Siobhan Rice – S00237990 PARA107 – Assessment 2 Case Study

From analysing this patient’s vitals, it is evident that the individual has, cardiac tamponade,
multiple rib fractures and obstructive shock. As this patient has reached Beck’s Triad cardiac
tamponade can be diagnosed. Beck’s triad involves hypotension, a distended jugular vein and
muffled heart sounds, this diagnosis is further supported by pulsus paradox (Honasoge,
2018). The multiple rib fractures are suspected due to the presence of a flail chest. This
patient is also displaying signs of obstructive shock. This is evident through not only the
diagnosis of cardiac tamponade but also through the reduced conscious state of the individual
and shallow breathing. By having the individual have their GCS (Glasgow Coma Scale) score
drop 2 points this is a clear indication that there is a significant decline in the individuals
conscious state and cognitive function. It is also suspected that this patient could be
experiencing a pneumothorax which is at risk of tensioning. This is supported by the flail
chest showing that there are multiple fractured ribs which are at a high risk of puncturing a
rib and causing a pneumothorax, this diagnosis can also be supported by the reduced tidal
volume of the lungs as well as the significantly reduced SpO2 levels. A pneumothorax would
also further support the diagnosis of obstructive shock for this patient. The bruising of the
upper left abdominal quadrant could indicate haemorrhage. This is suspected due to the
mechanism of injury, by having the individual crash into the steering wheel, this can cause
organ sheering and haemorrhage.

Cardiac tamponade can be lethal if left undiagnosed and without adequate medical attention
and treatment. The pericardium consists of two thin layers of tissue, these usually have a
minimal amount of fluid to prevent friction, however when there is a build-up of fluid or
other matter in this space this can cause an increase of pressure in the pericardium, this is
known as cardiac tamponade or pericardial tamponade (Buckberg, 2018). This creates an
increase in pericardial pressure, that will restrict the hear filling and in turn decrease cardiac
output. In this instance, the cardiac tamponade is suspected to be caused by a traumatic chest
injury. The major diagnostic signs of cardiac tamponade are known as Beck’s triad. Becks
triad involves hypotension, muffled heart sounds and a distended jugular vein. The muffled
heart sounds are a result of the increase of fluid or other matter in front of the heart making
the heart sounds more difficult to hear (Imazo, 2016). The hypotension associated with
cardiac tamponade is associated with the hearts inability to fill adequately. By having the
heart not filling adequately this will result in less blood being able to be pumped around the
body this means there is a significantly reduced tidal volume and as the heart is not filling
adequately the heart is also pumping at a lower pressure (Kuçi, 2019). The distended jugular
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vein is a result of the heart being unable to fill properly as the blood is being stored in the
vein. Veins are what carry blood back to the heart to be pumped to the lungs for oxygenation
(Buckberg, 2018). Cardiac tamponade will not resolve on its own and requires emergency
medical intervention. In order to best treat cardiac tamponade, it is important for a doctor to
remove the excess fluid from the pericardial cavity (Arsen et al., 2014). This can be done
through pericardiocentesis, this is the removal of fluid from the pericardium using a needle,
similar to a chest decompression (Witsenburg, 2019). This can also be achieved through a
pericardiectomy, the surgical removal of a part of the pericardium to remove pressure on the
heart or a thoracotomy which is the draining of blood or blood clots around the heart
(Tanaka, 2017).

Multiple rib fractures are often not lethal but can cause damage to major blood vessels or
internal organs such as the lung. Rib fractures are most commonly caused by a traumatic
injury such as a motor vehicle accident where the individuals chest strikes the steering wheel
(Marasco, 2015). Fractured ribs often heal on their own with little to no intervention. In this
case there have been multiple rib fractures causing a flail chest. This can be treated by
positioning the patient in an upright position if possible and by using pressure bandaging to
secure the flail segment in place, however surgery may still be required for the patient
(Cataneo, 2015). A flail segment can be identified by paradoxical breathing. Paradoxical
breathing is when there is a segment of chest that is not moving in unison with what is
expected of ‘normal’ breathing patterns, this involves the chest cavity increasing upon
inhalation and decreasing upon expiration. Paradoxical breathing consists of a segment of the
chest wall moving in upon inhalation and out upon expiration (Xu et al., 2015). Whilst flail
chest can heal without surgical intervention, surgery may still be required as will intubation,
this depends on what damage to the body the fractures may have caused.

A pneumothorax is air in the pleural space causing a partial or complete lung collapse. In this
instance the suspected pneumothorax is a result of the trauma experienced by the individual
during their motor vehicle accident (Imran & Eastman, 2017). Intrapleural pressure is
normally negative, this is due to the inward lung and outward chest wall recoil (Verma,
Ibrahim & Garcia-Contreas, 2015). In a pneumothorax, air can enter the pleural space from
outside the cavity or from the lung itself. As the intrapleural pressure increases the lung
volume will decrease. It is also possible that this pneumothorax could turn into a tension
pneumothorax or a hemopneumothorax the exact type of pneumothorax cannot be discovered
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until the individual has reached hospital where they can undergo a number of diagnostic tests.
There is a possibility of a hemopneumothorax as there is suspected internal haemorrhage
which would bleed into the pleural cavity. The signs of a pneumothorax can include pain,
decreased breath sounds an enlarged trachea that is visibly shifted to the left and in severe
cases hypotension can also be indicative of a tension pneumothorax (Shalhub et al., 2019).
All types of pneumothorax will require some level of medical intervention. A pneumothorax
is considered a medical emergency as it can become lethal if left untreated. Treatments for a
pneumothorax include a catheter aspiration or tube thoracostomy. Catheter aspiration
includes inserting a catheter into the 2nd intercostal space along the midclavicular line. This
should assist in decompressing the chest (Chang et al., 2018). A tube thoracostomy is
generally used to treat secondary and traumatic pneumothoraxes (Greene, C. & Callaway, D.
W., 2016).

Shock is a potentially life-threatening condition that occurs when the body, or a part of the
body is not getting adequate blood flow. By limiting blood flow cells and organs are not
receiving the necessary oxygen for cellular respiration and are unable to transport the ‘waste
products’ of respiration and de-oxygenated blood back towards the heart (Taha, M., &
Elbaih, A., 2017). There are many types of shock, these include obstructive shock,
cardiogenic shock, distributive shock and hypovolemic shock. The patient in this case study
is expected to be experiencing obstructive shock. Obstructive shock is when the body, or a
part of the body enters shock as a result of a physical obstruction (Vincent, J. L. & De
Backer, D., 2013). The obstruction could be a blood clot or severe swelling. Through an
examination of this case study it can be assumed that the patients obstructive shock is as a
result of the cardiac tamponade that they are experiencing, this is because the excess fluid is
impeding the hearts ability to fill properly and perfuse adequately. Obstructive shock will
require medical intervention to relieve the obstruction. In this instance the way to relieve this
type of obstructive shock is to address the cardiac tamponade that is believed to be causing
obstructive shock. The main symptoms associated with obstructive shock include decreased
neurological function, as seen by the patients decrease in GCS, an increase in heart rate and
shallow breathing. The individual in this case study is experiencing all of these symptoms as
well as having cardiac tamponade, this is a massive indicator of obstructive shock (Bodson,
L., Bouferrache, K., & Vieillard-Baron, A., 2011).

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Internal haemorrhage can be lethal to the patient if left untreated. It is suspected that this
patient has internal abdominal bleeding, this is very serious as an individual can lose over 5L
of blood in their abdominal cavity (Tasu et al., 2015). This can cause hypovolemic shock.
The major signs of internal bleeding include shortness of breath, abdominal pain, altered
level of consciousness and bruising. The patient in this case study is experiencing a number
of these signs as he has obvious bruising to the upper left quadrant of his abdomen. This
quadrant is home to the stomach, spleen, left kidney and the left lobe of the liver which all
have a number of major blood vessels that can lead to excessive bleeding. Due to internal
haemorrhage being potentially life threatening, especially when the bleed is in the abdominal
cavity, medical intervention is required to stop the bleeding (Oyo-Ita, Chinnock, & Ikpeme,
2015). This could mean that surgical intervention is necessary in order to save the patient’s
life and prevent them from entering hypovolemic shock which occurs when an individual
loses more than 20% of the body’s blood or fluid supply (DiPiro et al., 2014).

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