Tension pneumothorax resident survival guide: Difference between revisions
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{{familytree/start |summary=Diagnostic approach}} | {{familytree/start |summary=Diagnostic approach}} | ||
{{familytree | | | |A01 | | | | |A01= <div style="float: Left; text-align: left; width: 20em; padding:1em;">'''Characterize the symptoms:'''<ref name="pmid20696690">{{cite journal| author=MacDuff A, Arnold A, Harvey J, BTS Pleural Disease Guideline Group| title=Management of spontaneous pneumothorax: British Thoracic Society Pleural Disease Guideline 2010. | journal=Thorax | year= 2010 | volume= 65 Suppl 2 | issue= | pages= ii18-31 | pmid=20696690 | doi=10.1136/thx.2010.136986 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20696690 }} </ref><br> | {{familytree | | | |A01 | | | | |A01= <div style="float: Left; text-align: left; width: 20em; padding:1em;">'''Characterize the symptoms:'''<ref name="pmid20696690">{{cite journal| author=MacDuff A, Arnold A, Harvey J, BTS Pleural Disease Guideline Group| title=Management of spontaneous pneumothorax: British Thoracic Society Pleural Disease Guideline 2010. | journal=Thorax | year= 2010 | volume= 65 Suppl 2 | issue= | pages= ii18-31 | pmid=20696690 | doi=10.1136/thx.2010.136986 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20696690 }} </ref><br> | ||
[[Tension pneumothorax]] diagnosis should be made based on the history and physical examination findings<BR> | |||
❑ [[Breathlessness]]<BR> | ❑ [[Breathlessness]]<BR> | ||
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Imaging studies<BR> | Imaging studies<BR> | ||
❑ [[Chest X-ray]]<BR> | ❑ [[Chest X-ray]]<BR> | ||
:❑ Serial chest radiographs every 6 hrs on the first day after injury to rule out pneumothorax is ideal<ref name="pmid19561940">{{cite journal| author=Sharma A, Jindal P| title=Principles of diagnosis and management of traumatic pneumothorax. | journal=J Emerg Trauma Shock | year= 2008 | volume= 1 | issue= 1 | pages= 34-41 | pmid=19561940 | doi=10.4103/0974-2700.41789 | pmc=PMC2700561 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19561940 }} </ref><BR> | |||
[[File:Pneumothorax CXR.jpg|250px]]<BR> | [[File:Pneumothorax CXR.jpg|250px]]<BR> | ||
Left-sided tension pneumothorax<BR> | Left-sided tension pneumothorax<BR> | ||
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:❑ Ipsilateral flattening of heart border<BR> | :❑ Ipsilateral flattening of heart border<BR> | ||
:❑ Mid diaphragmatic depression<BR> | :❑ Mid diaphragmatic depression<BR> | ||
❑ Chest CT scanning<BR> | ❑ Chest CT scanning<BR> | ||
:❑ For uncertain or complex cases | :❑ For uncertain or complex cases | ||
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:❑ 2nd [[intercostal space]], [[midclavicular line]]<BR> | :❑ 2nd [[intercostal space]], [[midclavicular line]]<BR> | ||
:❑ 4th or 5th [[intercostal space]] mid or anterior axillary line, if Initial decompression is failed because of thick [[chest wall]]<ref name="pmid20696690">{{cite journal| author=MacDuff A, Arnold A, Harvey J, BTS Pleural Disease Guideline Group| title=Management of spontaneous pneumothorax: British Thoracic Society Pleural Disease Guideline 2010. | journal=Thorax | year= 2010 | volume= 65 Suppl 2 | issue= | pages= ii18-31 | pmid=20696690 | doi=10.1136/thx.2010.136986 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20696690 }} </ref> | :❑ 4th or 5th [[intercostal space]] mid or anterior axillary line, if Initial decompression is failed because of thick [[chest wall]]<ref name="pmid20696690">{{cite journal| author=MacDuff A, Arnold A, Harvey J, BTS Pleural Disease Guideline Group| title=Management of spontaneous pneumothorax: British Thoracic Society Pleural Disease Guideline 2010. | journal=Thorax | year= 2010 | volume= 65 Suppl 2 | issue= | pages= ii18-31 | pmid=20696690 | doi=10.1136/thx.2010.136986 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20696690 }} </ref> | ||
:❑ Leave the cannula in place until bubbling is confirmed in the chest drain underwater seal system<BR> | |||
:❑ Check chest tubes, as they can become plugged or malpositioned and stop functioning<BR> | |||
[[File:Site of needle insertion - 1.jpg|250px]]<BR> | [[File:Site of needle insertion - 1.jpg|250px]]<BR> | ||
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</div>}} | </div>}} | ||
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{{familytree | G01 | | | | G02 | | | | | | | | | |G01='''Aspirate using 14-16 G cannula''' |G02='''Admit the patient'''}} | {{familytree | G01 | | | | G02 | | | | | | | | | |G01='''Aspirate using 14-16 G cannula''' |G02='''Admit the patient'''<BR> | ||
❑ Refer the patient to respiratory specialist within 24h of admission}} | |||
{{familytree | |!| | | | | |!| | | | }} | {{familytree | |!| | | | | |!| | | | }} | ||
{{familytree | |!| | | | | H02 | | | | | | | | | |H02=<div style="float: Left; text-align: left; width: 20em; padding:1em;"> '''Insert chest drain'''<BR> | {{familytree | |!| | | | | H02 | | | | | | | | | |H02=<div style="float: Left; text-align: left; width: 20em; padding:1em;"> '''Insert chest drain'''<BR> | ||
❑ Give adequate analgesia to patients before chest tube insertion, as the procedure is extremely painful | |||
❑ Site: the triangle of safety bordered by<BR> | ❑ Site: the triangle of safety bordered by<BR> | ||
:❑ Superiorly: the base of the axilla<BR> | :❑ Superiorly: the base of the axilla<BR> |
Revision as of 19:06, 12 March 2014
Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]
Synonyms and keywords: Collapsed lung; air around the lung; air outside the lung
Overview
Tension pneumothorax is a medical emergency caused by accumulation of air in the pleural cavity. Air enter the intrapleural space through the lung parenchyma, or through a traumatic communication from the chest wall.
Causes
Life Threatening Causes
Life-threatening causes include conditions which may result in death or permanent disability within 24 hours if left untreated. Tension pneumothorax is a life-threatening condition and must be treated as such irrespective of the underlying causes.
Common Causes
- Mechanical ventilation
- Trauma
- Central venous catheter
- Cardiopulmonary resuscitation
- Emphysema
- Chronic obstructive pulmonary disease
- Asthma
Management
Shown below is an algorithm depicting the management of tension pneumothorax.[1]
Characterize the symptoms:[1] Tension pneumothorax diagnosis should be made based on the history and physical examination findings ❑ Breathlessness | |||||||||||||||||||||||||||||||||||||
Examine the patient: Vital signs ❑ Respiratory rate:
❑ Heart rate: ❑ Blood pressure Focused chest examination[1] Inspection ❑ Reduced lung expansion on the affected side Palpation ❑ Trachea shifted to the opposite side Percussion Auscultation ❑ Diminished breath sounds on the affected side | |||||||||||||||||||||||||||||||||||||
Manage the patient with a multidisciplinary team: ❑ Consult a thoracic surgeon ❑ Consult a cardiologist | |||||||||||||||||||||||||||||||||||||
Consider other diseases with similar presentations: ❑ Acute myocardial infarction ❑ Pericardial tamponade ❑ Emphysema | |||||||||||||||||||||||||||||||||||||
Categorize the Patient | |||||||||||||||||||||||||||||||||||||
Hemodynamically Stable | Hemodynamically Unstable | ||||||||||||||||||||||||||||||||||||
Confirm diagnosis Imaging studies
❑ Chest CT scanning
| Emergency needle decompression ❑ Aseptic preparation
❑ Use 14-16 G intravenous cannula
Antibiotic therapy | ||||||||||||||||||||||||||||||||||||
Aspirate using 14-16 G cannula | Admit the patient ❑ Refer the patient to respiratory specialist within 24h of admission | ||||||||||||||||||||||||||||||||||||
Insert chest drain ❑ Give adequate analgesia to patients before chest tube insertion, as the procedure is extremely painful
❑ Site: the triangle of safety bordered by
❑ Requirments
❑ Equipment required
| |||||||||||||||||||||||||||||||||||||
❑ Pleural space size < 2cm | ❑ Pleural space size > 2cm | ||||||||||||||||||||||||||||||||||||
Follow Up | Chest drain | ||||||||||||||||||||||||||||||||||||
Do`s
- Tension pneumothorax diagnosis should be made based on the history and physical examination findings.
- Serial chest radiographs every 6 hrs on the first day after injury to rule out pneumothorax is ideal.[2]
- Leave the cannula in place until bubbling is confirmed in the chest drain underwater seal system
- Suspect tension pneumothorax with blunt and penetrating trauma to the chest
- Differentiate tension pneumothorax from pericardial tamponade, and myocardial infarction.
- Suspect tension pneumothorax in patients on mechanical ventilations, who have a rapid onset of hemodynamic instability or cardiac arrest, and require increasing peak inspiratory pressures.
- Check chest tubes, as they can become plugged or malpositioned and stop functioning.
- Give adequate analgesia to patients before chest tube insertion, as the procedure is extremely painful.
- Refer the patient to respiratory specialist within 24h of admission.
Dont`s
- Don`t start using chest radiograph or CT scan unless in doubt regarding the diagnosis and when the patient's clinical condition is sufficiently stable.
- Don`t use large bore chest drains.[1]
- Don`t repeat needle aspiration unless there were technical difficulties.
References
- ↑ 1.0 1.1 1.2 1.3 1.4 MacDuff A, Arnold A, Harvey J, BTS Pleural Disease Guideline Group (2010). "Management of spontaneous pneumothorax: British Thoracic Society Pleural Disease Guideline 2010". Thorax. 65 Suppl 2: ii18–31. doi:10.1136/thx.2010.136986. PMID 20696690.
- ↑ 2.0 2.1 2.2 Sharma A, Jindal P (2008). "Principles of diagnosis and management of traumatic pneumothorax". J Emerg Trauma Shock. 1 (1): 34–41. doi:10.4103/0974-2700.41789. PMC 2700561. PMID 19561940.