Scenario Overview
Patient: Eligh, 14-year-old male
Event: High-impact motorbike accident on a rural trail
Initial Presentation:
- Severe left-sided chest pain
- Difficulty breathing
- Bruising across the left chest wall
- Diagnosed with pneumothorax and rib fractures (left 4th and 5th)
Immediate Actions Taken:
- Trauma alert issued, ATS Category 2
- Chest tube (ICC) inserted with 10cm H₂O suction
- Patient monitored for oscillation, air entry, and drainage
- Administered patient-controlled analgesia (PCA) – 1 mg morphine/5 min lockout
Vital Signs Timeline & Progress
Monday, 1730 – Emergency Department
- HR: 110 bpm | RR: 24 | SpO₂: 98% (2L NP)
- BP: 110/66 mmHg | Temp: 36.8°C | Pain: 6/10
- Drain Output: 0 mL | Air Entry: L < R>Surgical Emphysema: No
Monday, 2215 – Paediatric Ward Admission
- HR: 108 bpm | RR: 24 | SpO₂: 98% (2L NP)
- Pain: 3/10 | Drain Output: 0 mL
- Parents present and actively involved in care
Tuesday, 0735 – Deterioration Begins
- Parents raise concern about discomfort and restlessness
- Pain managed with regular analgesics
- PCA usage noted to increase
Tuesday, 0753 – Neurological & Respiratory Decline
- GCS: 13 (E3, V4, M6) – indicates mild confusion
- HR: 135 bpm | RR: 32 | SpO₂: 94% (2L NP)
- Increased work of breathing, accessory muscle use
- Surgical Emphysema: Yes | Oscillation: Absent
- Air Entry: Still reduced on left side | Drain Output: 0 mL
Clinical Red Flags
- Absent oscillation: Indicates potential chest tube blockage or lung collapse
- Surgical emphysema development
- Increased PCA use + grimacing = Inadequate pain control
- Neurological changes (↓ GCS) = Possible hypoxia or opioid side effects
- Elevated RR and HR = Physiological distress
Recommended Nursing Focus Areas
- Close monitoring of chest tube function
- Reassessment of analgesic strategy (PCA effectiveness)
- Continuous GCS monitoring
- Escalate care immediately if deterioration continues
- Support and reassure distressed family members
