Tension pneumothorax resident survival guide: Difference between revisions

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__NOTOC__
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{{CMG}}; {{AE}} {{MM}}
{{CMG}}; {{AE}} {{HQ}}, {{MM}}, {{TS}}, {{Rim}}
 
{{SK}} Collapsed lung; air around the lung; air outside the lung


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! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | [[Tension pneumothorax resident survival guide#Causes|Causes]]
! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | [[Tension pneumothorax resident survival guide#Causes|Causes]]
|-
|-
! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | [[Tension pneumothorax resident survival guide#Diagnosis|Diagnosis]]
! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left |[[Tension pneumothorax resident survival guide#FIRE: Focused Initial Rapid Evaluation|FIRE]]
|-
! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left |[[Tension pneumothorax resident survival guide#Complete Diagnostic Approach|Diagnosis]]
|-
|-
! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | [[Tension pneumothorax resident survival guide#Treatment|Treatment]]
! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | [[Tension pneumothorax resident survival guide#Treatment|Treatment]]
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==Overview==
=Overview=
Tension pneumothorax is a medical emergency caused by accumulation of air in the [[pleural cavity]].  Air enter the [[intrapleural space]] through the [[Lung|lung parenchyma]], or through a traumatic communication from the [[chest wall]].  It tends to occur in clinical situations such as ventilation, resuscitation, trauma, or in patients with lung disease.<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>  The aim of tension pneumothorax management is to relieve the pressure from thorax.
Tension pneumothorax is a life threatening condition that results from the accumulation of air in the [[pleural cavity]].  Air enters the [[intrapleural space]] through an injured [[parietal pleura]], [[visceral pleura]] or [[tracheobronchial tree]] that forms a one way valveThe one way valve allows the air to enter in the pleural cavity (during inspiration) but prevents its escape (during expiration). Subsequently, the intrapleural pressure rises and results in respiratory and cardiovascular failure.  [[Tension pneumothorax]] can occur as a result of [[trauma]], [[ventilation]] or [[resuscitation]].<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>  The cardinal symptoms and signs of [[tension pneumothorax]] are severe [[dyspnea]], [[chest pain]], [[hypotension]], [[hypoxia]], [[tachycardia]] and [[jugular vein distention]].  [[Tension pneumothorax]] should be managed immediately with emergency needle decompression followed by insertion of a [[chest tube]].


==Causes==
==Causes==
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===Common Causes===
===Common Causes===
Tension pneumothorax can be a complication of primary, or secondary [[pneumothorax]].  The most common causes of tension pneumothorax are:
* [[Asthma]]
 
* [[Mechanical ventilation]]
* [[Trauma]]
* [[Central venous catheter]]
* [[Central venous catheter]]
* [[Cardiopulmonary resuscitation]]
* [[Cardiopulmonary resuscitation]]
* [[Chronic obstructive pulmonary disease]]
* [[Emphysema]]
* [[Emphysema]]
* [[Chronic obstructive pulmonary disease]]
* [[Mechanical ventilation]]
* [[Asthma]]
* [[Trauma]]<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>
 


==Diagnosis==
Click '''[[Pneumothorax causes|here]]''' for the complete list of causes.
Shown below is an algorithm depicting the diagnostic approach of [[tension pneumothorax]] based on the British Thoracic Society Pleural Disease Guideline 2010.<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>


==FIRE: Focused Initial Rapid Evaluation==
A Focused Initial Rapid Evaluation (FIRE) as shown below should be performed to identify patients in need of immediate intervention.


<span style="font-size:85%">Boxes in red signify that an urgent management is needed.</span>


{{familytree/start |summary=Diagnostic approach}}
{{Family tree/start}}
{{familytree | | | |A01 | | | | |A01= <div style="float: Left; text-align: left; width: 40em; 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="text-align: left; width: 22em"> '''Identify cardinal findings that increase the pretest probability of tension pneumothorax:'''</div> <div style="text-align: left; width: 22em"> ❑ [[Chest pain]] <br>❑ [[Dyspnea]]<br>❑ [[Hypoxia]] <br>❑ [[Hypotension]]<br>❑ [[Tachycardia]] <br> ❑ [[Jugular venous distension]]<br>
❑ Absent [[breath sounds]] on the affected side <br>
❑ [[Percussion#Hypperresonance|Hyperresonance]] on the affected side <br>
❑ Hyperexpansion of the the affected side <br>
❑ [[Tracheal deviation]] towards the unaffected side<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></div>}}
{{familytree  | | | |!| | | }}
{{familytree  | | | A02 | | A02= <div style="text-align: left; width: 22em">Does the patient have high probability of tension pneumothorax?</div>}}
{{familytree  | |,|-|^|-|.| | | | |}}
{{familytree  | B01 | | B02 | | | | B01=<div style=" width: 22em"> <div style="background: #FA8072"> {{fontcolor|#F8F8FF|'''Yes'''}} </div> </div>| B02=<div style=" width: 25em">'''No'''</div>}}
{{familytree  | |!| | | |!| | | | | | | }}
{{familytree  | B03 | | B04 | | | | | |B03=<div style="float: left; text-align: left; width: 20em; background: #FA8072; padding:1em;"> {{fontcolor|#F8F8FF| '''❑ Immediately [[Tension pneumothorax resident survival guide#Treatment|<span style="color:white;">insert a 14-16 Gauge needle </span>]] in the 2nd [[intercostal space|<span style="color:white;">intercostal space</span>]] at the [[midclavicular line|<span style="color:white;">midclavicular line</span>]] of the affected hemithorax'''}} </div> |B04=<div style="float: left; text-align: left; width: 22em; padding:1em;">❑ '''[[Tension pneumothorax resident survival guide#Complete Diagnostic Approach of tension pneumothorax|Continue with the complete diagnostic approach below]]''' </div>}}
{{familytree  | |!| | | | | | | | | | | | | }}
{{familytree  | B06 | | | | | | | | | | | |B06=<div style=" width: 22em"> <div style="background: #FA8072"> {{fontcolor|#F8F8FF|'''❑ Insert chest drain immediately after needle decompression'''}} </div> </div>}}
{{Family tree/end}}
<br>


<span style="font-size:85%;color:red">Tension pneumothorax requires '''immediate''' intervention,and diagnosis should be made based on the history and physical examination findings</span> <br>
==Complete Diagnostic Approach==
A complete diagnostic approach should be carried out after a focused initial rapid evaluation is conducted and following initiation of any urgent intervention.<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>


❑ [[Breathlessness]]<BR>
{{familytree/start |summary=Diagnostic approach}}
{{familytree | | | |A01 | | | | |A01= <div style="float: Left; text-align: left; width: 40em; padding:1em;">'''Characterize the symptoms:'''<br>
❑ [[Dyspnea]]<BR>
❑ [[Chest pain]]<BR>
❑ [[Chest pain]]<BR>
❑ [[Cyanosis]]<BR>
❑ [[Cyanosis]]<BR>
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❑ [[Anxiety]]<BR>
❑ [[Anxiety]]<BR>
❑ [[Fatigue]]<BR>
❑ [[Fatigue]]<BR>
Air way pressure alarm: if on [[mechanical ventilation]]
❑ [[Altered mental status]] (in late stages)<br>
</div>}}
</div>}}
{{familytree | | | | |!| | | | | | | | | }}
{{familytree | | | | |!| | | | | | | | | }}
{{familytree | | | | K01 | | | | | K01=<div style="float: Left; text-align: left; width: 40em; padding:1em;"> '''Consider risk factors:'''<br>
{{familytree | | | | K01 | | | | | K01= <div style="float: Left; text-align: left; width: 40em; padding:1em;"> '''Identify the precipitating factors:'''<br>
 
❑ Recent invasive procedures<br>
❑ Recent invasive procedures<br>
:❑ [[Thoracentesis]]<br>
:❑ [[Thoracentesis]]<br>
:❑ [[Central venous catheter]]<br>
:❑ [[Central venous catheter]] <br>
:❑ [[Bronchoscopy]]<br>
:❑ [[Bronchoscopy]]<br>
Cigarette smoking<br>
:[[Biopsy|Pleural biopsy]]<br>
:Risk of pneumothorax is higher in smokers (12%) than non-smokers (0.1%).<ref name="pmid8484388">{{cite journal| author=Abolnik IZ, Lossos IS, Gillis D, Breuer R| title=Primary spontaneous pneumothorax in men. | journal=Am J Med Sci | year= 1993 | volume= 305 | issue= 5 | pages= 297-303 | pmid=8484388 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=8484388  }} </ref><br>
[[Mechanical ventilation]]<br>
 
❑ [[Cardiopulmonary resuscitation]]<br>
❑ [[Cystic fibrosis]]<br>
Presence of [[Drain (surgery)|chest drains]]<br>
:16% to 20% of patients with [[cystic fibrosis]] >18 years of age will experience pneumothorax.<ref name="pmid16100160">{{cite journal| author=Flume PA, Strange C, Ye X, Ebeling M, Hulsey T, Clark LL| title=Pneumothorax in cystic fibrosis. | journal=Chest | year= 2005 | volume= 128 | issue= 2 | pages= 720-8 | pmid=16100160 | doi=10.1378/chest.128.2.720 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16100160  }} </ref></div>}}
❑ [[Hyperbaric oxygen|Hyperbaric oxygen treatment]]<br>
❑ [[Trauma|Chest wall trauma]] </div>}}


{{familytree | | | | |!| | | | | }}
{{familytree | | | | |!| | | | | }}
{{familytree | | | | B01 | | | | |B01= <div style="float: Left; text-align: left; width: 40em; padding:1em;">'''Examine the patient:'''<BR>
{{familytree | | | | B01 | | | | |B01= <div style="float: Left; text-align: left; width: 30em; padding:1em;">'''Examine the patient:'''<BR>
'''Appearance of the patient'''<br>
❑ [[Distress|Severe distress]] and [[labored respiration]]


'''Vital signs'''<BR>
'''Vital signs'''<BR>


❑ [[Pulse]]:<BR>
❑ [[Tachycardia]]<BR>
 
[[Hypotension]] <BR>
:Rate
❑ [[Tachypnea]]<BR>
::❑ [[Tachycardia]]<BR>
❑ [[Pulsus paradoxus]]


:❑Strength
'''Skin'''<br>
::❑ Weak


❑ [[Respiratory rate]]:<BR>
❑ [[Cyanosis]]<br>
:❑ Severe [[tachypnea]]<BR>


❑ [[Blood pressure]]<BR>
'''Neck'''<br>
:❑ [[Hypotension]] <BR>


'''Focused chest examination'''<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>
❑ [[Jugular venous distension]] (absent in severe [[hypotension]])<BR>


'''Inspection'''<BR>
'''Respiratory examination'''<BR>


'''''Inspection'''''<BR>
❑ Enlargement of the involved side of the chest <BR>
❑ [[Intercostal space]] widening on the affected side<br>
'''''Palpation'''''<BR>
❑ Reduced lung expansion on the affected side <BR>
❑ Reduced lung expansion on the affected side <BR>
Enlarged involved [[Thorax|hemithorax]]<BR>
❑ [[Tracheal deviation]] to the contralateral side<BR>
❑ [[Jugular venous distension]]<BR>
❑ Decreased [[vocal fremitus]] over the affected side<BR>
 
'''Palpation'''<BR>
 
❑ Trachea shifted to the opposite side<BR>
❑ Decreased [[vocal fremitus]]<BR>
❑ Displacement of the [[apex beat]]<BR>
❑ Displacement of the [[apex beat]]<BR>
'''''Percussion'''''<BR>
❑ [[Percussion|Hyperresonance]] over the affected side<BR>
'''''Auscultation'''''<BR>
❑ Diminished [[breath sounds]] on the affected side<BR>


'''Percussion'''<BR>
'''Additional findings in ventilated patients'''<br>
 
❑ [[Percussion|Hyperresonance]]<BR>
 
'''Auscultation'''<BR>


Diminished [[breath sounds]] on the affected side<BR>
Decreased [[oxygen saturation]]<br>
 
❑ Increase in inflation pressure <br>
[[File:Tension pneumothorax 1.jpg|400px]]<BR>
❑ Increase in [[Mechanical ventilation initial ventilator settings|peak airway pressure]]<br>
</div>}}
❑ Airway pressure alarm in [[mechanical ventilation|mechanically ventilated]] patients<br></div>}}


{{familytree | | | | |!| | | | | | | | | }}
{{familytree | | | | |!| | | | | | | | | }}
{{familytree | | | | E01 | | | | | E01=<div style="float: Left; text-align: left; width: 40em; padding:1em;"> '''Consider alternative diagnoses:'''<br>
{{familytree | | | | E01 | | | | | E01=<div style="float: Left; text-align: left; width: 40em; padding:1em;"> '''Consider alternative diagnosis:'''<br>
❑ [[Acute myocardial infarction]] <br>
❑ [[Acute myocardial infarction]] <br>
:❑ Nausea, vomiting, and diaphoresis
:❑ Substernal [[chest discomfort]], [[chest pain|pain]] or tightness
:❑ Triggered by exercise<br>
:❑ Radiation of [[chest pain]] to the left arm or jaw
:❑ Substernal discomfort<br>
❑ [[Cardiac tamponade resident survival guide|Pericardial tamponade]] <br>
:❑ Pain radiate to the neck and the arms<br>
:❑ [[Hypotension]]
[[Asthma]]<BR>
:❑ [[Tachycardia]]
:❑ Expiratory wheeze
:❑ [[Muffled heart sounds]]
❑ [[Pericardial tamponade]] <br>
:❑ [[Jugular vein distention]]
:❑ Sharp,stabbing chest pain
:❑ [[Pulsus paradoxus]]
:❑ [[Syncope]]/[[presyncope]]
❑ [[Emphysema]]<BR>
:❑ Past history of [[emphysema]]
❑ [[Musculoskeletal pain]]<Br>
:❑ Tenderness on palpation
:❑ Pain increase with respiration
❑ [[Rib fracture]]<br>
:❑ History of trauma
:❑ Severe tenderness
❑ [[Pulmonary embolism]]<br>
❑ [[Pulmonary embolism]]<br>
:❑ Risk factors for [[thromboembolism]]<br>
:❑ Presence of [[Pulmonary embolism risk factors|risk factors for pulmonary embolism]]<br>
:❑ Recent fracture<br>
:❑ Localized warmth, [[tenderness]], [[edema]] and [[erythema]] in the leg suggestive of [[DVT|deep vein thrombosis]]</div>}}
:❑ [[Deep venous thrombosis]] <br>
{{familytree | | |,|-|^|-|.| | }}
</div>}}
{{familytree | | J01 | | J02 | |J01=❑ '''High probability of tension pneumothorax''' |J02= ❑ '''Low probability of tension pneumothorax and patient is hemodynamically stable''' }}
 
{{familytree | | |!| | | |!| | | | | }}
{{familytree | | | | |!| | | | | |}}
{{familytree |boxstyle=background: #FA8072; color: #F8F8FF;| | M01 | | |!| | M01=❑ Proceed with '''immediate''' [[Tension pneumothorax resident survival guide#Treatment|<span style="color:white;">needle decompression </span>]]}}
{{familytree | | | | J01 | | | | | J01=<div style="float: Left; text-align: left; width: 40em; padding:1em;"> '''Imaging studies'''<BR>
{{familytree | | | | | | M02 | M02= <div style="float: Left; text-align: left; width: 40em; padding:1em;"> '''Order imaging studies:'''<BR>
<span style="font-size:85%;color:red">'''Immediately''' proceed to needle decompression in clinically diagnosed hemodynamically unstable patients </span><br>
❑ Order [[chest X-ray]] looking for:<BR>
❑ [[Chest X-ray]]<BR>
 
:❑ Diagnostic test of choice<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>
Left-sided tension pneumothorax<BR>
:❑ Erect position in inspiration<BR>
:❑ Air in the [[pleural cavity]]<BR>
:❑ Air in the [[pleural cavity]]<BR>
:❑ Contralateral deviation of [[mediastinum]]<BR>
:❑ Contralateral [[deviation of trachea]]<BR>
:❑ Increased thoracic volume<BR>
:❑ Increased thoracic volume<BR>
:❑ Ipsilateral flattening of heart border<BR>
:❑ Ipsilateral flattening of heart border<BR>
:❑ Mid diaphragmatic depression<BR>
:❑ Mid diaphragmatic depression<BR>
 
<SMALL>Shown below is an image of a chest X-ray depicting tension pneumothorax in the left lung.</SMALL><br>
Chest CT scanning<BR>
[[File:Pneumothorax CXR.jpg|250px]]<BR>
:For uncertain or complex cases
Perform serial chest X-ray every 6 hours to rule out [[pneumothorax]] in cases of [[trauma]]<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>
 
Order chest [[CT scan]] for uncertain or complex cases <br>
<SMALL>Shown below is an image of CT scan depicting left-sided pneumothorax.  A chest tube is in place, the lumen (black) can be seen adjacent to the pleural cavity (black) and ribs (white).</SMALL><br>
[[File:Pneumothorax CT.jpg|250px]]<BR>
[[File:Pneumothorax CT.jpg|250px]]<BR>
Left-sided pneumothorax.  A chest tube is in place-side of chest, the lumen (black) can be seen adjacent to the pleural cavity (black) and ribs (white).<BR>
<BR>
❑ [[Ultrasonography]]<BR>
Order [[ultrasonography]] in supine trauma patients among whom a [[chest X-ray]] can not be performed <BR></div> }}
❑ Digital imaging<BR>
</div>}}
{{familytree/end}}
{{familytree/end}}


==Treatment==
==Treatment==
{{familytree/start |summary= Treatment}}
{{familytree/start}}
{{familytree | | | | C01 | | | | |C01= <div style="float: Left; text-align: left; width: 40em; padding:1em;">'''First aid:'''<BR>
{{familytree | | | | E01 | | | | | | | | | | | | | | E01= <div style="float: Left; text-align: left; width: 40em; padding:1em;">'''Perform emergency needle decompression:'''<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>
❑ Airway, breathing, and circulation ([[ABC (medical)|ABC]])<BR>
Wear a gown, face mask and eye shield <br>
❑ Sucking chest wounds immediately coveraged with an occlusive or pressure bandage<BR>
Ensure aseptic preparation<BR>
❑ 100% oxygen administration<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>
Determine the site of insertion of the [[needle]]
</div>}}
:❑ '''2nd [[intercostal space]] at the [[midclavicular line]]''' of affected hemithorax, OR <BR>
{{familytree | | | | |!| | | | | |}}
:❑ 4th or 5th [[intercostal space]] on mid or anterior axillary line, if the initial decompression failed because of a 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>
{{familytree | | | | D01 | | | | | D01=<div style="float: Left; text-align: left; width: 40em; padding:1em;"> '''Manage the patient with a multidisciplinary team:'''<br>
Insert a 14-16 gauge [[needle]] with a [[catheter]] at a 90° angle<BR>
Consult a thoracic surgeon <br> ❑ Consult a cardiologist <br> </div>}}
Remove the [[needle]] and leave the [[catheter]] in place<br>
 
❑ Secure the [[catheter]] in place while preparing for [[tube thoracostomy]] (chest drain) <br>
{{familytree | | | | |!| | | | | |}}
Confirm the diagnosis by observing instantaneous escape of air as the needle is inserted<br>
{{familytree | | | | E01 | | | | | | | | | | | | | | E01=<div style="float: Left; text-align: left; width: 40em; padding:1em;">'''Emergency needle decompression'''
Check for any improvement of the patient's status<br>
Aseptic preparation<BR>
<span style="color:red">Don't remove the catheter, until a chest drain is inserted and is functioning properly.</span><br>
:Use two alcohol-based skin disinfectant<BR>
<br>
❑ Use 14-16 G intravenous cannula<BR>
''Shown below is a video depicting the steps for needle decompression'' <br>
❑ Site
{{#ev:youtube|UvHJ4pjNh2Q|400|How to do a needle decompression}}
:❑ Tension pneumothorax may affect breath sounds on both sides, be sure you are on the diseased side<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>
 
Listen for gush of air<BR>
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>
Don`t repeat needle aspiration unless there were technical difficulties<BR>
 
[[File:Site of needle insertion - 1.jpg|400px]]<BR>
 
❑ Watch how to do a needle decompression {{#ev:youtube|UvHJ4pjNh2Q|400|How to do a needle decompression}}
<SMALL>''Video adapted from Youtube.com''</SMALL>
<SMALL>''Video adapted from Youtube.com''</SMALL>
'''Antibiotic therapy'''<BR>
❑ [[Cephalosporin|First-generation cephalosporin]]<BR>
:❑ Give initial parenteral dose to decrease the risk of [[empyema]] and [[pneumonia]]
</div>}}
</div>}}
{{familytree | | | | |!| | | | | | | }}
{{familytree | | | | |!| | | | | | | }}
{{familytree | | | | G02 | | | | | | | | | |G01='''Aspirate using 14-16 G cannula''' |G02='''Admit the patient'''<BR>
{{familytree | | | | H02 | | | | | | | | | |H02= <div style="float: Left; text-align: left; width: 40em; padding:1em;"> ''' Insert a chest tube (tube thoracostomy) immediately after needle decompression:'''<BR>
❑ Refer the patient to respiratory specialist within 24h of admission}}
Make sure that the following equipments are available:
 
:❑ 1% [[lidocaine]]
{{familytree | | | | |!| | | | }}
:❑ [[Iodine]] or [[chlorhexidine]] solution in [[alcohol]]
{{familytree | | | | H02 | | | | | | | | | |H02=<div style="float: Left; text-align: left; width: 40em; padding:1em;"> '''Insert chest drain'''<BR>
 
Timing of procedures:<br>
:❑ Complications are higher when performed after midnight
:❑ If emergent, do it immediately regardless the time
❑ Image guidance<BR>
 
:❑ A recent [[chest X-ray]] before the procedure
:❑ Standard erect Postro-anterior chest x-ray
:❑ Lateral x-rays provide additional information
 
❑ Ensure aseptic technique<br>
❑ Give adequate analgesia to patients before chest tube insertion, as the procedure is extremely painful<BR>
❑ Site: the triangle of safety bordered by<BR>
:❑ Superiorly: the base of the axilla<BR>
:❑ Anteriorly: lateral edge of pectoralis major<BR>
:❑ Laterally: lateral edge of latissimus dorsi<BR>
:❑ Inferiorly: the line of the fifth intercostal space<BR>
 
[[File:Triangle of safety-1.jpg|400px]]<BR>
 
❑ Requirments
:❑ [[Informed consent|Written consent]]<BR>
:❑ Clean area for the procedure<BR>
:❑ Competent operator and nursing staff<BR>
❑ Equipment required
:❑ 1% [[lignocaine]]
:❑ [[Alcohol]] based skin cleanser
:❑ Sterile drapes, gown, gloves
:❑ Sterile drapes, gown, gloves
:❑ Needles, syringes, gauze swabs
:❑ [[Needles]], [[syringes]], gauze [[swab]]s
:❑ Scalpel, suture (0 or 1-0 silk)
:❑ [[Scalpel]], [[suture]] (0 or 1-0 silk)
:❑ [[Chest tube]] kit
:❑ [[Chest tube]] kit
:❑ Closed system drain (including water) and tubing
:❑ Closed system drain (including water) and tubing
:❑ Dressing
:❑ [[Dressing (medical)|Dressing]]
:❑ Clamp
:❑ Clamp
'''Avoid complications:'''<BR>
❑ Administer adequate analgesics <BR>
Pain<BR>
❑ Determine the insertion site at the '''anterior axillary line over the 4th or 5th rib''' <br>
:Analgesia<BR>
Insert the chest drain <br>
:Local anesthesia<BR>
Remove the catheter inserted during needle decompression after the confirmation that the chest drain is functioning properly <BR>
Intrapleural infection<BR>
Check chest tubes frequently, as they can become plugged or malpositioned <BR>
:❑ Aseptic technique
Remove the chest tube after re-expansion of the affected lung is confirmed by a [[chest X-ray]]<br></div>}}
❑ Wound infection<BR>
{{familytree | | | | |!| | | | | | }}
:❑ Antibiotics prophylaxis<BR>
{{familytree | | | | I01 | | | | | | | | | | | | | | I01=<div style="float: Left; text-align: left; width: 40em; padding:1em;"> '''Follow up:'''<BR>
❑ Drain dislodgement and blockage<BR>
Refer the patient to a respiratory physician if pneumothorax does not respond within 48 hours<BR>
:❑ Frequent checking<BR>
❑ Advise to return to the hospital if increasing breathlessness develops<BR>
❑ Visceral injury<BR>
Advise to avoid air travel until the full resolution of the pneumothorax is confirmed by a chest X-ray<BR>
:❑ Proper insertion technique
Advise to avoid diving permanently unless the patient is treated with [[Pneumothorax surgery|surgical pleurectomy]]<BR>
</div>}}
{{familytree | | | | |!| | | | | |}}
{{familytree | | | | I01 | | | | | | | | | | | | | | I01=<div style="float: Left; text-align: left; width: 40em; padding:1em;"> '''Discharge and follow up'''<BR>
All patients should be followed up by respiratory physicians<BR>
❑ Advise to return to hospital if increasing breathlessness develops<BR>
Advice to avoid air travel<BR>
Advice to avoid Diving <BR>
</div>}}
</div>}}
{{familytree/end}}
{{familytree/end}}


==Do`s==
==Do's==
*[[Tension pneumothorax]] diagnosis should be made based on the history and physical examination findings.
* Suspect [[tension pneumothorax]] in the case of blunt and penetrating trauma to the chest.
*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>
* Immediately cover penetrating chest wounds with an occlusive or pressure bandage in trauma patients with suspected [[tension pneumothorax]].
*Leave the cannula in place until bubbling is confirmed in the chest drain underwater seal system
* Suspect [[tension pneumothorax]] among patients on mechanical ventilation who develop a rapid onset of hemodynamic instability or [[cardiac arrest]] and require an increase in the peak inspiratory pressure.
*Suspect [[tension pneumothorax]] with blunt and penetrating trauma to the chest
* Order serial chest radiographs every 6 hours on the first day following chest [[trauma]] to rule out [[pneumothorax]].<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>
*Differentiate tension pneumothorax from [[pericardial tamponade]], and [[myocardial infarction]].
* Refer the patient to a respiratory specialist within 24 hours of admission.
*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.
* Order a [[chest X-ray]] before chest tube removal to confirm the re-expansion of the affected lung.
*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'ts==
*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 remove the catheter from the 2nd [[intercostal space]] unless a chest tube is appropriately placed.
*Don`t use large bore chest drains.<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>
*Don't use large bore chest tubes.<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>
*Don`t repeat needle aspiration unless there were technical difficulties.
*Don't leave the chest tube more than 7 days, as it will increase the risk of infection.


==References==
==References==
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[[Category:Emergency medicine]]
[[Category:Emergency medicine]]
[[Category:Medicine]]
[[Category:Medicine]]
[[Category:Primary care]]
[[Category:Resident survival guide]]
[[Category:Resident survival guide]]
[[Category:Signs and symptoms]]


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Latest revision as of 20:02, 18 February 2018

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Hamid Qazi, MD, BSc [2], Mohamed Moubarak, M.D. [3], Twinkle Singh, M.B.B.S. [4], Rim Halaby, M.D. [5]

Tension Pneumothorax Resident Survival Guide Microchapters
Overview
Causes
FIRE
Diagnosis
Treatment
Do's
Don'ts

Overview

Tension pneumothorax is a life threatening condition that results from the accumulation of air in the pleural cavity. Air enters the intrapleural space through an injured parietal pleura, visceral pleura or tracheobronchial tree that forms a one way valve. The one way valve allows the air to enter in the pleural cavity (during inspiration) but prevents its escape (during expiration). Subsequently, the intrapleural pressure rises and results in respiratory and cardiovascular failure. Tension pneumothorax can occur as a result of trauma, ventilation or resuscitation.[1] The cardinal symptoms and signs of tension pneumothorax are severe dyspnea, chest pain, hypotension, hypoxia, tachycardia and jugular vein distention. Tension pneumothorax should be managed immediately with emergency needle decompression followed by insertion of a chest tube.

Causes

Life Threatening Causes

Tension pneumothorax is a life-threatening condition and must be treated as such irrespective of the underlying cause.

Common Causes


Click here for the complete list of causes.

FIRE: Focused Initial Rapid Evaluation

A Focused Initial Rapid Evaluation (FIRE) as shown below should be performed to identify patients in need of immediate intervention.

Boxes in red signify that an urgent management is needed.

 
 
Identify cardinal findings that increase the pretest probability of tension pneumothorax:
Chest pain
Dyspnea
Hypoxia
Hypotension
Tachycardia
Jugular venous distension

❑ Absent breath sounds on the affected side
Hyperresonance on the affected side
❑ Hyperexpansion of the the affected side

Tracheal deviation towards the unaffected side[1]
 
 
 
 
 
 
 
 
 
 
 
 
Does the patient have high probability of tension pneumothorax?
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Yes
 
No
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
❑ Immediately insert a 14-16 Gauge needle in the 2nd intercostal space at the midclavicular line of the affected hemithorax
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
❑ Insert chest drain immediately after needle decompression
 
 
 
 
 
 
 
 
 
 
 


Complete Diagnostic Approach

A complete diagnostic approach should be carried out after a focused initial rapid evaluation is conducted and following initiation of any urgent intervention.[1]

 
 
 
Characterize the symptoms:

Dyspnea
Chest pain
Cyanosis
Sweating
Anxiety
Fatigue
Altered mental status (in late stages)

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Identify the precipitating factors:

❑ Recent invasive procedures

Thoracentesis
Central venous catheter
Bronchoscopy
Pleural biopsy

Mechanical ventilation
Cardiopulmonary resuscitation
❑ Presence of chest drains
Hyperbaric oxygen treatment

Chest wall trauma
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Examine the patient:

Appearance of the patient
Severe distress and labored respiration

Vital signs

Tachycardia
Hypotension
Tachypnea
Pulsus paradoxus

Skin

Cyanosis

Neck

Jugular venous distension (absent in severe hypotension)

Respiratory examination

Inspection
❑ Enlargement of the involved side of the chest
Intercostal space widening on the affected side
Palpation
❑ Reduced lung expansion on the affected side
Tracheal deviation to the contralateral side
❑ Decreased vocal fremitus over the affected side
❑ Displacement of the apex beat
Percussion
Hyperresonance over the affected side
Auscultation
❑ Diminished breath sounds on the affected side

Additional findings in ventilated patients

❑ Decreased oxygen saturation
❑ Increase in inflation pressure
❑ Increase in peak airway pressure

❑ Airway pressure alarm in mechanically ventilated patients
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Consider alternative diagnosis:

Acute myocardial infarction

❑ Substernal chest discomfort, pain or tightness
❑ Radiation of chest pain to the left arm or jaw

Pericardial tamponade

Hypotension
Tachycardia
Muffled heart sounds
Jugular vein distention
Pulsus paradoxus

Pulmonary embolism

❑ Presence of risk factors for pulmonary embolism
❑ Localized warmth, tenderness, edema and erythema in the leg suggestive of deep vein thrombosis
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
High probability of tension pneumothorax
 
Low probability of tension pneumothorax and patient is hemodynamically stable
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
❑ Proceed with immediate needle decompression
 
 
 
 
 
 
 
 
 
 
Order imaging studies:

❑ Order chest X-ray looking for:

❑ Air in the pleural cavity
❑ Contralateral deviation of trachea
❑ Increased thoracic volume
❑ Ipsilateral flattening of heart border
❑ Mid diaphragmatic depression

Shown below is an image of a chest X-ray depicting tension pneumothorax in the left lung.

❑ Perform serial chest X-ray every 6 hours to rule out pneumothorax in cases of trauma[2]
❑ Order chest CT scan for uncertain or complex cases
Shown below is an image of CT scan depicting left-sided pneumothorax. A chest tube is in place, the lumen (black) can be seen adjacent to the pleural cavity (black) and ribs (white).


❑ Order ultrasonography in supine trauma patients among whom a chest X-ray can not be performed

Treatment

 
 
 
Perform emergency needle decompression:[1]

❑ Wear a gown, face mask and eye shield
❑ Ensure aseptic preparation
❑ Determine the site of insertion of the needle

2nd intercostal space at the midclavicular line of affected hemithorax, OR
❑ 4th or 5th intercostal space on mid or anterior axillary line, if the initial decompression failed because of a thick chest wall[1]

❑ Insert a 14-16 gauge needle with a catheter at a 90° angle
❑ Remove the needle and leave the catheter in place
❑ Secure the catheter in place while preparing for tube thoracostomy (chest drain)
❑ Confirm the diagnosis by observing instantaneous escape of air as the needle is inserted
❑ Check for any improvement of the patient's status
Don't remove the catheter, until a chest drain is inserted and is functioning properly.

Shown below is a video depicting the steps for needle decompression
{{#ev:youtube|UvHJ4pjNh2Q|400|How to do a needle decompression}} Video adapted from Youtube.com

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Insert a chest tube (tube thoracostomy) immediately after needle decompression:

❑ Make sure that the following equipments are available:

❑ 1% lidocaine
Iodine or chlorhexidine solution in alcohol
❑ Sterile drapes, gown, gloves
Needles, syringes, gauze swabs
Scalpel, suture (0 or 1-0 silk)
Chest tube kit
❑ Closed system drain (including water) and tubing
Dressing
❑ Clamp

❑ Administer adequate analgesics
❑ Determine the insertion site at the anterior axillary line over the 4th or 5th rib
❑ Insert the chest drain
❑ Remove the catheter inserted during needle decompression after the confirmation that the chest drain is functioning properly
❑ Check chest tubes frequently, as they can become plugged or malpositioned

❑ Remove the chest tube after re-expansion of the affected lung is confirmed by a chest X-ray
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Follow up:

❑ Refer the patient to a respiratory physician if pneumothorax does not respond within 48 hours
❑ Advise to return to the hospital if increasing breathlessness develops
❑ Advise to avoid air travel until the full resolution of the pneumothorax is confirmed by a chest X-ray
❑ Advise to avoid diving permanently unless the patient is treated with surgical pleurectomy

 
 
 
 
 
 
 
 
 
 
 
 
 

Do's

  • Suspect tension pneumothorax in the case of blunt and penetrating trauma to the chest.
  • Immediately cover penetrating chest wounds with an occlusive or pressure bandage in trauma patients with suspected tension pneumothorax.
  • Suspect tension pneumothorax among patients on mechanical ventilation who develop a rapid onset of hemodynamic instability or cardiac arrest and require an increase in the peak inspiratory pressure.
  • Order serial chest radiographs every 6 hours on the first day following chest trauma to rule out pneumothorax.[2]
  • Refer the patient to a respiratory specialist within 24 hours of admission.
  • Order a chest X-ray before chest tube removal to confirm the re-expansion of the affected lung.

Don'ts

  • Don't remove the catheter from the 2nd intercostal space unless a chest tube is appropriately placed.
  • Don't use large bore chest tubes.[1]
  • Don't leave the chest tube more than 7 days, as it will increase the risk of infection.

References

  1. 1.0 1.1 1.2 1.3 1.4 1.5 1.6 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. 2.0 2.1 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.


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