2.77-5.27)- Related to hypothyroid state Free T4 = .32 (0.78-2.19)- Related to hypothyroid state TSH= NA (0.5-5.0)

Diagnostic Tests
On Admission: Day #1 Chest X-ray: for suspected pneumothorax Large right pneumothorax Multiple right rib fractures CT scan: routine for falls/trauma Head = subgaleal hematoma Chest = right pneumothorax Cervical spine = wedging of T1 vertebral body (compression fracture) MRI: for pain post-trauma Lumbar = negative Thoracic = Mild fracture of T1, small right pleural effusion Cervical = Mild fracture of T1 Day #2 Chest X-ray: for status of pneumothorax and chest tube position

Right pneumothorax re-expanded following, chest tube in good position Day #3 Chest X-ray: for status of pneumothorax and chest tube position Right lung remains fully expanded, chest tube in good position Day #4 Chest X-ray: for status of pneumothorax and chest tube position Right lung remains fully expanded, chest time in good position, increased opacity of LLL suggestive of pneumonia.

Relevant Medications
Hydromorphone (Dilaudid) 10mg (2mL q4min) Epidural Reason: To control severe pain r/t rib fracture, etc. Classification: Opiate agonist Actions: Structurally similar to morphine but with 8-10 times more potent analgesic effect. Side Effects: Hypotension, bradycardia, respiratory depression, blurred vision. Morphine 2mg Q4h IV Administration: Dilute 210 mg in at least 5 mL of sterile water for injection. Give a single dose over 45 min. Avoid rapid administration. Reason: To control severe pain r/t rib fracture, etc. Classification: Opiate agonist Actions: Natural opium alkaloid with agonist activity by binding with the same receptors as endogenous opioid peptides Side effects: Respiratory depression, flush of face, neck, and upper thorax, oliguria, pulmonary edema **Narcan is antidote for overdose! Naloxone (Narcan) 40mL/h PRN IV Administration: Dilute 2 mg in 500 mL of D5W or NS to yield 4 mcg/mL (0.004 mg/mL). Give 0.4 mg or fraction thereof over 1015 sec. Reason: Opiate overdose antidote Classification: Opiate antagonist Actions: Reverses the effects of opiates, including respiratory depression, sedation, and hypotension. Side effects: Reversal of analgesia, increased BP, HR, and tachycardia. Oxycodone (Oxycontin) 5-10mg BID PO Reason: Treatment of moderate to severe pain (dislocation, simple fractures) Classification: Opiate analgesic

Actions: Binds with stereo-specific receptors in various sites of CNS to alter both the perception of pain and emotional response to pain. Side effects: Respiratory depression, pruritus, bradycardia, urinary retnetion or urinary frequency Cyclobenzaprine (Flexeril) 10mg TID PO Reason: Relief of muscle spasm associated with acute musculoskeletal conditions Classification: Skeletal muscle relaxant Actions: Acts primarily within CNS at brain stem; some action at spinal cord level is also probable. Depresses tonic somatic motor activity. Side effects: Edema of tongue and face, tachycardia, postural hypotension, flatulence, tremor, impotence. Levofloxacin (Levaquin) 750mg Q24h x 5 days IV Administration: Normal (750mg Q24 hours X 5 days). Diluted with D5W, NS, D5/NS, D5/RL from 500mg (25mg/mL) to produce 5mg/mL. Intermittent- adm over >60min, do not bolus or infuse too rapidly Reason: Community-acquired pneumonia Classification: Broad-spectrum fluoroquinolone antibiotic Actions: Inhibits bacterial DNA replication, transcription, repair, and recombination. Side effects: Decreased vision, foreign body sensation, transient ocular burning, ocular pain, photophobia, chest or back pain, phlebitis. Levalbuterol (Xopenex) 1.25mg TID IH Administration: Nebulizer treatment Reason: Reversal of bronchospasm with reversible obstructive airway disease. Increases vital capacity. Actions: Acts on the beta2 receptors of the smooth muscles of the bronchial tree, thus resulting in bronchodilation. Classification: Beta-adrenergic agonist Side effects: Migraine, tachycardia, increased serum glucose, dyspepsia, increased HR, insomnia. Diltiazem (Cardizem) 240mg Daily PO Administration: Do NOT crush, withhold if SBP <90, class="blsp-spelling-error" id="SPELLING_ERROR_14">subthreshold levels insufficient to stimulate cell excitation and contraction. Side effects: Syncope, arrhythmias, flushing, hypotension, weight increase.Liothyronine (Cytomel) 25mcg Daily PO Administration: In morning, after breakfast Reason: Hypothyroidism treatment (replace decreased amounts of T4) Classification: Thyroid hormone substitute, with more rapid action and disappearance. Actions: Replacement therapy for diminished/absent thyroid function resulting from primary or

secondary atrophy of gland. Increase in the metabolic rate of all body tissues. Side effects: Irritability, nervousness, HA, tremor, sweating, weight loss

Anatomy
The inner surface of the thoracic cage (parietal pleura) is contiguous with the outer surface of the lung (visceral pleura); this space contains a small amount of lubricating fluid and is normally under negative pressure compared to the alveoli. Determinants of pleural pressure are the opposing recoil forces of the lung and chest wall.