Traumatic pneumothorax

Background

• Present in 25% of pts w/ chest trauma
• Rib fx and penetrating trauma most common causes
• Isolated ptx does not cause severe symptoms until >40% of hemithorax is occupied

Types

1. Open
   • Communication between pleural space and atmospheric pressure (sucking chest wound)
2. Closed
3. Occult
   • PPV can convert an occult ptx to a tension ptx

Diagnosis

• Ptx after a stab wound may be delayed for up to 6 hr
  • If pt decompensates obtain repeat imaging
• CXR
  • Upright is best (esp expiratory film)
    • Thin white line (pleura) between 2 areas of lucency (lung parenchyma and air)
    • No lung markings distal to white line
  • Supine
    • Look for deep sulcus sign
• US
  • Absence of lung sliding; absence of seashore (M-mode)

Differential Diagnosis

Pneumothorax Types

The pleural cavity is normally a potential space, in which air collects in a pneumothorax.

• Tension pneumothorax
• Spontaneous pneumothorax
  • Catamenial pneumothorax
• Traumatic pneumothorax
  • Iatrogenic pneumothorax

Thoracic Trauma

• Airway/Pulmonary
  • Bronchial injury
  • Diaphragmatic trauma
  • Hemothorax
  • Pneumomediastinum
  • Pulmonary contusion
  • Tracheal injury
  • Trachobronchial injury
  • Traumatic pneumothorax
    • Tension pneumothorax
• Cardiac/Vascular
  • Cardiac injury
    • Blunt cardiac injury
      • Cardiac contusion
      • Commotio cordis
    • Penetrating cardiac injury
    • Cardiac tamponade
  • Traumatic aortic transection
• Musculoskeletal
  • Clavicle fracture
    • Clavicle fracture (peds)
  • Rib fracture
    • Flail chest
  • Scapular fracture
  • Scapulothoracic dissociation
  • Sternoclavicular dislocation
  • Sternum fracture
  • Thoracic and lumbar fractures and dislocations
• Other
  • Esophageal injury or Perforation
  • Pneumomediastinum
  • Pneumopericardium
  • Traumatic asphyxia

Treatment

• Tension ptx
  • Immediate needle thoracostomy
• Open ptx
  • Cover wound with three-sided dressing
    • Make sure to avoid complete occlusion (may convert injury to a tension ptx)
• Tube thoracostomy indicated if:
  • Pt cannot be observed closely
  • Pt requires intubation
  • Pt will be transported by air or over a long distance
• Observation alone ok if:
  • Small ptx (<1cm wide, confined to upper 1/3 of chest) is unchanged on two CXR 6hr apart
  • Occult ptx (seen only on CT) unless pt requires mechanical ventilation

Special Instructions

Flying

• Can consider flying 2 weeks after full resolution of traumatic pneumothroax

See Also

• Pneumothorax (main)
• Chest Tube
• Thoracentesis
• Thoracic Trauma
• Hemothorax

Source

• Roberts and Hedges Clinical Procedures in Emergency Medicine
• Rosen's
• American College of Chest Physicians Consensus Statement