Tension pneumothorax: Difference between revisions
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*Death occurs from hypoxic respiratory arrest (V-Q mismatch), not circulatory arrest | *Death occurs from hypoxic respiratory arrest (V-Q mismatch), not circulatory arrest | ||
== | ==Clinical Features== | ||
* | *Unilateral diminished or absent breath sounds | ||
*Hypotension or | *[[Hypotension]] or evidence of hypoperfusion | ||
*Distended neck veins | *Distended neck veins | ||
**May not occur if | **May not occur if patient is hypovolemic | ||
*Tracheal deviation | *Contralateral Tracheal deviation (late sign) | ||
* | *Type of obstructive shock since prevents venous return to the right side of the heart | ||
== | ==Differential Diagnosis== | ||
*Immediate needle | {{Pneumothorax types}} | ||
{{Thoracic trauma DDX}} | |||
{{SOB DDX}} | |||
==Evaluation== | |||
[[File:PMC2892654 CRM2010-213818.004.png|thumb|Left sided tension pneumothorax with mediastinal shift]] | |||
'''Ideally a clinical diagnosis treated emergently (without delay for studies)''' | |||
*[[CXR]] | |||
*[[Ultrasound: Lungs|Lung ultrasound]] | |||
{{Lung ultrasound pneumothorax}} | |||
==Management== | |||
*Immediate [[needle thoracostomy]] | |||
**14ga IV in midclavicular line just above the rib at the second intercostal space | **14ga IV in midclavicular line just above the rib at the second intercostal space | ||
**Evidence suggests lowest failure rate of needle decompression is at the 4th/5th rib space along the anterior axillary line <ref>Laan DV et al. Chest Wall Thickness and Decompression Failure: A systematic Review and Meta-Analysis Coparing Anatomic Locations in Needle Thoracostomy. Injury 2015 [Epub Ahead of Print]. PMID: 26724173</ref> | |||
*Always followed by [[Chest Tube]] placement | *Always followed by [[Chest Tube]] placement | ||
'''Pediatric Chest Tube''' | |||
*Estimated as 4*ETT | |||
**ETT=(4+age/4) | |||
{{Chest tube size table}} | |||
==Disposition== | |||
*Admit | |||
{{Flying instructions after pneumothorax}} | |||
==Complications== | |||
*[[Reexpansion pulmonary edema]] | |||
==See Also== | ==See Also== | ||
*[[Pneumothorax (main)]] | *[[Pneumothorax (main)]] | ||
*[[ | *[[Needle thoracostomy]] | ||
*[[ | *[[Finger Thoracostomy]] | ||
*[[ | *[[Adult pulseless arrest#Asystole and PEA (Non-Shockable)|Traumatic arrest]] | ||
== | ==References== | ||
<references/> | <references/> | ||
[[Category: | [[Category:Pulmonary]] | ||
[[Category:Trauma]] | [[Category:Trauma]] | ||
Latest revision as of 16:19, 24 August 2021
Background
- Death occurs from hypoxic respiratory arrest (V-Q mismatch), not circulatory arrest
Clinical Features
- Unilateral diminished or absent breath sounds
- Hypotension or evidence of hypoperfusion
- Distended neck veins
- May not occur if patient is hypovolemic
- Contralateral Tracheal deviation (late sign)
- Type of obstructive shock since prevents venous return to the right side of the heart
Differential Diagnosis
Pneumothorax Types
Thoracic Trauma
- Airway/Pulmonary
- Cardiac/Vascular
- Musculoskeletal
- Other
Acute dyspnea
Emergent
- Pulmonary
- Airway obstruction
- Anaphylaxis
- Angioedema
- Aspiration
- Asthma
- Cor pulmonale
- Inhalation exposure
- Noncardiogenic pulmonary edema
- Pneumonia
- Pneumocystis Pneumonia (PCP)
- Pulmonary embolism
- Pulmonary hypertension
- Tension pneumothorax
- Idiopathic pulmonary fibrosis acute exacerbation
- Cystic fibrosis exacerbation
- Cardiac
- Other Associated with Normal/↑ Respiratory Effort
- Other Associated with ↓ Respiratory Effort
Non-Emergent
- ALS
- Ascites
- Uncorrected ASD
- Congenital heart disease
- COPD exacerbation
- Fever
- Hyperventilation
- Interstitial lung disease
- Neoplasm
- Obesity
- Panic attack
- Pleural effusion
- Polymyositis
- Porphyria
- Pregnancy
- Rib fracture
- Spontaneous pneumothorax
- Thyroid Disease
- URI
Evaluation
Ideally a clinical diagnosis treated emergently (without delay for studies)
Lung ultrasound of pneumothorax
- No lung sliding seen (not specific for pneumothorax)
- May also identify "lung point": distinct point where you no longer see lung sliding (pathognomonic)
- Absence of lung sliding WITHOUT lung point could represent apnea or right mainstem intubation
- Evaluate other intercostal spaces because pneumothorax may only be seen in least dependent area of thorax
- NO comet tail artifact
- Bar Code appearance/"Stratosphere" sign on M-mode (absence of "seashore" waves)
- Ultrasound has greater sensitivity than chest x-ray for pneumothorax in trauma patients [1]
Management
- Immediate needle thoracostomy
- 14ga IV in midclavicular line just above the rib at the second intercostal space
- Evidence suggests lowest failure rate of needle decompression is at the 4th/5th rib space along the anterior axillary line [2]
- Always followed by Chest Tube placement
Pediatric Chest Tube
- Estimated as 4*ETT
- ETT=(4+age/4)
Adult Chest Tube Sizes
| Chest Tube Size | Type of Patient | Underlying Causes |
| Small (8-14 Fr) |
|
|
| Medium (20-28 Fr) |
|
|
| Large (36-40 Fr) |
|
Disposition
- Admit
Special Instructions
Flying
- Can consider flying 2 weeks after full resolution of traumatic pneumothroax[5]
Complications
See Also
References
- ↑ Nagarsheth K, Kurek S. Ultrasound detection of pneumothorax compared with chest X-ray and computed tomography scan. Am Surg. 2011 Apr;77(4):480-4. PMID: 21679560.
- ↑ Laan DV et al. Chest Wall Thickness and Decompression Failure: A systematic Review and Meta-Analysis Coparing Anatomic Locations in Needle Thoracostomy. Injury 2015 [Epub Ahead of Print]. PMID: 26724173
- ↑ Inaba Et. al J Trauma Acute Care Surg. 2012 Feb;72(2):422-7.
- ↑ Advanced Trauma Life Support® Update 2019: Management and Applications for Adults and Special Populations.
- ↑ "Management of spontaneous pneumothorax: British Thoracic Society pleural disease guideline 2010" British Thoracic Society Guidelines. Thorax 2010;65:ii18-ii31 doi:10.1136/thx.2010.136986 PDF