Intraoperative Tension Pneumothorax in a Trauma Patient: An Adult Simulation Case for Anesthesia Residents
Abstract
:1. Introduction
2. Materials and Methods
2.1. Educational Objectives
- Collect pertinent medical history from a trauma patient that is not optimized for the proposed surgery, where the patient–physician interaction occurs in the ED with a distracting environment.
- Communicate effectively with surgeons who are trying to rush the patient to the operating room (OR).
- Communicate with family members if the patient is considered not eligible to consent.
- Diagnose the intraoperative tension pneumothorax by identifying the signs and symptoms and discuss the differential diagnosis of tension pneumothorax.
- Perform a needle decompression to treat the critical cardiopulmonary decompensation caused by tension pneumothorax.
2.2. Equipment and Environment
2.3. Personnel
2.4. Implementation
2.5. Assessment
2.6. Debriefing
- Evaluation of the patient in ED: This scenario involves multiple communication barriers during the assessment of the patient. The learner anesthesiologist should discuss how to stay focused in order to determine the best and the safest anesthesia plan in the middle of multiple distractors. Discuss if the anesthesiologist missed any information due to the distractions. Participants may share their real-life experiences in dealing with similar situations.
- Communication with the surgical team: The learners should discuss the feasibility of obtaining anesthesia consent from a patient with questionable mental status. Where do you draw the line? What should you do if the family member or surrogate decision-maker is not available for consent? Additionally, discuss how to communicate with the surgeon in an assertive manner if you have any concerns about proceeding with the case.
- Identification of tension pneumothorax: The learner anesthesiologist should discuss the differential diagnosis for the collective findings of desaturation, tachycardia, hypotension, and increased peak airway pressure. What are the differences between anaphylaxis, pulmonary thromboembolism, bronchospasm, and tension pneumothorax? Pros and cons of additional diagnostic measures such as chest auscultation, lung POCUS, and chest X-ray should be discussed.
- Treatment of tension pneumothorax: The learners should discuss the pathophysiology and treatment of tension pneumothorax. Both the recommended needle size and the insertion site location for the needle decompression should be emphasized.
- Postoperative airway management planning: The learners should discuss whether the tension pneumothorax patient who has already received definitive treatment with the chest tube could be extubated or would need to remain intubated after the surgery. It should be noted that many thoracic surgery patients can be safely extubated immediately after the procedure.
3. Results
4. Discussion
Author Contributions
Funding
Institutional Review Board Statement
Informed Consent Statement
Data Availability Statement
Conflicts of Interest
Appendix A. Simulation Case
SIMULATION CASE TITLE: Intraoperative Tension Pneumothorax in a Trauma Patient: An Adult Simulation Case for Anesthesia Residents | |
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Brief narrative description of case | The patient is in the ED holding area after a motorcycle crash. He has a right femoral compound fracture. He is in minimal distress but appears nervous and restless. The anesthesiologist is asked to evaluate and consent the patient for an emergency surgery. This scenario was developed to train the anesthesia residents to learn how to collect the relevant information quickly without being distracted by distractions, and efficiently plan the best and the safest anesthesia for the planned emergency surgery. The residents will also learn how to recognize the clinical manifestation of tension pneumothorax, make the diagnosis, and properly treat this life-threatening complication in a timely manner. |
Primary Learning Objectives |
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Critical Actions |
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Learner Preparation or Prework | This is a 50 min small group simulation scenario designed for CA-1 anesthesia residents who are typically 8 to 9 weeks into their residency training. They are expected to be competent in endotracheal intubations of easy to moderately difficult airways, with additional knowledge of rapid sequence induction and in-line stabilization of the cervical spine on possible cervical spine injury patients. Two minutes prior to the patient encounter, the learners are given a stem with a brief description of the patient. |
PATIENT NAME: Randy Danger PATIENT AGE: 49 CHIEF COMPLAINT: Right Femoral Compound Fracture after a Motorcycle Crash PHYSICAL SETTING: ED HOLDING AREA (SCENE 1), THEN OPERATING ROOM (SCENE 2) | |||
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Initial vital signs | BP 156/97 mmHg, HR 102, RR 20, SpO2 97% on 8L O2 face mask, T 36.8 °C, Sinus rhythm | ||
Overall Setting and Appearance | Scene 1: ED Holding The learner will find the patient sitting up on the gurney in a room that is designed to appear as an ED holding room. The patient is awake and alert, and complains of some pain in the head, neck, and the open wound of the right thigh but not is in apparent distress. The patient appears nervous and restless. He is connected to a monitor EKG, pulse oximeter, and non-invasive blood pressure cuff. Bandages are applied around the patient’s head, and right thigh. He is also wearing a neck collar. Scene 2: Operating Room The learner will find the mannequin wearing a neck collar, laying supine on the OR table, hooked up to IVs, monitors, and already prepped and draped. The OR is a room that is designed to appear as an OR. The mannequin patient is still awake and talking. A surgeon fully scrubbed in, and a circulator nurse are waiting for the anesthesiologist to get the case started in the OR. There are standard general anesthesia induction medicines drawn up in syringes and laid out on the anesthesia machine. A fully equipped anesthesia cart including a video laryngoscope, a stethoscope, and other medicines required for anesthesia is placed right next to the anesthesia machine. A code cart is available in the hallway right outside the OR. | ||
Standardized Participants (and their roles in the room at case start) | The instructor will observe the progress of the scenario from outside the room in both scenes via half-mirror or audiovisual feed. Scene 1: ED Holding Patient: Played by another anesthesia resident in the small group. The patient is likely under the influence of alcohol and/or illicit drug(s) at the time of presentation. When the anesthesiologist tries to engage in conversation with the patient, the patient gives ambiguous answers to the anesthesiologist’s questions, and keeps asking “Where’s my Buddy?”, “I need to go!”, and “Give me pain meds!”; see “HPI” below as well as Appendix B. Surgeon: Played by the other anesthesia resident in the small group. The surgeon will be waiting outside the ED holding, and 30 s after the anesthesiologist starts talking to the patient, walks into the room and interrupts their conversation. They will introduce themself to the patient, start explaining the surgical plan, and try to obtain surgical consent. See Appendix C. The other roles (the distractors) participate later in the scene but do not appear at the beginning. These can all be played by the instructor; see the “INSTRUCTOR NOTES” table below. Scene 2: Operating Room Patient: Now played by the mannequin. Surgeon: Played by the other anesthesia resident in the small group. This is the same surgeon from the ED holding. The surgeon is fully scrubbed in and standing by the OR table. Says “Let us start the procedure immediately” as soon as the anesthesiologist enters the OR. Another surgeon: Played by the anesthesia resident who was playing the role of the patient in Scene 1. Fully scrubbed in and standing by the OR table. Circulator nurse: Played by another anesthesia resident in the small group. Waiting in the OR and initiates the “Time Out” as soon as the anesthesiologist enters the room. “Time Out! This is Mr. Randy Danger, date of birth 11/03/19**, here for emergency right femoral ORIF and vascular reconstruction of the right deep femoral vein. He is allergic to morphine, codeine, meperidine, and hydrocodone. Does everyone agree?” | ||
HPI | The patient is a 49-year-old male transferred to ED after a motorcycle accident. He was the driver, and his “Buddy” was riding on the back seat. They were both not wearing helmets. The patient is awake and alert and complains of some pain in the head, neck, and the open wound of the right thigh but is not in apparent distress. The patient is restless and appears to be more concerned about his “buddy.” The patient is a very poor historian and cannot give a detailed past medical history, often incoherent in regard to the situation and showing erratic behavior in the ED but admits to habitual use of illicit drugs. Smokes 3 packs of cigarettes per day, drinks 8–12 cans of beer daily, daily marijuana use, and cocaine last week. The anesthesiologist is asked to evaluate and obtain anesthesia consent for the planned emergency surgery of the compound fracture of the right femur. | ||
Past Medical/Surgical History | Medications | Allergies | Family History |
Patient uncooperative and unable to obtain | Patient uncooperative and unable to obtain | morphine (hives) codeine (sick to the stomach) meperidine (sick to the stomach) hydrocodone (sick to the stomach) | Patient uncooperative and unable to obtain |
Physical Examination | |||
General | Well-developed, non-obese male, sitting up on a gurney in no apparent distress but behaving nervous and restless | ||
HEENT | Minor abrasions on the head and face. Has bandages on his head. | ||
Neck | No deformities, no open wounds. Wears a neck collar. | ||
Lungs | Clear to auscultation bilaterally. Sharp pains on right ribs with arm movements. | ||
Cardiovascular | Regular rate and rhythm. No murmurs, rubs, or gallops. | ||
Abdomen | Soft and nontender. Normal bowel sounds. | ||
Neurological | Awake, alert, and mostly oriented to person, place, and time. Often incoherent in regard to the situation and showing erratic behavior in the ED. CN II-XII are grossly intact and there are no focal deficits. | ||
Skin | Multiple minor abrasions on the right side of the body including head, face, upper and lower extremities, and chest wall. | ||
GU | Normal | ||
Psychiatric | Nervous, indifferent to own current situation, and easily agitated. |
Intervention/Time Point | Change in Case | Additional Information |
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Initiation of Scene 1 | Anesthesiologist tries to engage in conversation with the patient. | Patient gives ambiguous answers to anesthesiologist’s questions and keeps asking “Where’s my Buddy? I need to go” “Give me pain meds!” |
Distractor 1: 30 s into scenario | Surgeon walks into the holding area and starts talking to the patient, interrupting the conversation. The anesthesiologist tries to re-engage with the patient. | Surgeon: “Hello, I am Dr. Bone taking care of your leg surgery today” Patient: “Who are you? I need to go” Incoherent conversation continues |
Distractor 2: 1 min after the surgeon entered the room (from Distractor 1) | Meal service aid (played by the instructor) brings the meal tray into the room. The anesthesiologist stops the patient from reaching for the food (in the interest of being NPO) and tries to re-engage with the patient. | Aid: “Mr. Randy Danger? Your dinner’s here!” Patient: “Oh that is great!” |
Distractor 3: 1 min after the Meal service aid left the room (from Distractor 2) | Patient is convinced the overhead Code Blue (voice only, played by the instructor) is about his “buddy” and tries to get off the gurney. The anesthesiologist stops the patient and tries to re-engage with the patient. | Overhead voice: “Code Blue, shock room 5. Code Blue, shock room 5” Patient: “That is my Buddy! I gotta go! Is he okay?” |
Distractor 4: 2 min after the Code Blue (from Distractor 3) | OR circulator nurse (voice only, played by the instructor) rings the anesthesiologist’s cell phone and asks how many units of pRBC should be ordered. | Circulator: “Hello anesthesia? How many units of blood do you want in the room?” “Can you order type and cross then?” |
Anesthesiologist requests for the chest X-ray | Chest X-ray shows multiple rib fractures with no apparent pneumothorax or hemothorax. | |
Anesthesiologist feels the patient is not optimized for the surgery and asks surgeon if this case can be postponed | Surgeon does not want to postpone the surgery. | Surgeon: “This is not just an open fracture. A branch of the femoral vein is damaged, and it really needs to be fixed emergently” |
Anesthesiologist decides to call the patient’s family member to obtain anesthesia consent | The family member on the phone (voice only, played by the instructor) agrees to proceed with the surgery after brief conversation with the anesthesiologist. | |
Initiation of Scene 2 Anesthesiologist prepares for rapid sequence induction | Patient still awake and talking | Anesthesiologist should ask the circulator to bring the video laryngoscope as a back-up |
Anesthesiologist starts the rapid sequence induction of anesthesia | Patient stops talking and closes the eyes. | Anesthesiologist should ask the circulator to apply cricoid pressure as well as in-line stabilization of the cervical spine. |
Endotracheal intubation accomplished successfully | BP 186/101, HR 109, SpO2 99, ETCO2 42, Peak airway pressure (PAP) 21 | Anesthesiologist can use a video laryngoscope if needed. |
2 min after the intubation | Surgeon makes the incision. BP 135/84, HR 101, SpO2 92, ETCO2 43, PAP 34 | Anesthesiologist should recognize the increase in PAP. |
4 min after the intubation | Patient becomes noticeably hypotensive and hypoxic. BP 72/34, HR 118, SpO2 71, ETCO2 24, PAP 48 | |
Anesthesiologist alerts the surgeon and other surgical team members | Surgeon halts the surgery. Code cart is brought into the OR. | |
Anesthesiologist turns up the FiO2 to 100% and initiates the investigation to find the reason for decompensation | Patient continues to decompensate. BP 58/26, HR 124, SpO2 63, ETCO2 21, PAP 53 | Anesthesiologist should rule out the mechanical failure of the anesthesia machine and circuit. |
Anesthesiologist administers pressors | Vital signs do not improve with pressors | |
Anesthesiologist performs the auscultation of the chest | Severely diminished right breath sound and moderately diminished left breath sound | Anesthesiologist should make the clinical diagnosis of right tension pneumothorax. |
Anesthesiologist performs the needle decompression with a large bore needle at the right second intercostal space, midclavicular line | An audible release of trapped air occurs, and the patient vitals start to improve. | If the anesthesiologist hesitates to place the needle in SimMan 3G, surgeon can indicate there is a dedicated needle decompression port on the mannequin’s chest. |
1 min after needle decompression | BP 117/76, HR 109, SpO2 96, ETCO2 48, PAP 19 | |
Anesthesiologist asks the surgeon to place the chest tube | Surgeon places the right chest tube. | A chest X-ray was ordered to confirm the lung expansion and correct chest tube placement. |
Surgeon finishes the surgery and asks if the patient is going to be extubated postoperatively | Anesthesiologist should give rational reasoning whether the patient can be extubated or should remain intubated | This will end the scenario. |
Ideal Scenario Flow |
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This simulation scenario has two scenes. Scene 1 starts with an encounter with a trauma patient in the ED holding area. The patient was transferred to the ED following a motorcycle crash. The anesthesiologist was called to evaluate and consent the patient for an emergency surgery. The anesthesiologist will do their best to evaluate the patient to plan for the best and safest anesthesia despite the 4 distractors. First, the surgeon will interrupt the anesthesiologist’s conversation with the patient. Second, the meal service delivers a meal tray by mistake. Third, an overhead Code Blue will make the patient agitated. Fourth, the OR circulator nurse calls the anesthesiologist’s phone with a question about blood order. The anesthesiologist confirms the preoperative chest X-ray and acknowledges there are multiple rib fractures with no apparent pneumothorax. The anesthesiologist considers this patient not eligible to consent for anesthesia and obtains one from the family member over the phone. Scene 2 is in the OR. Utilizing a video laryngoscope, the anesthesiologist successfully performs a rapid sequence induction applying an in-line stabilization to the cervical spine, since the possibility of full-stomach and cervical spine injury has not been ruled out. The patient is put on the ventilator, when he starts to develop progressive tachycardia, hypoxia, hypotension, and increased peak airway pressure. The anesthesiologist alerts the surgeon and the OR surgical team member, then quickly increases the FiO2 to 100%, disconnects the anesthesia circuit from the patient, checks the machine, and determines the problem is on the patient side. Once the anesthesiologist recognizes the hypoxia and hypotension are not improving with the 100% FiO2 and pressors, they list the differential diagnosis of tension pneumothorax, anaphylaxis, pulmonary thromboembolism, or bronchospasm. The anesthesiologist auscultates the patient’s chest and finds out there is no breath sound on the right side. No skin rashes were seen that may indicate anaphylaxis. Knowing that there is no time for confirmation with an imaging study, the anesthesiologist makes the clinical diagnosis of tension pneumothorax. A large-bore needle is inserted into the right second intercostal, mid-clavicular line, and audible release of the trapped air occurs. The patient’s vital signs quickly start to improve. The anesthesiologist asks the surgeon to place a right chest tube for the definitive treatment of the pneumothorax. A chest X-ray was ordered to confirm the lung expansion and correct chest tube placement. The surgery was resumed and finished with the patient still in stable condition. The anesthesiologist decides to extubate the patient and transfer to PACU. |
Anticipated Management Mistakes |
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Appendix B. Critical Action Checklist: To Be Used during Sim to Check Off Critical Actions as Learners Participate. Can Be Used to Facilitate Debriefing of Items Completed Well or Items That Could Be Improved
Critical Action | Definitely Completed | Maybe | Missed | |
1 | Respond in person to evaluate and consent the patient in the ED for the planned emergency surgery | |||
2 | Conduct a focused history and physical examination of the patient | |||
3 | Obtain a preoperative chest X-ray report | |||
4 | Communicate with the surgeon and clarify the need for the emergency surgery | |||
5 | Once the patient is deemed not able to consent, contact his family member to obtain the anesthesia consent over the phone | |||
6 | Perform rapid sequence induction with in-line stabilization of the patient’s cervical spine | |||
7 | Turn on the ventilator and Sevoflurane | |||
8 | Recognize the development of hypotension, hypoxia, tachycardia, and increased peak airway pressure | |||
9 | Turn the inspiratory oxygen to 100% | |||
10 | Check the anesthesia machine and circuit to rule out equipment errors | |||
11 | Notify the surgeon of the situation and ask to hold the procedure | |||
12 | Start administering medications to treat the hypotension | |||
13 | Develop a differential diagnosis based on the acquired information | |||
14 | Auscultate the patient’s respiratory sound to gather further information | |||
15 | Make a clinical diagnosis of tension pneumothorax | |||
16 | Perform a needle decompression | |||
17 | Ask the surgeon to place a chest tube | |||
18 | Order a chest X-ray to confirm the expansion of the lung | |||
19 | Tell the surgeon to resume the procedure | |||
20 | Make the decision whether the patient can or cannot be extubated immediately after the surgery and develop a disposition plan |
Appendix C. Debriefing Materials
The following points should be discussed during the debriefing with the learners:
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Appendix D. Information for Patient
Your role: You are the patient. You were transferred to the ED after a motorcycle accident. You are under the influence of illicit drugs and are restless. You have multiple abrasions. The rib fractures on your right chest elicit sharp pain as you move your right arm. You keep asking for more pain meds. You are hungry and try to reach for food when the food tray is delivered. You are more worried about your “Buddy” who was riding on the back seat of the motorcycle. When you hear the overhead Code Blue, you become agitated, believing he could be in a serious condition. Your conversation is somewhat incoherent and may not be eligible for giving consent for the anesthesia. Once the encounter in the ED finishes, your next role will be as an additional surgeon in the OR. |
Mr. Randy Danger, a 49-year-old male, was transferred to the ED after a motorcycle accident. He was not wearing a helmet. The planned emergency surgery is open reduction and internal fixation of the compound fracture of the right femur, and vascular reconstruction of the right deep femoral vein. Allergies: morphine, codeine, meperidine, hydrocodone Past Medical History: Unable to obtain Past Surgical History: Unable to obtain Current Medications: Unable to obtain Social History: Tobacco Use: 3 packs of cigarettes per day Alcohol Use: 8–12 cans of beer daily Drug Use: marijuana daily, cocaine last week. Pertinent Physical Examination: Height: 183 cm, Weight: 75 kg Vital Signs: BP 156/97 mmHg, HR 102 Sinus, RR 20, SpO2 97% on 8L O2 face mask, T 36.8 °C General: Well-developed, well-nourished adult. The patient is awake and alert. Multiple abrasions in the head, face, chest, upper and lower extremities. A cervical collar has been placed. Cervical spine injury has not been ruled out yet. Airway: Poor dentition Lungs: Normal breath sounds bilaterally Heart: RRR Abdomen: Soft, non-tender CBC: Basic Metabolic Panel: WBC 13,000 Sodium 141 Glucose 201 Hgb 28.2 Potassium 3.8 BUN 23 Hct 9.1 Chloride 101 Creatinine 1.4 Plt 210,000 Carbon Dioxide 23 |
Appendix E. Information for Surgeon
Your role: You are the surgeon. You are waiting outside the ED holding. You enter the ED 30 s after the anesthesiologist and interrupt the anesthesiologist’s conversation by introducing yourself and start explaining today’s surgery plan. If the anesthesiologist questions the need for the emergency surgery, you will explain that this is a true emergency because it also requires vascular reconstruction. If the anesthesiologist tries to obtain consent from the patient, suggest the patient may be ineligible to consent and the family member should be available to give consent over the phone. You will be wearing a headset and the Simulation Instructor will tell you what you say or how to behave throughout the scenario. You will have to try and end the anesthesiologist’s encounter as quickly as possible by saying that you have to bring the patient to the OR immediately. |
Mr. Randy Danger, a 49-year-old male, was transferred to ED after a motorcycle accident. He was not wearing a helmet. The planned emergency surgery is open reduction and internal fixation of the compound fracture of the right femur, and vascular reconstruction of the right deep femoral vein. Allergies: morphine, codeine, meperidine, hydrocodone Past Medical History: Unable to obtain Past Surgical History: Unable to obtain Current Medications: Unable to obtain Social History: Tobacco Use: 3 packs of cigarettes per day Alcohol Use: 8–12 cans of beer daily Drug Use: marijuana daily, cocaine last week. Pertinent Physical Examination: Height: 183 cm, Weight: 75 kg Vital Signs: BP 156/97 mmHg, HR 102 Sinus, RR 20, SpO2 97% on 8L O2 face mask, T 36.8 °C General: Well-developed, well-nourished adult. The patient is awake and alert. Multiple abrasions in the head, face, chest, upper and lower extremities. A cervical collar has been placed. Cervical spine injury has not been ruled out yet. Airway: Poor dentition Lungs: Normal breath sounds bilaterally Heart: RRR Abdomen: Soft, non-tender CBC: Basic Metabolic Panel: WBC 13,000 Sodium 141 Glucose 201 Hgb 28.2 Potassium 3.8 BUN 23 Hct 9.1 Chloride 101 Creatinine 1.4 Plt 210,000 Carbon Dioxide 23 |
Appendix F. Information for Anesthesiologist
Your role: You are the anesthesiologist. You are asked to evaluate and consent the patient for anesthesia for the planned emergency surgery. |
Mr. Randy Danger, a 49-year-old male, was transferred to ED after a motorcycle accident. He was not wearing a helmet. The planned emergency surgery is open reduction and internal fixation of the compound fracture of the right femur, and vascular reconstruction of the right deep femoral vein.
Allergies: morphine, codeine, meperidine, hydrocodone Past Medical History: Unable to obtain Past Surgical History: Unable to obtain Current Medications: Unable to obtain Social History: Tobacco Use: 3 packs of cigarettes per day Alcohol Use: 8–12 cans of beer daily Drug Use: marijuana daily, cocaine last week. Pertinent Physical Examination: Height: 183 cm, Weight: 75 kg Vital Signs: BP 156/97 mmHg, HR 102 Sinus, RR 20, SpO2 97% on 8L O2 face mask, T 36.8 °C General: Well-developed, well-nourished adult. The patient is awake and alert. Multiple abrasions in the head, face, chest, upper and lower extremities. A cervical collar has been placed. Cervical spine injury has not been ruled out yet. Airway: Poor dentition Lungs: Normal breath sounds bilaterally Heart: RRR Abdomen: Soft, non-tender CBC: Basic Metabolic Panel: WBC 13,000 Sodium 141 Glucose 201 Hgb 28.2 Potassium 3.8 BUN 23 Hct 9.1 Chloride 101 Creatinine 1.4 Plt 210,000 Carbon Dioxide 23 |
Appendix G. Preoperative Chest X-ray
FINDINGS: A frontal and lateral study of the chest shows a midline trachea. The heart, aorta, and remaining visualized mediastinal structures appear unremarkable. Right-sided non-displaced right lateral third, fourth and fifth rib fractures are seen. No evidence of pneumothorax. No pleural effusion or parenchymal infiltration is seen. IMPRESSION:
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Appendix H. Intraoperative Chest X-ray
FINDINGS: A frontal and lateral study of the chest shows a midline trachea. There is a new placement of an endotracheal tube, and the tip is 15 mm above the carina. There is a new right-sided chest tube placed with the tip at the third rib. New onset of minimal pneumothorax is seen in the right lung. No pleural effusion. Stable right-sided rib fractures including the third, fourth and fifth ribs. IMPRESSION:
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Percent % (Raw Count) | |||||
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Item 1 | Agree 2 | Neutral 3 | Disagree 4 | M 5 | SD |
| 56% (14) | 28% (7) | 16% (4) | 2.44 | 0.94 |
| 32% (8) | 20% (5) | 48% (12) | 3.20 | 1.26 |
| 92% (23) | 8% (2) | 0% (0) | 1.44 | 0.64 |
| 88% (22) | 12% (3) | 0% (0) | 1.44 | 0.70 |
| 96% (24) | 4% (1) | 0% (0) | 1.12 | 0.43 |
| 100% (25) | 0% (0) | 0% (0) | 1.08 | 0.27 |
| 100% (25) 7 | 0% (0) 8 | 0% (0) 9 | 1.20 | 0.40 |
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Okano, D.R.; Chen, A.W.; Mitchell, S.A.; Cartwright, J.F.; Moore, C.; Boyer, T.J. Intraoperative Tension Pneumothorax in a Trauma Patient: An Adult Simulation Case for Anesthesia Residents. Healthcare 2022, 10, 1787. https://doi.org/10.3390/healthcare10091787
Okano DR, Chen AW, Mitchell SA, Cartwright JF, Moore C, Boyer TJ. Intraoperative Tension Pneumothorax in a Trauma Patient: An Adult Simulation Case for Anesthesia Residents. Healthcare. 2022; 10(9):1787. https://doi.org/10.3390/healthcare10091787
Chicago/Turabian StyleOkano, David Ryusuke, Andy W. Chen, Sally A. Mitchell, Johnny F. Cartwright, Christopher Moore, and Tanna J. Boyer. 2022. "Intraoperative Tension Pneumothorax in a Trauma Patient: An Adult Simulation Case for Anesthesia Residents" Healthcare 10, no. 9: 1787. https://doi.org/10.3390/healthcare10091787
APA StyleOkano, D. R., Chen, A. W., Mitchell, S. A., Cartwright, J. F., Moore, C., & Boyer, T. J. (2022). Intraoperative Tension Pneumothorax in a Trauma Patient: An Adult Simulation Case for Anesthesia Residents. Healthcare, 10(9), 1787. https://doi.org/10.3390/healthcare10091787