Pneumothorax (main)

Revision as of 18:12, 4 December 2014 by Rossdonaldson1 (talk | contribs)

Types

Pneumothorax.jpeg

Tension pneumothorax

  • Death occurs from hypoxic respiratory arrest (V-Q mismatch), not circulatory arrest

Diagnosis

  • Diminished or absent breath sounds
  • Hypotension or e/o hypoperfusion
  • Distended neck veins
    • May not occur if pt is hypovolemic
  • Tracheal deviation
    • Late sign

Treatment

  • Immediate needle decompression if unstable
    • 14ga IV in midclavicular line just above the rib at the second intercostal space
  • Always followed by Chest Tube placement


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

  • Can be open, closed, or occult
    • Open
      • Communication between pleural space and atmospheric pressure (sucking chest wound)
    • 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)

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[1]

See Also

Source

  • Roberts and Hedges Clinical Procedures in Emergency Medicine
  • Rosen's
  • American College of Chest Physicians Consensus Statement
  1. Cite error: Invalid <ref> tag; no text was provided for refs named BTC