Anatomy Case Discussion 2

A 22 yo woman was stabbed with an ice pick in the L side of the chest and was rushed to the hospital. At the ER, PE revealed vital signs of BP: 70/30 PR: 120 RR: 30. The veins of his face and neck were engorged. The puncture wound was in the 4rd L ICS, 2 cm from the lateral sternal line, Trachea midline, breath sounds are clear both lung fields but heart sounds are distant. Impression was Cardiac Tamponade. Pericardiocentesis was done and revealed blood.He was then brought to the Operating room for Thoracotomy. OR Findings revealed: about 20cc of blood was evacuated with clot formation and a small puncture wound measuring about 1.5mm in depth in the R ventricle

Terms
Thoracotomy
an incision into the pleural space of the chest, performed by a surgeon and rarely, by emergency physicians to gain access to the thoracic organs, mostly commonly the heart and lungs, esophagus and thoracic aorta.

Distended neck veins

neck veins are bloated, could also be diagnosed as Pembertons sign, which is the development of Facial Flushing, due to the distended neck and head superficial veins, inspiratory stridor, and the elevation of the Jugular venous pressure upon the raising of the patients arms above the head simultaneously.

Pericardiocentesis
a procedure where fluid is aspirated from the peridcardium

Cardiac tamponade
emergency condition in which fluid accumulates in the pericardium (sac in which the heart is enclosed), occurs when the pericardial space fills up with faster than the pericardial sac can stretch. Amount of fluid increases slowly

Signs and Symptoms

Symptoms: 1. Conscious

2. Coherent 3. Oriented 4. Dyspneic Signs 1. BP 70/30 Abnormally low 2. Pulse rate 120/min High 3. RR 30/min 4. Presence of distended neck veins upon ocular inspection 5. Chest inaudible heart sounds during auscultation 6. Decreased intercostals retractions 7. Decreased area of resonance to percussion on let lower lung

Hypothesis
1. Damage to the tricuspid valve, which could lead to Tricuspid valve insufficiency a. Which is known as tricuspid regurgitation, which is the failure of the valve to close properly during systole, hence each heart beat, some blood passes from right ventricle to the right atrium, in the opposite direction. b. Symptoms of Tricuspid insufficiency could be asymptomatic, especially if right ventricular function is well preserved. c. It is generally right sided heart failure, such as hepatomegaly, edema, jugular venous distension. d. Signs are Jugular venous pressure are elevated, CV waves can be seen with a prominent V wave, with a rapid descent in jugular venous pressure. e. May lead to the presense of pansystolic heart murmur, which is low frequency and best heard low on the lower left sterna border. It increases with inspiration and decrease in expiration f. It could be inaudible reflecting the relatively low pressure in the right side of the heart.

g. S3 sound could be present, 2. Decrease in breathing sounds a. Can be detected via auscultation

b. Normal sounds occur in all parts of the chest area, such as collarbones, at the bottom of rib cage c. The decrease in sounds could be the result in the following i. Air or fluid around the lungs ii. Increased thickness of chestwall iii. Over inflation of one part of the lung iv. Reduced airflow in the lungs v. Heart failure d. Types of sounds that are abnormal for breathing sounds i. Rales 1. Small clicking bubbling or rattling sounds in the lung, occurs when air opens closed air spaces, can be moist dry, fine and coarse ii. Rhonchi 1. Resemble snoring, occurs when air is blocked or becomes rough through the large airways iii. Wheezing 1. High pitched sounds produced by narrowed airways, can be heard when person exhales, these are heard without stethoscope iv. Stridor 1. A wheeze like sound heard when a person breathes, usually due to the blocking of airflow in the windpipe. e. Since there are no abnormal breathing sounds could be heard it could be assumed that the abnormal breathing and decreased breathing sounds could be the result of dyspnea, and at the same time the damage done to the heart. 3. Intercostal retraction decrease due to respiratory distress which is caused by the Injury to the heart and distended neck veins a. These are inward movement of the muscles between ribs and results in the reduced pressure in the chest cavity, the movements of these muscles are a sign of difficulty in breathing. b. Chestwall is flexible which allows for normal breathing

c. Cartilage that attaches the ribs to the sternum allows free movement of bony structures hence the rib cage can expand and contract. d. Intercostals muscles during breathing, contract and pull the ribcage upward, while the diaphragm moves downward, hence expands the chest and causes air to fill the lungs. e. When there is difficulty in breathing the intercostals muscles are sucked inward between ribs, this is a sign of obstruction of airway. This will then result in intercostals retraction. 4. Distended Neck veins are a result of Right heart failure a. The backward failure of RV which leads to congestion of systemic capillaries, b. Generation of excess fluid accumulation in the body c. Causes swelling under the skin, peripheral edema or anasarca d. Affects the parts of the body such as foot, and ankle swelling in people e. Failure of pumping blood efficiently causing blood to back up and produce congestion, which is caused by heart valve damage f. Symptoms of Right sided failure could lead to swelling of the liver (hepatomegaly) accompanied by Nocturia (night time urination), swelling in the foot and ankle, and sacral edema for those who are inclined to lie down.

g. Decreased blood clotting could occurs 5. Lung resonance a. The lung is filled with air, hence there is percussion and gives a resonance b. Normal resonance should have a dullness in the left anterior chest due to heart and in the right due to the liver, there is hyper resonance on the left lower anterior chest due to air filled stomach c. Abnormal resonance is i. Decreased or increased resonance 1. Increased resonance is due to the lung distension seen in asthma, emphysema, bullous disease or due to pneumothorax 2. Decreased resonance is noted with pleural effusion and lung disease, a. Pleural effusion is the excess fluid that accumulates in the pleura and since there is right heart failure which leads to accumulation of blood in the pleura (haemothorax) 6. Low Blood pressure, and high Pulse rate

a. b. c. d. e. f.

A low blood pressure is caused by reduced blood volume Can be caused by widening of blood vessels Can be caused by excessive bloodloss hemorrhage Decreased cardiac output via congestive heard failure, However there is a high pulse rate which is a result in the heart pumping out more blood into the system, Since the stab wound could have damaged the Tricuspid valve, the normal blood flow through the right atrium and right ventricle has been affected. Thus an increased effort in supplying the body with the required oxygenated blood.

Auscultation of the heart

Aortic: 2nd right intercostal space. Pulmonary: 2nd left intercostal space. Tricuspid: 4th intercostal space, at lower left sternal border. Mitral: 5th left intercostal space, 1 cm medial to midclavicular line.