An unexpected case of difficulty in ventilation

shenxiu2

37 year old man , 70 Kg .Smoker.No medical problem . Had a motorvehicle accident at 1am this morning. Sustained right  4th to 7th Ribs fractures, and right lung contusion.He had # right clavicle , # right index finger & little finger, # left thumb and laceration wound at the right elbow. Chest X-rays did not show obvious finding except for multiple  ribs #. ECG was normal .Blood test results were essentially normal .Patient was alert , talking rationally.

He was scheduled for  open reduction & internal fixation of right clavicle, right fingers, left thumb & toilet & suturing of the laceration wound at the right elbow at 8 pm today.

He was given general anesthesia .
Induction : IV  Sodium Thiopentone 300mg, IV Rocuronium 50 mg , IV Morphine 10 mg .
After laryngoscopy , larynx with vocal cords  was seen & endotracheal tube size 8mm was inserted into the larynx.
After intubation , it was found that there was difficulty in ventilating , there was tightness at the reservoir bag, the ETCO2 monitor showed no waveform . Meanwhile the SpO2 had dropped to 80%.Heart rate was 44/min. Blood Pressure was 200/ 105mmHg.

1.What could have happened?
2.How would you manage this problem?

心超

回复 1# shenxiu2


    听诊了没有，有没有呼吸音哦？

心超

回复 1# shenxiu2


    we will thinking about tension pneomothorax

shenxiu2

回复 2# 心超


    两边呼吸音都没有.

shenxiu2

回复 1# shenxiu2

    There was no breath sounds on both sides of the chest.

We diagnosed a right sided tension pneumothorax causing a mediastinal shift to the left ( therefore the breathsounds on the left side was also not heard ).  In view of the multiple rib  # on the right side.

A 16G Intravenous cannula was inserted into the 2nd intercostal space at the midclavicular line .
The SPO2 slowly improved to 92% , EtCO2 appeared  on the monitor . and there was breath sound heard on auscultation .

A chest drain was inserted at  the right 4th intercostal space. The SPO2 improved to 99% , air entry equal on both sides. The patient was put on ventilator (IPPV).The surgery proceeded and patient was extubated well .