Traumatic pneumothorax: Difference between revisions
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==Background==
==Background==
*Present in 25% of pts w/ chest trauma
*Present in 25% of patients with [[chest trauma]]
*Rib fx and penetrating trauma most common causes
 
*Isolated ptx does not cause severe symptoms until >40% of hemithorax is occupied
===Types===
===Types===
*Open
#Open
***Communication between pleural space and atmospheric pressure (sucking chest wound)
#*Communication between pleural space and atmospheric pressure (sucking chest wound)
*Closed
#Closed
*Occult
#Occult
***PPV can convert an occult ptx to a tension ptx
#*Positive pressure ventilation (e.g. [[intubation]]) can convert an occult pneumothorax to a [[tension pneumothorax]]


==Diagnosis==
==Clinical Features==
*Ptx after a stab wound may be delayed for up to 6 hr
*[[Rib fracture]] and penetrating trauma most common causes
**If pt decompensates obtain repeat imaging
*Isolated pneumothorax does not cause severe symptoms until >40% of hemithorax is occupied
*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==
==Differential Diagnosis==
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{{Thoracic trauma DDX}}
{{Thoracic trauma DDX}}


==Treatment==
==Evaluation==
*Tension ptx
*Occult pneumothorax after a stab wound may be delayed for up to 6 hours
**Immediate needle thoracostomy
**If patient decompensates, obtain repeat imaging
*Open ptx
{{Pneumothorax diagnosis}}
**Cover wound with three-sided dressing
{{Lung ultrasound pneumothorax}}
***Make sure to avoid complete occlusion (may convert injury to a tension ptx)
{{Estimating pneumothorax size}}
*Tube thoracostomy indicated if:
 
**Pt cannot be observed closely
==Management==
**Pt requires intubation
''[[Supplemental oxygen]] with [[non-rebreather]] for all''
**Pt will be transported by air or over a long distance
===[[Tension pneumothorax]]===
*Observation alone ok if:
*Immediate [[needle thoracostomy]] followed by [[chest tube]]
**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
===Open pneumothorax===
*Cover wound with three-sided dressing
**Make sure to avoid complete occlusion (may convert injury to a tension pneumothorax)
 
===Closed traumatic pneumothorax===
*[[Tube thoracostomy]] indicated if:
**Cannot be observed closely
**Requires intubation
**Will be transported by air or over a long distance
*Observation if:
**''Very'' small AND does not require mechanical ventilation
**Unchanged on repeat [[CXR]] in 6 hours
*Decision to intubate
**Intubation can lead to positive pressure which may worsen a stable traumatic pneumothorax
**If patient stable, preferable to just perform [[Thoracostomy|thoracostomy]]
**If GCS < 8 or patient having difficulty, they should be intubated
 
{{Chest tube size table}}
 
==Disposition==
Admit
 
{{Flying instructions after pneumothorax}}


===Special Instructions===
==Complications==
'''Flying'''
*[[Reexpansion pulmonary edema]]
*Can consider flying 2 weeks after full resolution of traumatic pneumothroax<ref name="BTC"></ref>


==See Also==
==See Also==
*[[Pneumothorax (main)]]
*[[Pneumothorax (main)]]
*[[Chest Tube]]
*[[Thoracentesis]]
*[[Thoracic Trauma]]
*[[Thoracic Trauma]]
*[[Hemothorax]]
*[[Hemothorax]]


==Source==
==References==
*Roberts and Hedges Clinical Procedures in Emergency Medicine
*Rosen's
*American College of Chest Physicians Consensus Statement
<references/>
<references/>


[[Category:Pulm]]
[[Category:Pulmonary]]
[[Category:Trauma]]
[[Category:Trauma]]

Latest revision as of 21:40, 13 October 2019

Background

Types

  1. Open
    • Communication between pleural space and atmospheric pressure (sucking chest wound)
  2. Closed
  3. Occult

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

Thoracic Trauma

Evaluation

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

Clinically Stable

Defined as having all of the following:

  • Resp rate < 24
  • Heart rate 60-120 beats per minute
  • Normal BP
  • SaO2 >90% on room air and patient can speak in whole sentences

Workup

Pneumothorax.jpeg
  • CXR
    • Displaced visceral pleural line without lung markings between pleural line and chest wall
    • Upright is best
      • Expiratory films DO NOT improve accuracy[1]
      • Lateral decubitus films with suspected side up do increase sensitivity. Good approach in pediatrics to avoid CT
    • Supine CXR = deep sulcus sign
  • CT Chest
    • Very sensitive and specific

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 [2]
  • Z-lines and lung sliding.png
  • No lung sliding.png
  • Lung sliding M mode.png
  • Lung point.gif

Estimating Pneumothorax Size

Measuring pneumothoraxes. Line A = lung apex to cupola. Line B = interpleural distance.
  • On a conventional, upright posterior-anterior chest radiograph:
    • Very small: <1 cm interpleural distance (confined to upper 1/3 of chest) OR only seen on CT
    • Small: ≤3cm lung apex to cupola (chest wall apex) on CXR
    • Large: >3cm lung apex to cupola (chest wall apex) on CXR
3cm apex to cupola measurement is roughly equivalent to 2cm interpleural distance (at the level of the hilum)
Both roughly correlate with a 50% pneumothorax by volume

Management

Supplemental oxygen with non-rebreather for all

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

  • Tube thoracostomy indicated if:
    • Cannot be observed closely
    • Requires intubation
    • Will be transported by air or over a long distance
  • Observation if:
    • Very small AND does not require mechanical ventilation
    • Unchanged on repeat CXR in 6 hours
  • Decision to intubate
    • Intubation can lead to positive pressure which may worsen a stable traumatic pneumothorax
    • If patient stable, preferable to just perform thoracostomy
    • If GCS < 8 or patient having difficulty, they should be intubated

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

Admit

Special Instructions

Flying

  • Can consider flying 2 weeks after full resolution of traumatic pneumothroax[5]

Complications

See Also

References

  1. ↑ Eur Respir J. 1996 Mar;9(3):406-9
  2. ↑ 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.
  3. ↑ Inaba Et. al J Trauma Acute Care Surg. 2012 Feb;72(2):422-7.
  4. ↑ Advanced Trauma Life Support® Update 2019: Management and Applications for Adults and Special Populations.
  5. ↑ "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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