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Johnny Tsunami, a 21 year-old male, was suffering off the coast of Leo Carrillo State Park when he was viciously attacked by a Great White Shark. The shark traumatically amputated his left arm before biting his chest and thrashing him against a coral reef. johnny was able to punch the shark in the nose, causing it to release him. He then floundered back to shore, before collapsing in a pool of his own blood. Lifeguards took action immediately. They activated the emergency response system, applied an emergency tourniquet, initiated c-spine precautions, packed his wounds, and administered oxygen via bag valve mask. EMS arrived promptly and loaded Johnny onto a medevac helicopter. Johnny’s vitals were BP: 78/65, HR: 167, RR: 43, SPO2: 81, T: 36.4 C, GCS: 11. His breathing was fast and labored with asymmetric chest expansion and use of accessory muscles, but no paradoxical movement. Breath sounds were absent on the left, diminished on the right, and his trachea was slightly deviated to the right. A sucking chest wound was discovered on the left side of his chest wound. They continued to ventilate him via bag valve mask, placed a right AC 18 gauge, and began a 1 L bolus of Lactated Ringers.
Upon arrival to the VCMC emergency department, Johnny’s vital signs were: BP: 84/68, HR: 158, RR: 36, SPO2: 88, T: 36.5 C, GCS: 11. Assessment findings revealed shallow and rapid respirations, cool and clammy skin, deep lacerations on his chest and back, a left arm amputated at the elbow, and a compound fracture of his right tibia and fibula. Johnny was confused and lethargic.
Johnny was admitted to the ED, stabilized in OR, and transferred to the ICU. Case management helped coordinate Johnny’s care with the rehab team, physical therapy, psychological services, and connect him with additional support services.
Case Study Questions
- Explain the mechanisms of injury affecting Johnny?
- What diagnostic tests should the nurse anticipate?
- What life saving interventions can the nurse anticipate?
Case Study Answers
1.Explain the mechanisms of injury affecting Johnny?
- Blunt force trauma to his right lower extremity from being thrashed against the coral reef by the shark
- Blunt force trauma to his chest from jaws of shark
- Penetrating trauma from the shark teeth
- Hypovolemia/hemorrhage
- Traumatic amputation of left arm
- Risk for introduction of infectious agents
- Punctured lung/Pneumothorax
- Tib/Fib Fracture
- Sea-water aspiration/risk for aspiration pneumonia
2.What diagnostic tests should the nurse anticipate?
- Labs (Trauma Panel, including: CBC, ABGs, PT/PTT, BMP, U/A)
- X-ray (arm, chest,leg)
- CT scan (chest, abdomen, head, spine)
- Ultrasound FAST
- EKG (heart monitor for changes in rhythm)
3.What life saving interventions can the nurse anticipate?
- Tube thoracostomy for tension pneumothorax/Chest tube
- Oxygen therapy 15 L non-rebreather at 100% FiO2
- Large bore IV access followed by fluid resuscitation with crystalloids, colloids, and blood products
- Surgical debridement/closure of amputated limb
References
Harrois, A., Duranteau, J., & Intensive Care Department. (2019, February 05). Fluid Choices in Trauma. Retrieved from https://healthmanagement.org/c/icu/issuearticle/fluid-choices-in-trauma
MedlinePlus. (2019). Medical tests. Retrieved from https://medlineplus.gov/lab-tests/Morton & Fontaine. (2013). Essentials of critical care nursing: A holistic approach. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins.
