TENSION PNEUMOTHORAX

TENSION PNEUMOTHORAXTENSION PNEUMOTHORAX

Luke R. Scalcione, MS IIILuke R. Scalcione, MS IIIScott Q. Nguyen, M.D.Scott Q. Nguyen, M.D.Celia M. Divino, M.D.Celia M. Divino, M.D.

Mount Sinai School of MedicineMount Sinai School of Medicine

Mrs. GreenwichMrs. Greenwich

47 y/o female pedestrian struck is brought to 47 y/o female pedestrian struck is brought to the ER by EMS c/o SOB and Chest Painthe ER by EMS c/o SOB and Chest Pain

HistoryHistory

What other points of the history do What other points of the history do you want to know?you want to know?

History, Mrs. GreenwichHistory, Mrs. Greenwich

AAllergies:llergies: NKDANKDA MMedications:edications:

• 1- Sulfasalazine 500 mg bid• 2- Methotrexate 7.5 mg qweek• 3- Hydroxychloroquine 300 mg daily• 4- Prednisolone 10 mg daily

PPMHMH::• RA (Dx: 1999) currently treated w/ DMARD RA (Dx: 1999) currently treated w/ DMARD

therapytherapy LLast Mealast Meal:: 1800 1800

EEvents Surrounding Injury:vents Surrounding Injury:• Time of injuryTime of injury: 2100: 2100• Mechanism of injuryMechanism of injury: Pedestrian struck crossing : Pedestrian struck crossing

intersection of busy street. Pedestrian struck on intersection of busy street. Pedestrian struck on right aspect of body. Patient rolled over hood of right aspect of body. Patient rolled over hood of taxi and fell to ground.taxi and fell to ground.

• Estimated taxi velocityEstimated taxi velocity: 10 mph decelerating: 10 mph decelerating

Characterization of Characterization of Symptoms: Symptoms: Chest pain worsening on inspiration Chest pain worsening on inspiration w/ localized thorax tenderness over w/ localized thorax tenderness over ribs 6-7, visible right thorax ribs 6-7, visible right thorax abrasions, non radiating pain, abrasions, non radiating pain, dyspneadyspnea

Temporal sequenceTemporal sequence • Abrupt onset SOB (3 minutes s/p Abrupt onset SOB (3 minutes s/p accident).accident).

A-M-P-L-EA-M-P-L-E TRAUMA HISTORYTRAUMA HISTORY

What is your Differential What is your Differential Diagnosis?Diagnosis?

Differential DiagnosisDifferential DiagnosisBased on History and PresentationBased on History and Presentation

PneumothoraxPneumothorax Musculoskeletal PainMusculoskeletal Pain Rib FracturesRib Fractures MIMI Acute Pulmonary EmbolismAcute Pulmonary Embolism

Physical ExaminationPhysical Examination

What would you look for?What would you look for?

Physical Examination, Mrs. GreenwichPhysical Examination, Mrs. Greenwich

Vital SignsVital Signs: : Tc= 98.7 BP= 98/60 HR=115 RR= 26 Sat 89% RATc= 98.7 BP= 98/60 HR=115 RR= 26 Sat 89% RA

PRIMARY SURVEYPRIMARY SURVEY::• AIRWAY:AIRWAY:

− No altered mental statusNo altered mental status− No airway obstruction notedNo airway obstruction noted− No maxillofacial fractures notedNo maxillofacial fractures noted− Gag reflex intactGag reflex intact

• BREATHING:BREATHING:− Tachypnea; RR=26Tachypnea; RR=26− Decreased breath sounds and hyper Decreased breath sounds and hyper

resonance over the entire R lung fieldresonance over the entire R lung field− tracheal deviation to the L of midlinetracheal deviation to the L of midline− poor respiratory excursionpoor respiratory excursion− no flail movement of chest wallno flail movement of chest wall− local tenderness over R flank at ribs 6-7local tenderness over R flank at ribs 6-7− chest wall asymmetrychest wall asymmetry− notable JVD 8cm above the sternal notable JVD 8cm above the sternal

angleangle

• CIRCULATION:CIRCULATION:‾ No obvious signs of gross No obvious signs of gross

hemorrhagehemorrhage

‾ Hypotensive; BP= 98/60; Hypotensive; BP= 98/60; MAP= 72.67 (1/3 systolic + 2/3 MAP= 72.67 (1/3 systolic + 2/3 diastolic) diastolic)

‾ Tachycardia; HR=115Tachycardia; HR=115

‾ cold/moist extremities w/ cold/moist extremities w/ decreased pulse pressuredecreased pulse pressure

‾ capillary refill >5 seccapillary refill >5 sec

SECONDARY SURVEY:SECONDARY SURVEY:

• NOT ASSESSED AT THIS NOT ASSESSED AT THIS TIME – IMMEDIATE TIME – IMMEDIATE INTERVENTION INTERVENTION NECESSARYNECESSARY

Would you like to revise your Would you like to revise your Differential Diagnosis?Differential Diagnosis?

Revised DifferentialRevised Differential

Tension PneumothoraxTension Pneumothorax Rib FracturesRib Fractures

LaboratoryLaboratory

What would you obtain?What would you obtain?

LaboratoryLaboratory

NO LAB STUDIES AT THIS TIME NO LAB STUDIES AT THIS TIME IMMEDIATE INTERVENTION IMMEDIATE INTERVENTION NECESSARYNECESSARY

See Discussion Section for expected labsSee Discussion Section for expected labs

Interventions at this point?Interventions at this point?

Interventions at this pointInterventions at this point

Supplemental O2Supplemental O2 Decompression Needle ThoracostomyDecompression Needle Thoracostomy

Needle Thoracostomy, DiscussionNeedle Thoracostomy, Discussion

ProcedureProcedure1.1. Use a large bore needle w/ catheter (14-16 gauge)Use a large bore needle w/ catheter (14-16 gauge)2.2. Identify 2Identify 2ndnd intercostal space at midclavicular line (1-2 cm lateral to the intercostal space at midclavicular line (1-2 cm lateral to the

sternal angle). This will minimize likelihood of IMA injurysternal angle). This will minimize likelihood of IMA injury3.3. Prepare area with BetadinePrepare area with Betadine4.4. Insert needle directly superior to the 3rd rib. This prevents injury to Insert needle directly superior to the 3rd rib. This prevents injury to

neurovascular bundle located on the inferior aspect of each rib. neurovascular bundle located on the inferior aspect of each rib. 5.5. Insert needle perpendicular to the chest wall, approximately 3-6 cm in Insert needle perpendicular to the chest wall, approximately 3-6 cm in

depthdepth6.6. Stop advancement of needle upon hearing opening hiss/pressure Stop advancement of needle upon hearing opening hiss/pressure

release of pleural space.release of pleural space.7.7. Remove needle; leave catheter in placeRemove needle; leave catheter in place

What next?What next?


Tube ThoracostomyTube Thoracostomy1.1. Identify and prepare the area w/ Betadine at ICS 4 or 5 along the mid-axillary Identify and prepare the area w/ Betadine at ICS 4 or 5 along the mid-axillary

or anterior axillary lineor anterior axillary line2.2. Anesthetize the area (subcutaneous tissue, intercostal muscles) with Lidocaine. Anesthetize the area (subcutaneous tissue, intercostal muscles) with Lidocaine.

Some physicians use opioid analgesia or a combination of an opioid + Benzo.Some physicians use opioid analgesia or a combination of an opioid + Benzo.3.3. Make a 2 cm incisionMake a 2 cm incision4.4. Insert a large blunt clamp over superior aspect of rib (preventing damage to the Insert a large blunt clamp over superior aspect of rib (preventing damage to the

neurovascular bundle that lies on the inferior border of the rib). Apply gentle neurovascular bundle that lies on the inferior border of the rib). Apply gentle pressure until the parietal pleura is pierced.pressure until the parietal pleura is pierced.

5.5. Open clamp to establish a tract for the chest tube.Open clamp to establish a tract for the chest tube.6. Bluntly dissect w/ finger.7.7. Clamp proximal end of tube tangentially w/ Clamp. Insert tube over superior Clamp proximal end of tube tangentially w/ Clamp. Insert tube over superior

aspect of rib into pleural space.aspect of rib into pleural space.8.8. Insert the chest tube past the last hole. Note the last hole disrupts the continuity Insert the chest tube past the last hole. Note the last hole disrupts the continuity

of the radiopaque line—this facilitates radiographic placement confirmation. of the radiopaque line—this facilitates radiographic placement confirmation. Suture chest tube w/ Silk sutures.Suture chest tube w/ Silk sutures.



Portable Chest X-RayPortable Chest X-Ray(confirm chest tube placement)(confirm chest tube placement)

ManagementManagement

All patient’s with tension pneumothorax All patient’s with tension pneumothorax must be admitted to an inpatient must be admitted to an inpatient service.service.

What should be done next?What should be done next?

ManagementManagement

Monitor patient continuously with arterial O2 saturation—Monitor patient continuously with arterial O2 saturation—watch for sudden desaturationswatch for sudden desaturations

F/U CXR may be ordered to assess re-expansion of lung and F/U CXR may be ordered to assess re-expansion of lung and resolution of pneumothorax. Important: re-expansion resolution of pneumothorax. Important: re-expansion pulmonary edema may occur with rapid lung re-expansion s/p pulmonary edema may occur with rapid lung re-expansion s/p tube thoracostomy. This is a potential life threatening situation tube thoracostomy. This is a potential life threatening situation which can lead to cardiovascular collapse.which can lead to cardiovascular collapse.

Keep chest tube on water seal. Chest tube may be removed Keep chest tube on water seal. Chest tube may be removed when indication for placing it has resolved. F/U CXR must be when indication for placing it has resolved. F/U CXR must be ordered immediately s/p chest tube removal and 24 hrs post-ordered immediately s/p chest tube removal and 24 hrs post-removal to assess for presence of a reoccurring pneumothorax.removal to assess for presence of a reoccurring pneumothorax.

DiscussionDiscussion

Etiology of Tension PneumothoraxEtiology of Tension Pneumothorax TraumaTrauma (blunt or penetrating):(blunt or penetrating): disruption of the parietal or visceral pleura.disruption of the parietal or visceral pleura. Fractures:Fractures: most prevalent as a result of rib fractures, however also seen in most prevalent as a result of rib fractures, however also seen in

displaced thoracic spine fractures.displaced thoracic spine fractures. Barotrauma:Barotrauma: ventilator dependent patients on large volume PEEP may ventilator dependent patients on large volume PEEP may

rupture peripheral alveoli sacs secondarily disrupting the visceral pleura. rupture peripheral alveoli sacs secondarily disrupting the visceral pleura. Index of suspicion is raised when larger peak airway pressures are needed Index of suspicion is raised when larger peak airway pressures are needed to achieve a specific tidal volume.to achieve a specific tidal volume.

Iatrogenic:Iatrogenic: secondary to trauma induced bysecondary to trauma induced by BronchoscopyBronchoscopy Chest compressions during CPRChest compressions during CPR Central venous catheter placementCentral venous catheter placement

Conversion of Simple Pneumothorax -> Tension PneumothoraxConversion of Simple Pneumothorax -> Tension Pneumothorax


Pathophysiology of Simple PneumothoraxPathophysiology of Simple PneumothoraxAir enters the pleural space during inspiration. The pleural space increases in volume Air enters the pleural space during inspiration. The pleural space increases in volume thus compressing the ipsilateral lung. The ipsilateral lung collapses. During expiration thus compressing the ipsilateral lung. The ipsilateral lung collapses. During expiration intrathoracic pressure increases, the diaphragm relaxes, and air is pushed out of the intrathoracic pressure increases, the diaphragm relaxes, and air is pushed out of the pleural space. Note mediastinal structures remain relatively fixed.pleural space. Note mediastinal structures remain relatively fixed.


Pathophysiology of Tension PneumothoraxPathophysiology of Tension PneumothoraxDisruption of the lung parenchyma or parietal pleura acts like a one Disruption of the lung parenchyma or parietal pleura acts like a one way valve. During inspiration air is drawn into the pleural space. way valve. During inspiration air is drawn into the pleural space. During expiration the tissue flap/valve prevents air from escaping. During expiration the tissue flap/valve prevents air from escaping. Subsequent inspirations additively draw more air into the pleural Subsequent inspirations additively draw more air into the pleural space. Increasing intrapleural pressures result in collapse of ipsilateral space. Increasing intrapleural pressures result in collapse of ipsilateral lung and deviation of mediastinal structures contralaterallylung and deviation of mediastinal structures contralaterally


Complications:Complications:

Cardiovascular Collapse:Cardiovascular Collapse: the implications of a tension the implications of a tension pneumothorax are profound. Displacement of mediastinal pneumothorax are profound. Displacement of mediastinal structures contralaterally causes kinking of the SVC and structures contralaterally causes kinking of the SVC and IVC. Venous return to the heart is severely compromised IVC. Venous return to the heart is severely compromised resulting in decreased cardiac output. Shock and resulting in decreased cardiac output. Shock and hypoperfusion ensue.hypoperfusion ensue.

Lab Results, Mrs. GreenwichLab Results, Mrs. Greenwich

ABG:ABG: 7.32/50/60/24/ 89 % RA7.32/50/60/24/ 89 % RA

Chem 7Chem 7

138 102 18138 102 18

110110

3.7 25 1.23.7 25 1.2

Cardiac Enzymes:Cardiac Enzymes: TnI: 0TnI: 0

TnT: 0 TnT: 0

CKMB: 1.2CKMB: 1.2

If Lab Tests were ordered at presentation the If Lab Tests were ordered at presentation the following are expected:following are expected:

Lab Results, DiscussionLab Results, Discussion

ABGs:ABGs: Often seen in tension pneumothorax is a varying Often seen in tension pneumothorax is a varying degree of acidemia, hypercarbia, and hypoxia. Note in acute degree of acidemia, hypercarbia, and hypoxia. Note in acute respiratory acidosis increases in PaCO2 by 10mmHg will respiratory acidosis increases in PaCO2 by 10mmHg will decrease pH by 0.08 (i.e. PaCO2 40->50 lowers pH 7.4-decrease pH by 0.08 (i.e. PaCO2 40->50 lowers pH 7.4->7.32). The reduction in PaO2 is caused by alveolar >7.32). The reduction in PaO2 is caused by alveolar hypoperfusion secondary to atelectasis, low hypoperfusion secondary to atelectasis, low ventilation/perfusion ratios, and anatomic shunts.ventilation/perfusion ratios, and anatomic shunts.

Chem 7:Chem 7: Principally used for the CO2 value. More Principally used for the CO2 value. More accurate for calculations of compensated respiratory accurate for calculations of compensated respiratory acidosis than HCO3- values in ABGs which represents an acidosis than HCO3- values in ABGs which represents an average of computed PaCO2 levels.average of computed PaCO2 levels.

Cardiac Enzymes:Cardiac Enzymes: necessary to r/o acute MI and necessary to r/o acute MI and resulting cardiogenic shock, must have serial reading to resulting cardiogenic shock, must have serial reading to accurately r/o acute MIaccurately r/o acute MI


If CXR was ordered at presentation the If CXR was ordered at presentation the following are expected:following are expected:

Tension Pneumothorax LeftSubpulmonic Pneumothorax Right

SQ AIR

Pulmonary Contusion

Deep Chest Tube

Persistant

Subpulmonic

Pneumothorax

May not see mediastinal shift if pneumothorax is bilateral!


Do not delay treatment of a Tension PneumothoraxDo not delay treatment of a Tension Pneumothorax . CXR can be taken . CXR can be taken for confirmatory measures after decompression needle thoracostomy or tube for confirmatory measures after decompression needle thoracostomy or tube thoracostomy. The diagnosis of a Tension pneumothorax is made clinically thoracostomy. The diagnosis of a Tension pneumothorax is made clinically when one has a high index of suspicion.when one has a high index of suspicion.

Findings on CXR:Findings on CXR: Large radiodense lung fieldLarge radiodense lung field Absent lung markings on ipsilateral sideAbsent lung markings on ipsilateral side Contralateral deviation of trachea and mediastinal structuresContralateral deviation of trachea and mediastinal structures If tension pneumothorax involves left lung the left hemidiaphragm may If tension pneumothorax involves left lung the left hemidiaphragm may

be depressed/flattened. The liver prevents this radiographic finding on be depressed/flattened. The liver prevents this radiographic finding on the right sidethe right side

QUESTIONS ??????QUESTIONS ??????

SummarySummary

Tension Peumothorax is a life threatening condition which Tension Peumothorax is a life threatening condition which may quickly lead to cardiovascular collapse and shock.may quickly lead to cardiovascular collapse and shock.

Immediate intervention must be initiated if there is a high Immediate intervention must be initiated if there is a high clinical suspicion of a tension pneumothorax.clinical suspicion of a tension pneumothorax.

Intervention includes decompression needle thoracostomy Intervention includes decompression needle thoracostomy followed by chest tube thoracostomy, followed by a portable followed by chest tube thoracostomy, followed by a portable chest x-ray to confirm tube placement and re-expansion of chest x-ray to confirm tube placement and re-expansion of collapsed lung fields.collapsed lung fields.

Laboratory and diagnostics may confirm the diagnosis of a Laboratory and diagnostics may confirm the diagnosis of a tension pneumothorax (i.e. ABG, CXR) however the diagnosis tension pneumothorax (i.e. ABG, CXR) however the diagnosis lies predominantly on clinical presenting symptoms.lies predominantly on clinical presenting symptoms.

ReferencesReferences

Check out these sitesCheck out these sites• Needle Thoracostomy photo courtesy ofNeedle Thoracostomy photo courtesy of

http://www.biodigital.org/voz2/slide8.htmhttp://www.biodigital.org/voz2/slide8.htm• Tube Thoracostomy photos courtesy of http://www.vesalius.comTube Thoracostomy photos courtesy of http://www.vesalius.com• CXR w/ 2 Chest Tubes photo courtesy ofCXR w/ 2 Chest Tubes photo courtesy of

http://www.trauma.org/imagebank/chest/images/chest0037.htmlhttp://www.trauma.org/imagebank/chest/images/chest0037.html• Pathophysiology of Pneumothorax photos courtesy ofPathophysiology of Pneumothorax photos courtesy of

http://home.ewha.ac.kr/~chestsg/dong/poster/99/2.htmhttp://home.ewha.ac.kr/~chestsg/dong/poster/99/2.htm• CXR of tension pneumothorax courtesy ofCXR of tension pneumothorax courtesy of

http://www.emedicine.com/med/topic2793.htmhttp://www.emedicine.com/med/topic2793.htm

Acknowledgment The preceding educational materials were made available through the

ASSOCIATION FOR SURGICAL EDUCATIONASSOCIATION FOR SURGICAL EDUCATION

In order to improve our educational materials wewelcome your comments/ suggestions at:

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TENSION PNEUMOTHORAX

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