I recently (but not too recently) had a patient with chest trauma who left
us in a bit of a clinicla dilemma.
Hx.
Pedestrian
Blunt chest trauma to right side chest resulting in #2,3,4,5, ribs, flail
segment, large pulmonary contusion and tension pneumothorax.
The mechanism was a direct blow from a passing vehicle, there was no other
trauma. The left side of the chest appeared fine (on 3 x-rays and
clinically)
Tension was drained and the patient was observed, however after about 15
hours he became tired and was intubated and ventilated on ITU. 10 minutes
later airway pressures up, SBP down, pulse up, sao2 down (34%!!!!!!). Both
sides of the chest were then decompressed, tension on the left relieved
leading to resolution of symptoms. Interestingly, because he was ventilated
on SIMV with a large contusion (plus collapse) on the left breath sounds
were heard well on the right despite there being a large tension (potential
trap for the unwary - if in doubt and things are going badly wrong consider
decompressing both sides).
Anyway, I placed a right subclavian triple lumen central line. This was
easily done (performed >200 in past) with nothing different from usual,
(bright red blood but ventilated on 80% at this point), non-pulsatile flow
on cannulation of the vessel.
However, Check XRay shows triple lumen line in left subclavian artery -
bugger!
So the questions:
1. Do you just pull the line out, press and hope? (or do something
different?)
2. Some people claim to transduce the intoducer needle routinely to avoid a
arterial puncture - is this over the top?
I can let you know what happened later.
Simon Carley
Anaesthetics / Intensive Care
Stepping Hill Hospital
Stockport
England
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