Case study - what would you do?

[Lev]

Mr. Jones is a 42 year old male who arrived via EMS to your hospital's ER with complaints of sudden shortness of breath and sharp 10/10 chest pain radiating to his left shoulder and back. Vital signs on arrival to the room are BP 138/65, HR 127 BPM, RR 36, and SpO2 is 99% on 15L of oxygen via a non rebreather mask. Mr. Jones has no underlying health conditions. He has a slim build and smokes 3/4 pack of cigarettes per day. The MD arrives to the room as the patient rolls in and respiratory therapy is called to the bedside. Mr. Jones in is visible respiratory distress and is using accessory muscles to breath. Mr. Jones is very agitated and states in full sentences that all he needs is some oxygen and insists that he will be fine without having labs drawn or an IV inserted. His family is very surprised at how he is acting. As this patient's nurse, what are your next steps?

[icuRNmaggie, BSN, RN]

Smoking accounts for the diminished lung sounds and probable emphysema-

I don't diagnose.

Left side diminished > Right side suggests a blockage or collapse of the upper lobe.

Did he get that CXR yet?

[Lev, MSN, RN, NP]

1. Spontaneous pneumothorax. Slim build and smoker. Chest X-ray, ABG, set up for chest tube. Agitation secondary to hypoxia.

Yes yes yes!!!

[Lev, MSN, RN, NP]

A portable chest x ray was done which was highly suspicious for a large pneumothorax (about 80% collapsed) of the left lung. Given Mr. Jones' symptoms, asymmetric lung expansion, and x ray results, the decision was made to insert a chest tube. After much pleading and tears from Mr. Jones's family he agreed to have an IV inserted and the procedure was complete. One the chest tube was in and the lung began to reexpand, Mr. Jones was much less resistant to receive some morphine for pain (which helped calm him down a little too). Mr. Jones was admitted to the med-surg unit with the chest tube in place. Although there were some issues with full lung expansion at first, Mr. Jones was discharged after a 5 day hospitalization with instructions for smoking cessation.

Primary Spontaneous Pneumothorax (PSP) is thought to occur when a fluid filled blister (bleb) typically in the apices of the lungs ruptures causing atmospheric air from the airways to leak into the pleural space. These blebs can be seen in a CT scan. Patient are asymptomatic until the bleb ruptures causing sudden onset of symptoms. Naturally greater pressure in the alveoli causes air to flow from the alveoli into the pleural cavity. Due to the natural recoil of the lungs, the air continues to flow until a pressure gradient is reached or if the lung collapses enough to seal the leak. Patients with a primary spontaneous pneumothorax typically present with shortness of breath, tachycardia, and may have sharp/stabbing chest pain on the affected side that radiates toward the shoulder. Anxiety may occur in some cases. (This patient clearly had a severe case).

PSP is common in tall, young, lean men, usually between the ages of 20-40. It is thought that in taller people there is a greater difference in pleural pressure from the top to bottom of the lung and this can lead to the development of blebs. This condition is also more common in smokers, because smoking increases inflammation of the cells of the small airways which can also contribute to blebs by causing emphysematous changes of the alveoli. The alveoli can rupture and cause air to escape into the lung tissue which can cause blebs and bullae (larger blebs).

Many PSP's are benign and resolve on their own. However, some patients who are symptomatic many not seek medical attention right away. (The risk of pulmonary edema related to re-expansion increases in those who had a chest tube placed more than 3 days of onset of the pneumothorax). There is about a 30% chance of recurrence within 5 years. Smoking cessation is encouraged to prevent recurrence.

Medscape: Medscape Access

[Lev, MSN, RN, NP]

Left side diminished > Right side suggests a blockage or collapse of the upper lobe.

Yes, lungs were diminished throughout. Lung sounds were heard on the affected side but sounded more diminished than the affected side. The CXR show a large "black" area on the affected side so clearly air was not passing there but lung sounds could have echoed from the unaffected side given the patient's slim build.

[Lev, MSN, RN, NP]

His reluctance certainly isn't unusual, particularly for youngish men, and our usual routine is to get the 12 lead first and if it shows STEMI then you've got some ammunition to try and convince them to consent to a heart cath (other option=death), we still have patients that clearly refuse a heart cath even after everything's been explained, in which case we shift to other treatments they do consent to, which may be nothing more than comfort care, which is completely within their rights.

I think age definitely played a role here. This was a scary event in an otherwise young healthy individual.

[InvisibleDove]

oxygen, EKG( if cleaR move to option two) Asa, morphine, labs, cath lab, icu.

#2- if EKG clear: morphine, labs (d dimer,) chest X-ray, ct, mri maybe?

If PE: clot buster, long term anticoag, Stop smoking....

If pneumothorax: chest tube.

I'm pretty sure all options end in Icu (pulm/cardiac)

[Been there,done that, ASN, RN]

Next step is turf it to the doc."Joe blow is refusing care". The attending physician is responsible for obtaining legal permission to administer medical treatment.

[That Guy, BSN, RN, EMT-B]

So what was happening with patient number 2 and 3 while this was going on. Whats their story this was a good one

[SierraBravo]

This makes me think of the post from the guy who said he was an ED nurse and didn't think it was necessary to carry a stethoscope or use one for assessment. I digress...

[smf0903]

I love reading these case studies, I always learn from them! Thank you for sharing :)

As an aside, "bleb" is one of my favorite terms lol

[mikala3]

if that guy refuses labs and an iv, i would personally "educate" him every few minutes then document my attempt each and every time. That way when his family sues because he wasnt treated, they lose.

[Lev, MSN, RN, NP]

So what was happening with patient number 2 and 3 while this was going on. Whats their story this was a good one

Don't remember which means they were "boring"... I.e. not critical...I was probably ignoring them while dealing with Mr. Drama...sorry patients.