Tension pneumothorax: Difference between revisions

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==[[Tension pneumothorax]]==
==Background==
*Death occurs from hypoxic respiratory arrest (V-Q mismatch), not circulatory arrest
*Death occurs from hypoxic respiratory arrest (V-Q mismatch), not circulatory arrest
===Diagnosis===
 
*Diminished or absent breath sounds
==Clinical Features==
*Hypotension or e/o hypoperfusion
*Unilateral diminished or absent breath sounds
*[[Hypotension]] or evidence of hypoperfusion
*Distended neck veins
*Distended neck veins
**May not occur if pt is hypovolemic
**May not occur if patient is hypovolemic
*Tracheal deviation
*Contralateral Tracheal deviation (late sign)
**Late sign
*Type of obstructive shock since prevents venous return to the right side of the heart
===Treatment===
 
*Immediate needle decompression if unstable
==Differential Diagnosis==
{{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)]]
*[[Chest Tube]]
*[[Needle thoracostomy]]
*[[Thoracentesis]]
*[[Finger Thoracostomy]]
*[[Thoracic Trauma]]
*[[Adult pulseless arrest#Asystole and PEA (Non-Shockable)|Traumatic arrest]]
*[[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 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

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

Thoracic Trauma

Acute dyspnea

Emergent

Non-Emergent

Evaluation

Left sided tension pneumothorax with mediastinal shift

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

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)
  • 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. ↑ 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.
  2. ↑ 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
  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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