Pneumothorax

[Ediron]

I know hemothorax is blood in the the lungs
and pneumothorax, open pneumothorax, tension penumothorax, and cardiac contusion present with the same signs and symptoms

like decreased breath sounds and JVD

how do you differ them???
its frustrating

this is my only weak part

and im taking my national tomorrow

 

[Shishkabob]

Open Pneumo-- You can see it. It has an open wound.

Pneumothorax-- Air in the pleural space of the chest cavity. You'll have decreased / diminished breath sounds over that portion.

Tension pneumo- A pneumo, either simple or open, that traps more air then it releases. This trapped air eventually causes so much pressure in the chest that it collapses a lung and pushes against the heart, causing absent breath sounds and a decreasing blood pressure. JVD can be caused because of decreased pre-load, so the excess blood is not being allowed to enter the heart and backs up. Simplest explanation.



Now, do you mean pulmonary contusion, or cardiac?

 

[18G]

Its not always possible to diagnose all these specifically in the field. Linuss summed it up pretty good though.

A pneumothorax you will have decreased or absent breath sounds with a history of chest trauma. Low SpO2, dyspnea, S/S of poor gas exchange.

Tension pneumothorax - absent breath sounds with severe dyspnea and hemodynamic instability. Can see JVD. Trachial deviation is a rare find.

Hemathorax - blood instead of air in the pleural space. Decreased air entry with crackles. A fair amount of blood can collect in the chest cavity so hemodynamics will be unstable.

Don't just look at a subset of S/S... looking at the overall condition will clue you in.

Cardiac contusion? Hx of chest trauma with EKG changes. PVC's, ST-segment changes, etc.

Pulmonary contusion? Again, chest trauma with low Spo2 and other parameters indicating poor diffusion.

This is all very condensed but hopefully will point ya in the right direction for thinking and differentiation.

 

[Ediron]

Open Pneumo-- You can see it. It has an open wound.

Pneumothorax-- Air in the pleural space of the chest cavity. You'll have decreased / diminished breath sounds over that portion.

Tension pneumo- A pneumo, either simple or open, that traps more air then it releases. This trapped air eventually causes so much pressure in the chest that it collapses a lung and pushes against the heart, causing absent breath sounds and a decreasing blood pressure. JVD can be caused because of decreased pre-load, so the excess blood is not being allowed to enter the heart and backs up. Simplest explanation.



Now, do you mean pulmonary contusion, or cardiac?

yea im sorry
i meant cardiac contusion

 

[18G]

Just to clarify, pneumothorax can have a non-traumatic etiology. I was assuming you wanted to know more about traumatic cause and recognition and wasnt 100% clear on that in my post.

 

[Jeffrey_169]

I have to agree with Linuss. Excellent job on the explanation.

 

[kingsfan33]

Your thoughts please

We had a patient last night with a spontaneous Tension Pneumothorax (as the ER later confirmed).
She went into respiratory arrest immediately (she was walking in her kitchen and collapsed and immediately stopped breathing, as per family) and emt's were on scene within 2 minutes. BVM was not getting good chest rise/fall (with a good seal and with OPA and good head tilt). I believe the person who listened to lungs stated that one side was absent sounds and the other side he heard minimal air movement. is this normal for the tension pneumo?
Some color came back. She was initially blue, and then started to pink up. (leading me to believe maybe she was getting some air?)

she then lost a pulse after about 2 minutes. CPR initiated initiated, she regained a pulse after about 2 more minutes. (AED: "No shock advised" when she was pulseless). At this point ALS arrives. but it was very frustrating on scene. emt on scene noticed trachial deviation, advised the als units, but they just treat her being in arrest and ignore the trach deviation and lack of a patent airway.

They try tubing, failed on first try (hit the stimach). lost pulse again, then she regained it in ER.

Last status check I heard she had BP of 110 systolic. Stable pulse, but on a vent. pupils fixed/non-reactive.

What are your thoughts on this? Could/Should ALS have done more?

Thanks!

 

[Shishkabob]

Can't tell by just your story alone on what was going through their minds.

Typically a tension pneumo is part of our Hs + Ts when trying to correct a cardiac arrest, so if they thought it was a tension pneumo causing a PEA, they would / should have darted her chest.


What did the hospital do to correct the situation?

 

[kingsfan33]

as far as the hospital interventions i believe they did a tracheotomy

 

[LondonMedic]

as far as the hospital interventions i believe they did a tracheotomy

:unsure:

 

[LondonMedic]

Typically a tension pneumo is part of our Hs + Ts when trying to correct a cardiac arrest, so if they thought it was a tension pneumo causing a PEA, they would / should have darted her chest.

Crack on with bilat thoracotomies +/- convert to clamshell? B)

 

[Shishkabob]

as far as the hospital interventions i believe they did a tracheotomy

A trach is a surgical incision in the trachea (neck). A needle thoracostomy is what is used in the field for a tension pneumo... typically a 14ga IV catheter inserted into the affected side to let the excess air out.


So obviously there is more to the story, and to the patient, then you either know or are letting us know if the hospital "confired a tension pneumo" and used a trach to fix it.

Crack on with bilat thoracotomies +/- convert to clamshell? B)

And I got back to my response to you in the other thread:

What the heck did you just say?! :wacko:

 

[LondonMedic]

And I got back to my response to you in the other thread:

What the heck did you just say?! :wacko:

In traumatic arrest, we would intubate and get straight onto to doing bilateral anterolaterial thoracostomies (quick and dirty - scalpel and fingers) to relieve any potential tension pneumothorax. If that doesn't work, they'll convert the two thoracostomies by cutting through the intercostal tissue and sternum to create a clamshell thoracotomy so that any tamponade can be relieved.

http://emj.bmj.com/content/22/1/22.abstract
http://emj.bmj.com/content/19/6/587.extract

(I can send you full texts if you can't)

 

[Shishkabob]

Oh. See, I knew the procedures, but I was confused by your lingo which I instantly assumed was Brit slang

 

[VentMedic]

A clamshell is one of the largest thoracotomy incision that opens up the entire thoracic cavity. It is a bilateral anterolateral thoracotomy combined with a transverse sternotomy. This is serious surgery.

A trach will not fix a pneumothorax but may have been their option for a difficult or messed up intubation.

If an ED can do a trach, they should be able to insert chest tubes rather than doing a "clamshell".

 

[LondonMedic]

If an ED can do a trach, they should be able to insert chest tubes rather than doing a "clamshell".

London HEMS do them to treat potential tamponade in traumatic arrest. Clamshell is done rather than a left extended anterolateral because it is quicker, easier and provides a better field of view to a non-surgeon.

Thoracostomies are used instead of chest tubes because they are easier and quicker in the I&V patient.

 

[VentMedic]

London HEMS do them to treat potential tamponade in traumatic arrest. Clamshell is done rather than a left extended anterolateral because it is quicker, easier and provides a better field of view to a non-surgeon.

Can you post the protocols (both the incision and anaesthesia) to that since the previous links you posted clearly stated this was done by a prehospital physician?

Thoracostomies are used instead of chest tubes because they are easier and quicker in the I&V patient.

When you do a chest tube, you generally do make a thoracostomy. It does not take that long and for several years, Paramedics (not a doctor) in the U.S. were taught to perform them in the field. Now, a few rural services still have the protocols as do Flight and Specialty.

 

[LondonMedic]

Can you post the protocols (both the incision and anaesthesia) to that since the previous links you posted clearly stated this was done by a prehospital physician?

To the best of my knowledge there's not a 'protocol' as such. The services, in- and out-of-hospital, that perform it teach their doctors to do it using the medicines, equipment and facilities that they have.

The incision, as was taught to me, is a 3cm incision made at the anterior axillary line, fifth intercostal space immediately above the sixth rib. Once the skin and subcut tissue is dissected, fingers or dissecting forceps can be used to get down to, and through, the pleura. That's normally it, a formal chest tube can be inserted and secured later.

To extend to a clamshell, insert a pair of shears (tuff cuts are a popular choice) into the thoracostomy and cut transversely until you (hopefully) meet up with the other thoracostomy. After that the thorax can be levered open.

Anaesthesia wise, it's a bog standard RSI with medications as appropriate for the patient and injury pattern chosen by the doctor.

When you do a chest tube, you generally do make a thoracostomy. It does not take that long and for several years, Paramedics (not a doctor) in the U.S. were taught to perform them in the field. Now, a few rural services still have the protocols as do Flight and Specialty.

It's something paramedics in this country wouldn't be able to do, they're limited to needle chest decompression.

 

[VentMedic]

A well trained EM physician or surgeon can do just about anything in the field. With portable ECMO units, we can also get patients that would otherwise have died at a small rural hospital back to the trauma center.

Interesting articles for thoracotomies and London HEMS:
http://www.jephc.com/uploads/990356TC1.pdf

Are doctors a routine part of their HEMS and fly each time?

 

[LondonMedic]

A well trained EM physician or surgeon can do just about anything in the field. With portable ECMO units, we can also get patients that would otherwise have died at a small rural hospital back to the trauma center.

Interesting, I have a little exposure to ECMO in neonatesand heard of it in grown-up critical care, never heard of it being used in pre-hospital care. Do you have any literature?

Are doctors a routine part of their HEMS and fly each time?

In London, at least one doctor and one paramedic goes on each sortie whether in the aircraft or on the cars. The doctor will be a senior registrar or consultant (senior resident / attending) in anaesthetics, emergency medicine or surgery. The paramedic will be an experienced medic seconded from London Ambulance who will have recieved some top up training but we don't have formal 'flight paramedic' qualifications over here. Other services in other parts of the UK do their own thing, the use of doctors is increasing but I'm not sure I know of another service that sends doctors on all sorties.