Traumatic pneumothorax: Difference between revisions
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===Closed traumatic pneumothorax===
===Closed traumatic pneumothorax===
''[[Supplemental oxygen]] with [[non-rebreather]] for all''
*[[Tube thoracostomy]] indicated if:
*[[Tube thoracostomy]] indicated if:
**Cannot be observed closely
**Cannot be observed closely
**Requires intubation
**Requires intubation
**Will be transported by air or over a long distance
**Will be transported by air or over a long distance
*Observation alone if:
*Observation if:
**Small AND does not require mechanical ventilation
**Small AND does not require mechanical ventilation
***Initial [[CXR]]: <1cm wide (confined to upper 1/3 of chest) OR seen only on CT
***Initial [[CXR]]: <1cm wide (confined to upper 1/3 of chest) OR seen only on CT

Revision as of 21:16, 13 May 2015

Background

Types

  1. Open
    • Communication between pleural space and atmospheric pressure (sucking chest wound)
  2. Closed
  3. Occult
    • Positive pressure ventilation (e.g. intubation) can convert an occult pneumothorax to a tension pneumothorax

Clinical Features

  • Rib fracture and penetrating trauma most common causes
  • Isolated pneumothorax does not cause severe symptoms until >40% of hemithorax is occupied

Differential Diagnosis

Pneumothorax Types

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

Thoracic Trauma

Diagnosis

  • Occult pneumothorax after a stab wound may be delayed for up to 6 hours
    • If patient decompensates, obtain repeat imaging

Workup

  • 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
  • Ultrasound
    • Absence of lung sliding; absence of seashore (M-mode)
  • CT chest
    • Most sensitive

Treatment

Tension pneumothorax

Open pneumothorax

  • Cover wound with three-sided dressing
    • Make sure to avoid complete occlusion (may convert injury to a tension pneumothorax)

Closed traumatic pneumothorax

Supplemental oxygen with non-rebreather for all

  • Tube thoracostomy indicated if:
    • Cannot be observed closely
    • Requires intubation
    • Will be transported by air or over a long distance
  • Observation if:
    • Small AND does not require mechanical ventilation
      • Initial CXR: <1cm wide (confined to upper 1/3 of chest) OR seen only on CT
      • Unchanged on repeat CXR in hours

Adult Chest Tube Sizes

Chest Tube Size Type of Patient Underlying Causes
Small (8-14 Fr)
  • Alveolar-pleural fistulae (small air leak)
  • Iatrogenic air
Medium (20-28 Fr)
  • Trauma/bleeding (hemothorax/hemopneumothorax)
  • Bronchial-pleural fistulae (large air leak)
  • Malignant fluid
Large (36-40 Fr)
  • Thick pus

Disposition

Special Instructions

Flying

  • Can consider flying 2 weeks after full resolution of traumatic pneumothroax[3]

See Also

Source

  1. ↑ Inaba Et. al J Trauma Acute Care Surg. 2012 Feb;72(2):422-7.
  2. ↑ Advanced Trauma Life Support® Update 2019: Management and Applications for Adults and Special Populations.
  3. ↑ "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
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