The Case of the Week for the week of
June 27
Daisy Mae King was presented to the hospital on emergency on
the morning of 6-22-99. She had been hit by car at low speed 20
minutes earlier. Her gum color was a little pale and she was breathing
a little hard but she was fairly stable. We started therapy for
shock and proceeded with the normal physical exam we try to make
ourselve do on each trauma case. Her "long bones" all
appeared to be OK and no spinal pain was identified. Minimal abdominal
pain was identified and her color
improved with fluid and corticosteroid administration. During
the exam we noted that the lung sounds on the right side of the
chest were a little dull. We admitted Daisy for observation and
noted that we should probably get some chest films to make sure
that the diaphram was intact and that pulmonary contusions or
pneumothorax was not present. We were able to get chest films
without undue stress for Daisy. I must say I am thanking my lucky
stars that I did not try to skimp on the chest films. As can be
seen on the "x-rays" the contrast between the abdoman
and the chest is lost and abnormal gas filled structures are present
in the chest.
Daisy was very stable until surgery was performed the next
day. It is scary that she was so 
stable.
She was in fact bright, active and bouncy until the premeds were
given. At surgery a 180 degree tear of the entire right side of
the diaphram from it's attachment to the chest wall was present.
It was a challenge to close. Surgery on the diaphram is complicated
by the fact that we are working with an open chest . . . thus
we have to use ventilation since the patient cannot exchange air
on it's own. We were thankful that one of our "old hands",
Nancy Graybeal, was there to advise our temporarily depleted staff
and Sonia Little assisted with the surgery. We were pleased with
the surgery and Daisy is shown in these pictures in the recovery
cage.
As we have mentioned before we do use a lot of intranasal oxygen
with cases such as Daisy. This takes a lot of the load off of
Daisy's partialy deflated lungs. Sometimes we install a chest
tube in these cases and sometimes
we don't. The decision to use one or not depends on a lot of factors.
If lung leakage or fluid accumulation is expected we should use
one. However, they can also be a source of problems themselves,
especially if one fails and it is not recognized. Since our staff
is so stretched thin right now I decided that the chest tube might
not be watched as closely as we might wish. I felt that the risk
of lung collapse from natural causes would be more likely to be
recognized in time since it would usually happen more slowly and
we did not install a chest (drainage) tube in this case.
Daisy experienced some post-operative nausea but was bright
otherwise in the evening following surgery. We continued intranasal
oxygen over the first night at decreasing flows until the following
morning when Daisy seeemed to be able to breath easily without
supplementation. We were somewhat concerned about inflammation
of the abdominal organs including the pancreas associated with
the surgery and withheld food until late the following day. We
saw a poor appetite once we offered food but Daisy was bright
and alert. We force fed a small amount of food. We saw no vomiting
so we felt more comfortable with Daisy's condition. Daisy's appetite
returned that evening and we sent her home on 6-25 with instructions
to limit activity for about 3 weeks. Daisy was active and eating
well.
Other interesting Cases
Home