Open Pneumothorax

See Tube thoracostomy

Background

Pathophysiology

Diagnostics

Differential Diagnosis

Treatment

  1. Should be treated immediately when found
  2. Initial treatment
  3. Surgical consult
  4. Tetanus prophylaxis

Disposition

  1. Admit to OR



 

Immediately Life-Threatening Chest Injuries
  Physical Exam Investigations Management
Airway Obstruction - Anxiety, stridor, hoarseness, altered mental status
- Apnea, cyanosis
- Do not wait for ABG's to intubate - definitive airway management
- intubate early
Tension Pneumothorax
- a clinical diagnosis
- one-way valve causing accumulation of air in pleural space
- Respiratory distress, tachycardia, distended neck veins, cyanosis, asymmetry of chest wall motion
- Tracheal deviation away from pneumothorax
- Percussion hyperresonnance
- Unilateral absence of breath sounds, hypotension
- Non-radiographic diagnosis - large bore IV needle, 2nd ICS mid clavicular line, followed by chest tube in 5th ICS, anterior axillary line
- ICS = intercostal space
Open Pneumothorax
- air entering chest from wound rather than trachea
- Gunshot or other wound (hole > 2/3 tracheal diameter) +/- exit wound
- Unequal breathsounds
- ABG's: decreased pO2 - Air-tight dressing sealed on 3 sides
- Chest tube
- Surgery
Massive Hemothorax
- > 1500 cc blood loss in chest cavity
- Pallor, flat neck veins, shock
- Unilateral dullness
- Absent breath sounds, hypotension
- Upright CXR: costophrenic blunting - Restore blood volume
- Chest tube
- May receive thoracotomy: > 1500 cc total blood volume
200 cc/hr continued drainage
Flail Chest
- Free-floating segment of chest wall due to > 4 rib fractures, each at 2 sites
- Underlying lung contusion (cause of morbidity and mortality)
- paradoxical movement of flail segment
- palpable crepitus of ribs
- decreased air entry on affected side
- ABGs: decreased pO 2 , increased pCO 2
- CXR: rib fractures, lung contusion
- O2 + fluid therapy + pain control
- Judicious fluid therapy in absence of systemic hypotension
- Positive pressure ventilation
- +/- intubation and ventilation
Cardiac Tamponade - penetrating wound (usually)
- Beck's triad (hypotension, distended neck veins, muffled heart sounds)
- pulsus paradoxus
- Kussmaul's sign
- ECHO - IV fluids
- pericardiocentesis
- open thoracotomy