Lecture 33: Chest Trauma and Pneumothorax I

Negative

Pressure in pleural space is _____________ with respect to alveolar pressure

Pneumothorax

accumulation of air in the pleural space

Open Pneumothorax

open thoracic wall injury causing accumulation of air in the pleural space

Closed Pneumothorax

Alveolar Injury/tearing resulting in accumulation of aire in the pleural space

Inspiration

During _________________, Air enters the pleural space and accumulates, leading to collapse of ipsilateral lung

Decreases

In a pneumothorax, the tidal volume of the healthy lung ________________

Pneumothorax

-decreased vital capacity

-decreased arterial PO2 (Hypoxia)

-areas of low V/Q ratios

-Right to Left shunt

-Alveolar Hypoventilation

Pneumothorax

-sudden onset of ipsilateral chest or shoulder pain

-dyspnea

-cough

-mild resting tachycardia

-tachypnea

-unilateral decreased breath sounds

Pneumothorax

-respiratory distress

-hyperresonance to percussion

-unilateral enlargement of hemithorax

-decreased chest excursion with respiration

Chest X-Ray

most important initial test if there is a suspected Pneumothorax

Upright (except Tension pneumothorax)

what position is recommended for CXR for suspected Pneumothorax

Pneumothorax

Thin visceral pleural line lying parallel to the chest wall separated by a radiolucent band containing no lung markings

Pneumothorax

Pneumothorax

Expiratory

Historically ______________ CXR thought to help optimize visualization of small ptx, but they are not more sensitive so not generally recommended

CT

-much more sensitive than plain CXR

-more accurate in sizing ptx than plain CXR

-not routinely ordered in evaluation of suspected pneumothorax

-can identify blebs or bulla as source of primary pneumothoracies

Pneumothorax

Primary Pneumothorax

-Spontaneous PTX in pts without known pulmonary dx

-<40 yo

-occurs at rest, not related to physical exertion

-related to cigarette smoking and Marfan's syndrome

Primary Pneumothorax

-chest pain and dyspnea

-acute onset, ipsilateral

-often pleuritic

-vital signs normal

-tachycardia

-Ipsilateral: decreased movement with breathing, hyperresonant to percussion, decreased breathing sounds, and decreased fremitus

• Tall patients

• Those who continue to smoke

who is at greatest risk for recurrence or primary pneumothorax

Secondary Pneumothorax

• PTX in setting of underlying lung disease

• Peak age 60-65 years; male to female 3:1

• More likely to present with dyspnea & more severe symptoms . Why?

• Much higher mortality

Secondary Pneumothorax

-primary symptom is dyspnea; often severe and out of proportion to size of pneumothorax

-chest pain

-hypoxia and hypotension

-vitals signs abnormal

Iatrogenic Pneumothorax

assoc with:

-Transthoracic needle aspiration or biopsy

-Thoracentesis

-Transbronchial biopsy

-Subclavian or IJ central line catheterization

-Mechanical ventilation

-CPR

-Nasogastric tube (NG) placement

• Eliminate air from the pleural space

• Decrease likelihood of occurrence

the two major goals of treatment of a pneumothorax

• Observation*

• Supplemental Oxygen*

• Simple aspiration*

• Tube thoracostomy*

treatment of a pneumothorax

• Tube thoracostomy with pleurodesis

• Thoracoscopy with oversewing of blebs & pleurodesis

• Open thoracotomy

prevents recurrence of a pneumothorax

• Small PSP (< 2-3 cm)

• Patient stable

• Observation for SSP NOT generally recommended

eligibility of observation of pneumothorax

• Observe for 3-6 hours

• Repeat CXR

• If no progression & patient stable, can discharge home

• Pts should return in 24-48 hours for f/u CXR

guidelines for observation of a pneumothorax

Increases

Supplemental O2 ________________ rate of pleural air absorption

High %O2

Pts given ____________ reabsorb their pneumothorax approx 4x faster

Simple Aspiration

• Initial tx of choice for most pts with primary spontaneous pneumothraces

• NOT generally recommended for secondary spontaneous pneumothorax

• Lower success rates; generally require chest tube

• Less pain - smaller needle

• Hospitalization often not required or \/ stay; less expensive

Tube thoracostomy

If aspiration unsuccessful, __________________________ required

Tube Thoracostomy ("Chest Tube")

-Historically most common initial treatment for ptx

-Rapid re-expansion of underlying lung

-Indications: large pneymothoraces, or pneumothorax where pt is unstable

32-40

tube size if associated with hemothorax/trauma

4th-5th ICS (about nipple level)

Mid to anterior axillary line

what is the location of chest tube placement

Pleurodesis

Creation of fibrous adhesion between visceral & parietal layers of the pleura, obliterates pleural space

Video-Assisted Thoracoscopic Surgery (VATS)

-used to prevent recurrentce of Ptx

-facilitates elimination of blebs and pleurodesis

-preferred to thoracotomy

Open Thoracotomy

• Generally done if VATS unavailable, unsuccessful

• Surgical removal of blebs

• Oversewing of blebs

• Pleurodesis

• Most invasive

• Very effective in preventing recurrences

• Look at added morbidity compared to VATS

Small Wounds

-act as a one way valve

-air enters during inspiration and cant leave during expiration

-may rapidly lead to tension pneumothorax

Large Open Wounds

->2/3rd the area of the trachea

-air enters pleural cavity through chest wall, not the tracheobronchial tree

-sucking chest wound

-causes significant ventilation impairment

Cover wound immediately with an occlusive dressing taped on 3 sides and then place chest tube

What do you need to do if you have an open pneumothorax due to a large open wound

Tension Pneumothorax

-air trapping that increases intraspleural pressure and compression of contralateral lung

Tension Pneumothorax

-Respiratory distress

-Diminished breath sounds

-Hyperresonance to percussion

-Hypotension

-Tachycardia

-Hypoxia

-JVD

-Tracheal deviation

Tension Pneumothorax

-Complete lung collapse on affected side

-Gross distention of thoracic cavity on the affected side

-shift of heart/mediastinum to opposite side

-Collapse of contralateral lung

Tension Pneumothorax

Immediate Needle Decompression followed by chest tube

What is the first thing you are gonna do for a tension pneumothorax?

Needle Decompression

-Temporizing measure

-Insert 14-16 gauge IV catheter over rib at 2nd ICS, midclavicular

line

-Advance catheter & remove needle

-Rush of air is confirmatory

Tube Thoracostomy

-28-36F in Trauma

-16-20F for Spontaneous

-4th-5th ICS (about nipple level)

-Mid to anterior axillary line

Deep Sulcus Sign

• A deep lateral costophrenic angle in a supine patient is suggestive of a pneumothorax on that side

• May be the only indication of a ptx in a supine patient**

Deep Sulcus Sign