Objective: To investigate the rescue and nursing process of a trauma patient with multiple injuries and rupture of the right main bronchus. Methods: A patient with multiple injuries and rupture of the right main bronchus admitted to the emergency department of the Shenzhen Hospital of the University of Hong Kong was selected as the research object on December 11, 2019. Results: In this case, the medical team treated the patient under the guidance of ATLS (Advanced Traumatic Life Support), and for the first time in our department, we used bronchoscopy to replace the double-lumen endotracheal tube for left lung single-lung ventilation, finally the patient was successfully treated. Conclusion: Through a literature search, it is found that the main bronchus rupture is less common in clinical practice. In the trauma group, the use of fiberoptic bronchoscopy and the replacement of a double-lumen tracheal tube for left lung single-lung ventilation can improve the treatment rate of such patients and is worthy of clinical application.
Severe blunt chest trauma can cause rupture or rupture of the trachea and bronchus [
by damage to the lung and chest wall. It is not easy to detect them at an early stage, and diagnosis is usually difficult.
Once the right main bronchus ruptures, the air immediately enters the chest cavity and forms subcutaneous emphysema on the neck, chest, and back. The main clinical symptoms are dyspnea, hoarseness, hemoptysis, subcutaneous emphysema, and weakened or disappeared breath sounds. Because the symptoms and signs of tracheal rupture are similar to those of chest trauma, it is easy to confuse them. If the medical staff know little about this, it will be impossible to find out in time that the patient is indeed suffering from a bronchial injury [
ATLS is a guideline for the treatment of trauma patients formulated by the American College of Surgeons and the Trauma Committee [
On December 11, 2019, a patient with multiple injuries and rupture of the right main bronchus was admitted to our hospital. Compared with traditional treatment methods, the use of fiberoptic bronchoscopy and replacement of double-lumen endotracheal tubes for patients with left lung single-lung ventilation can increase the treatment rate, shorten the hospital stay, and promote rapid recovery of patients. The report is as follows:
Patient’s personal information: Jin, female, 50 years old; Han nationality, from Sichuan, China; Born in Shenzhen, Guangdong on May 29, 1969; Freelance.
The patient’s personal history: normal development, no history of allergies, no history of life in a different place, no history of life in a non-affected area, no history of smoking, no history of smelting, no history of life in a different place, drinking, no history of radiation exposure.
Patient’s past history: Appendectomy in 2008, no history of chronic diseases such as coronary heart disease, diabetes, hypertension, no history of infectious diseases such as hepatitis, typhoid fever, tuberculosis, and no history of blood transfusion. The history of vaccination is unknown.
Family history: There is no history of infectious diseases and genetic diseases in the family.
The patient was admitted to the emergency department 10 minutes after the car accident trauma. The patient was in a coma, occipital bleeding, urinary incontinence, and no vomiting. The Pre-hospital report is shown in
Severe trauma includes 1 point for head and neck, face, chest, abdomen, and pelvis, 1 point for limbs and pelvis, 1 point for body surface, and 42 points for ISS, which is a critical injury (ISS score, ISS < 16 is classified as a minor injury, ISS16-24 is classified as serious injury, ISS > 25 is classified as critical injury [
| Project | Content |
|---|---|
| M (Mechanism and time of injury) Injury mechanism and time | The speed of the car was unknown 10 minutes ago when it was knocked down. |
| I (Injuries found and suspected) Found and suspected injuries | Unconscious, head trauma, chest trauma, scattered bruises. |
| S (Symptoms and signs) Symptoms and signs | HR: 110 times/min, RR: 34 times/min, Bp: 140/74 mmHg GCS 3 points, SpO2 36%. |
| T (Treatment initiated) Treatment measures that have been given | Neck bracing fixed, spine fixed, open airway, negative pressure attraction, open Put the intravenous pathway and suck up oxygen. |
1) The right nasal bone may be fractured; 2) Multiple bilateral ribs, left clavicle, scapula, upper thoracic spine have multiple spinous processes and fractures, which may be accompanied by main tracheal bifurcation breaks; The right main bronchus is ruptured and the right thoracic cavity may be accompanied by blood pneumothorax; the left main bronchus is injured, the tracheal intubation is placed in the left thoracic cavity, the left lung is ventilated normally, and the left lung has multiple exudative foci; 3) Emphysema in the mediastinum, bilateral Neck subcutaneous emphysema, bilateral thoracic drainage after operation, and no obvious abnormalities in the abdominal organs.
1) Right main bronchial rupture, and left main bronchial injury; 2) Right blood gas chest; 3) Multiple fractures: left collarbone fracture, left shoulder blade fracture, two side rib fractures, and third metacarpal fracture of right hand.
| Summary of treatment |
|---|
| 11:28 Open the airway to the patient, place an oropharyngeal vent tube in the oropharynx, and give oxygen to the high-flow mask. Establish 2 venous accesses for the patient, and then perform blood test. 11:38 The patient was given balloon-assisted ventilation; 20 mg etomidate and 100 mg succinylcholine chloride were given intravenously. 11:50 The patient was successfully placed in a 7.0# tracheal tube for sputum suction. The tracheal tube is connected to the ventilator for assisted breathing; the ventilator is set to SIMV mode, with a tidal volume of 400 ml, a respiratory rate of 14 times/min, and a positive end-breathing pressure of 4 cmH2O. 11:54 The DR chest radiograph was performed at the bedside, and the image results are shown in |
On December 11, 2021, the patient underwent “open reduction and internal fixation of the left clavicle under the guidance of bronchoscope”, “open chest exploration”, “reconstruction of semi-uplift with the aid of thoracoscopy”, and “closed thoracic drainage”. On December 27, 2021, the patient received “open reduction and internal fixation for the third metacarpal fracture of the right hand”.
After admission to hospital, trachea intubation, ventilator-assisted breathing, chest closed drainage, pain relief, anti-infection, acid suppression, rehydration, phlegm, and other treatment. After being hospitalized in the ICU, Thoracic Surgery, Traumatology and Orthopedic Oncology, and Rehabilitation Medicine Department H, the patient was discharged on January 22, 2020.
Based on the patient’s pre-hospital report, the trauma team is established, and the emergency team leader immediately opens the green channel and activates the trauma team (including Trauma Leader, Anesthesiology, ICU, Orthopedics, Neurology) upon receiving the pre-hospital first aid report.
Nursing assessment: 1) Patients with a small amount of nose and mouth secretions, no rhinorrhea, no otorrhea; 2) The neck brace has been fixed before arriving to the hospital, and the fixation is good; 3) Patient’s jaw face is free of deformities, swelling, skull integrity, and bone rub; 4) No deformities or dislocations were found in the cervical vertebrae. The trachea is centered with no obvious airway obstruction.
Nursing diagnosis: There is a risk of suffocation.
Care goals: 1) Keep the patient’s airways open; 2) Cooperate with the doctor to establish a deterministic airway; 3) No airway obstruction occurs.
Care measures: 1) Open the airway immediately, place OPA, attract oral and nasal secretions with Negative pressure, designate a person to manage the airways on the patient’s head side; 2) keep cervical brace fixation, keep the spine in a straight line; 3) After the oxygen flow is adjusted to 15 L/min, the patient’s SP02 has not been significantly improved. Therefore, change the balloon to assist ventilation; 4) Give intravenous bolus of etomidate 20 mg and succinylcholine 100 mg, and follow the doctor’s advice to cooperate with the doctor for tracheal intubation. After successful placement of the tube, properly fix the tracheal tube and connect the ventilator to assist breathing; 5) Patients’ blood oxygen continues to be below normal, and report to the doctor; 6) Cooperate with the doctor for bedside fiberoptic bronchoscopy; 7) When replacing the tracheal tube, move quickly and gently to avoid pulling the tube; at the same time, prepare breathing balloons, syringes, tapes, and dental pads by the bed; 8) After the trachea intubation, observe diligently, clean the catheter endocrine and blood in time to avoid causing airway obstruction; 9) When attracting, the action should be gentle, and the pressure should not be too deep to avoid irritating the injured end of the trachea.
Nursing assessment: 1) RR: 35 times/min, shortness of breath, purple. SpO2: 58% (mask oxygen 15 L/min); 2) Exposed patient’s chest, and the bilateral thorax was symmetrical without collapse. The right thoracic undulation is worse than that on the left, the breath sounds are weakened, and the percussion is dull. Breath sounds on the left side are clear; 3) No three concave signs, no cervical veins; 4) When palpating both chest walls, there is a feeling of bony rubbing and subcutaneous emphysema in the right armpit, and heart tone is clear.
Nursing diagnosis: 1) Damaged self-breathing; 2) Damaged gas exchange, inefficient respiratory form.
Care goals: 1) Maintain oxygen saturation ≥ 94% and EtCO2 fluctuates at 35 - 40 mmHg after intubation; 2) Put in place the nursing measures for thoracic closed drainage; 3) Avoid ventilator lung injury to avoid aspiration caused by reflux of stomach contents.
Care measures: 1) Closely observe the patient’s breathing, chest fluctuations, breathing frequency, and patterns; 2) The DR of the bedside chest shows the right blood pneumothorax. Cooperate with the doctor to perform bedside thoracic puncture catheterization and connect the thoracic cavity closed drainage bottle. Properly fix the chest tube and the closed drainage bottle of the chest cavity to avoid stretching. Observe the color and shape of the drainage fluid and the fluctuation of the fluid column. Prepare 4 toothless forceps for clamping the chest tube during transfer; 3) Connect the ventilator to assist breathing, then set the SIMV mode, VT 400 ml, RR 14 times/min, and PEEP 4 cmH2O; 4) Connect the EtCO2 monitor to observe the changes in values and waveforms; 5) Since the succinylcholine has a fast onset, the airway should be opened immediately after administration, and balloon assisted breathing or ventilator ventilation should be used to maintain the patient’s oxygen supply. It is necessary to focus on the changes in the patient’s heart rhythm, blood pressure and blood oxygen saturation, which may cause hypoxemia or hypotension, and even paralyze the patient’s muscles, leading to respiratory and cardiac arrest and even death [
Nursing assessment: 1) HR 115 beats/min; Bp 206/106 mmHg; palpable carotid pulsation with strong pulsation; 2) A small amount of bleeding can be seen in the wound of the head and pillow, the left clavicle is swollen, the right hand is bruised and swollen with scattered abrasions, the perineum is normal, and the digital rectal examination is normal; 3) The limb end is wet and cold, and the CRT is larger than 2 seconds. There was no bulging in the abdomen, and the pelvic compression test was negative.
Nursing diagnosis: 1) Organizational perfusion change; 2) Insufficient body fluids.
Care goals: 1) Maintain the stability of the patient’s vital signs; 2) Avoid shock, respiratory cardiac arrest. 3 Patients respond to fluid resuscitation. The patient’s blood pressure is shown in
Care measures: 1) Indwell an indwelling needle in each of the upper limbs. Inject 500ml of normal saline intravenously according to the doctor’s advice; 2) After using the warming device for fluid replacement, evaluate the effect of
fluid resuscitation and the patient’s response; fluid resuscitation and the patient’s response; 3) Wrap the head wound to stop the bleeding, and there is no active bleeding in the abrasions; 4) Cooperate with the doctor to perform bedside FAST ultrasound, and the result was negative; 5) Closely observe the bleeding from the wound, protect the fracture site, and immobilize both upper limbs; 6) Observe the changes in the patient’s heart rate and blood pressure, and prepare for resuscitation; follow the doctor’s instructions to indwell the catheter, export approximately 550 ml of clear urine, and observe and record the urine output.
Nursing assessment: 1) Consciousness: U; 2) GCS: E1V1M1; Right pupil: R 3.0/−, Left pupil: L 3.0/+; 3) Before using sedative drugs and muscle relaxants, the muscle strength of the limbs is 0; 4) Perform an axial turn for the patient: no abnormalities in the back, no wounds, intact spine, no bony sensation, no dislocation.
Nursing diagnosis: The ability to regulate intracranial pressure decreases.
Care goals: Avoid secondary damage caused by physical examination or transporting the patient.
Care measures: 1) Closely observe the change of the patient’s pupil; 2) Observe the patient’s blood pressure changes, and if the MAP fluctuation exceeds 50 - 150 mmHg [
Nursing assessment: T: 35.8˚C.
Nursing diagnosis: Hypothermia.
Care goals: Avoid hypothermia.
Care measures: 1) Turn off the air conditioning refrigeration of the rescue room and raise the air conditioning temperature; 2) The use of warm cotton from the temperature box is given to the patient to keep warm, to assist the doctor as soon as possible to complete the examination, reduce exposure time; 3) Use an infusion warming instrument for infusion; 4) Give patients humane care and protect their privacy.
The whole rescue process is smooth, the nursing measures are effective, the patient’s vital signs are stable when leaving the rescue room, no adverse events occur, and the transfer and evacuation process is safe.
15 minutes after the patient entered the rescue room, an artificial high-level airway was established, and airway secretions and blood were cleared in time. No airway obstruction occurred during the rescue.
Under the coordination of the fiberoptic bronchoscopy, the ordinary tracheal intubation was changed to a double-lumen endotracheal intubation, and after the right lung was sealed and the left lung was used for single-lung ventilation, the patient’s blood oxygen rose to over 96%. The Oxygen concentration, patient oxygen saturation and exhalation end carbon dioxide value is shown in
Use an infusion warming device for the patient to ensure that the patient is infused with a suitable temperature of liquid, and to avoid the patient’s hypothermia after the infusion of a large amount of liquid. During the rescue, we infused the patient with 1500 ml crystalloid. At the same time, indwelling urinary catheterization for the patient, the drained urine is about 550 ml. According to the patient’s input and output, it can be seen that the patient’s renal blood perfusion is acceptable, but it is still necessary to continuously monitor the patient’s input and output and make relevant records. The patient’s shock index (Shock Index, SI) is less than 1.0, so the patient has no shock correction [
During the rescue process, the patient was in a deep coma, and no obvious abnormality was found on cranial CT. Due to the use of sedatives, changes in GCS could not be assessed. Although the pupils of the patient changed during the rescue, the CT scans of the brain after admission were normal. Changes in the pupils of patients are shown in
After adopting warming measures and warming the fluid infusion, the patient’s body temperature was 35.8˚C when entering the room, and 36.2˚C when leaving the room.
After timely chest compressions, the patient quickly resumed spontaneous circulation, and the electrocardiogram showed sinus tachycardia.
In this rescue process, I have real experience: First, for every emergency department nurse, only by correctly understanding trauma care knowledge and proficiently mastering trauma first aid skills, can he be unflappable and at ease in actual clinical work. Second, most nurses can only simply execute medical orders, and lack the critical thinking that is really needed in the clinic. It can be seen that nursing staff need a set of independent nursing procedures in order to correctly assess the patient’s condition [
| Pupil Time | 11:28-12:12 | 12:15-13:30 | 13:40-13:49 |
|---|---|---|---|
| Right | 3.0/− | 3.0/− | 4.0/− |
| Left | 3.0/+ | 3.0/− | 2.0/++ |
the ATLS guideline is quite different from other traditional nursing procedures. It has the following three advantages: 1) Quick preliminary assessment of trauma patients and taking intervention or treatment measures; 2) It can be dealt with the greatest harm to the life of the patient in the shortest time; 3) In the absence of a definitive clinical diagnosis, taking measures in advance for the potential disease can prevent the occurrence of major potential harm. The ABCDE assessment method and ATCN nursing model in this guideline [
In the first aid process of severe trauma patients, the roles of doctors and nurses are not strictly distinguished, especially in the pre-hospital first aid and nursing process [
When the patient was first sent to the hospital, the patient’s family had not arrived, and we were unable to understand the basic situation of the patient. In this regard, we have opened up a green channel to ensure the smooth progress of rescue work. The first is to use the ABCDE method to conduct a systematic preliminary evaluation of the patient’s airway, breathing, circulatory, nervous system, and exposure according to the ATCN process guidelines. At the same time, medical staffs help doctors accurately assess the injury and cooperate with the doctors to rescue them in time, so that they can quickly and accurately judge the patient’s injury and relieve life-threatening symptoms in time. Second, after the patient received a series of first aid measures, the gradual stabilization of the breathing cycle provided the doctor with a basic guarantee for further diagnosis and treatment. The third is the cooperation of medical staff to determine the priority of the rescue of trauma patients. Fourth, the nurses summed up experience and lessons and put forward constructive opinions through this rescue work. This article summarizes the following points: 1) Nursing staff should learn to use predictive thinking and actively cooperate with doctors to perform diagnostic operations such as FAST ultrasound and bronchoscopy; 2) When performing physical examinations and disease analysis, doctors should do various first aid tasks in advance, such as maintaining the patient’s airway unobstructed, establishing venous access as soon as possible, and testing and matching blood in time after blood sampling; 3) Prepare the tracheal intubation according to the patient’s injury, and notify the imaging department as soon as possible to perform a bedside chest radiograph; 4) Contact the CT room to make the CT room fully prepared and shorten the inspection time. In summary, the implementation of advanced trauma care measures in the hospital can effectively increase the rescue rate of trauma patients.
For patients with severe trauma, the assessment and management of the airway is the most important step [
General departments use single-chamber ventilation, single-chamber isolation, and double-chamber bronchial intubation to improve bronchial obstruction, but it is rarely used in emergency departments. In this case, the anesthesiologist uses a bronchoscope to replace the double-lumen endotracheal tube for single-lung ventilation of the left lung. As shown in
After the trachea or main bronchus is found to be injured, the patient should be treated immediately [
Nurses should have a strong sense of first aid and skilled nursing skills to make quick and accurate judgments about emergencies and take first aid measures in time to shorten the rescue time. The training of “trauma nurses” and the introduction of trauma care technology have greatly improved the treatment rate of trauma patients [
The authors declare no conflicts of interest regarding the publication of this paper.
Li, T.R. and Shi, L.P. (2021) Emergency Treatment and Nursing Care of a Patient with Multiple Injuries and Right Main Bronchus Rupture. Journal of Biosciences and Medicines, 9, 231-245. https://doi.org/10.4236/jbm.2021.97021