A Case Study
A chest X-ray is ordered and is shown below. (tension hepatic hydrothorax, https://openi.nlm.nih.gov/detailedresult.php?img=PMC2769311_1757-1626-0002-0000006767-001&req=4)
Additional imaging is suggested by the chief resident. A CT scan of the chest is ordered by the attending physician. The patient is having an increasingly difficult time breathing but vital signs remain unchanged. The nurse is given orders to monitor oxygen saturation closely and to page the medicine resident on call if saturation drops below 92% on 5L nasal cannula.
Which of the following is the next best step in management?
A. Chest tube placement
B. Echocardiogram
C. Intubation
D. Needle decompression, 14G
E. Thoracentesis
Answer
Choice "E" is the best answer. …show more content…
A chest tube or tube thoracostomy is reserved for loculated pleural effusions. Placement of a chest tube will increase the patient’s risk of infection and other complications, although it does help in resolving symptoms. It is more than is needed at this time.
Choice "B" is not the best answer. An echocardiogram can be used for those patients where the cause of the effusion is suspected to be cardiogenic in origin. A decrease in functionality of the heart can lead to increased hydrostatic pressure in the pulmonary vasculature, leading to a transudative pulmonary effusion. Although ECHO is a reasonable option that has diagnostic value in the work up of a transudative pleural effusion, it is more important to first determine that it is indeed a transudate .
Choice "C" is not the best answer. Intubation is not needed at this time, although the patient is having difficulty breathing, his vital signs are currently stable, and are being monitored closely by the nurse for increasing desaturation, at which time the patient can be intubated if he demonstrates inadequate ventilation.
Choice "D" is not the best answer. Needle decompression is an emergency procedure reserved for those with suspected tension pneumothorax. A 14-16G intravenous cannula is inserted in the second intercostal space (above the third rib on the mid-axillary
Additional imaging is suggested by the chief resident. A CT scan of the chest is ordered by the attending physician. The patient is having an increasingly difficult time breathing but vital signs remain unchanged. The nurse is given orders to monitor oxygen saturation closely and to page the medicine resident on call if saturation drops below 92% on 5L nasal cannula.
Which of the following is the next best step in management?
A. Chest tube placement
B. Echocardiogram
C. Intubation
D. Needle decompression, 14G
E. Thoracentesis
Answer
Choice "E" is the best answer. …show more content…
A chest tube or tube thoracostomy is reserved for loculated pleural effusions. Placement of a chest tube will increase the patient’s risk of infection and other complications, although it does help in resolving symptoms. It is more than is needed at this time.
Choice "B" is not the best answer. An echocardiogram can be used for those patients where the cause of the effusion is suspected to be cardiogenic in origin. A decrease in functionality of the heart can lead to increased hydrostatic pressure in the pulmonary vasculature, leading to a transudative pulmonary effusion. Although ECHO is a reasonable option that has diagnostic value in the work up of a transudative pleural effusion, it is more important to first determine that it is indeed a transudate .
Choice "C" is not the best answer. Intubation is not needed at this time, although the patient is having difficulty breathing, his vital signs are currently stable, and are being monitored closely by the nurse for increasing desaturation, at which time the patient can be intubated if he demonstrates inadequate ventilation.
Choice "D" is not the best answer. Needle decompression is an emergency procedure reserved for those with suspected tension pneumothorax. A 14-16G intravenous cannula is inserted in the second intercostal space (above the third rib on the mid-axillary