pneumothorax - ACEM Fellowship Notes

see: [Dunn management of pneumothorax](x-devonthink-item://6A784754-6907-461A-9FFB-C9910E7355D3), [Dunn pulmonary injuries](x-devonthink-item://68C7574E-C7F8-4D99-91C4-B6FE4965AF31), [Dunn management of pneumothorax](x-devonthink-item://6A784754-6907-461A-9FFB-C9910E7355D3), [tintinalli pneumothorax](x-devonthink-item://1ADC8D20-7826-44D0-9DEE-31D41057C9A3?page=64), [Conservative versus Interventional Treatment for Spontaneous Pneumothorax - NEJM 2020](bookends://sonnysoftware.com/ref/DL/247982) see also: [[Thoracostomy|ICC]] > [!treatment] > - Oxygen (4x fold ↑ reabsorption rate of air by pleura) > - if tension: > - finger or needle thoracentesis # Traumatic pneumothorax ## Sucking chest wound - allows air to pass in and out of the pleural cavity - impairs ventilatory function **management** - immediate treatment with an occlusive dressing - tube thoracostomy # primary vs secondary # tension pneumothorax | treatment | advantage | disadvantage | | -------------------- | ---------------------------------------------------------------------------------------------------------------------------------------- | -------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- | | needle decompression | - can perform in anterior chest - fast uses familiar equipment | - needle may not reach pleural space - easily kinked, obstructed, dislodged - difficult to confirm tx - may cause pulmonary or vascular injury | | finger thoracostomy | - allows assessment of pleural space (lung up or down), definite access to pleural space confirmed - does not require tube attachment | - often requires anaesthesia, analgesia - no accurate measurement of blood loss - can cause s*ucking chest wound* if pt not adequately spont ventilating or on positive pressure - requires access to axilla - no blood drainage | | tube thoracostomy | - assists in maintaining patency of thoracostomy - does not require positive pressure - confirms access to pleurla space | - longer to perform - complicates transport - tube may become blocked, kinked, malpositioned, or misplaced - iatrogenic injuries from tube misplacement | # diagnosis ## ultrasound pneumothorax #pocus ![[Pasted image 20240226004002.png| bar code sign showing lack of movement of pleura, consistent with PTX]] ![[Pasted image 20240226004046.png| seashore sign seen in normal lung]] # Bronchopleural fistula persisting air leak into the pleural space - PTx not resolving in spite of properly placed chest drain (lung not re-inflating - worsening pnemomediastinum of s/c emphysema - poor alveolar ventilation i.e. large physiologic dead space **treatment** - large-bore drainage - may damage more lung - low VT, low PEEP, low RR, short inspiratory time - independent lung ventilation - surgicla repair - bronchial stenting or occlusion - PEEP to ICC - compromises drainage and risk of rapid tension pneumothorax - ECMO # Treatment ## conservative treatment - primary pneumothorax with minimal breathlessness - high rate of resolution (~95%) - ED observation for 3-6 hours and repeat CXR at that time to exclude progression of pneumothorax - admission is usually required for secondary pneumothoraces, including those managed conservatively - follow up CXR - 24 hours - 3-5 days ## chest tube insertion - see [[Thoracostomy|ICC]] # Discharge advice - avoid air flight, scuba diving, snorkelling - ensure ready access to emergency medical service - cease smoking - **Air travel** - 6 weeks btwn resolution of PTx or definitive surgical procedure and air travel (some guidelines say 1 week if primary PTx) - CXR should confirm resolution prior to flight - still risks up to 12 months - **Diving** - permanently avoid after ptx unless had definitive preventative treatment - prior traumatic ptx may not be absolute contraindication if healed and CT normal → see expert for advice - recurrence - recurrence rate is 30% in all pts; ↓ after age 40 # Related Questions ## chest trauma - [ ] 1Q: [Chest trauma](x-devonthink-item://B257662E-D069-4044-AF7A-736487B5CA99?page=5) -- [Answer](x-devonthink-item://1658DB69-4D34-47EF-9495-B6B43E0BE3BE?page=6) -- [prop](x-devonthink-item://51B63B5B-D684-4BF3-8B62-95FCA5EF7503?page=3) - [ ] 2Q: [Penetrating Chest Trauma](x-devonthink-item://5DC0999B-D537-4002-86AF-FD7B54B45E2E?page=42) -- [Answer](x-devonthink-item://406AF611-5CD4-4B3B-9795-327E8F4E3626?page=19) - [ ] 3Q: [Chest and Head Trauma](x-devonthink-item://834C484F-DDAA-4819-8DF0-84AE5E70DA1D?page=2) -- [Answer](x-devonthink-item://D46998FE-62E2-4A3A-860D-C32C94B86E42?page=0) -- [prop](x-devonthink-item://834C484F-DDAA-4819-8DF0-84AE5E70DA1D?page=64) - [ ] 4Q: [High Speed Motor Vehicle Collision](x-devonthink-item://C4CCEB12-61D5-4308-AA41-5078F3D96CC0?page=2) -- [Answer](x-devonthink-item://75D8E35B-EE77-4D1B-A665-438451C976AE?page=11) -- [prop](x-devonthink-item://E34679F3-102F-4E16-AF81-9D679412EDAC?page=7) - [ ] 5Q: [Chest Trauma](x-devonthink-item://2504F01B-CEAF-41E8-803B-B3AE1B07A49E?page=13) -- [Answer](x-devonthink-item://00427DF6-6D28-4FEB-A0CA-DF96DBBBCE97?page=28) -- [prop](x-devonthink-item://AB9BDA6D-9CA8-4E73-9D15-B6105225A1B4?page=13) ## intercostal catheter - [ ] 11Q: [Penetrating Chest Trauma](x-devonthink-item://5DC0999B-D537-4002-86AF-FD7B54B45E2E?page=42) -- [Answer](x-devonthink-item://406AF611-5CD4-4B3B-9795-327E8F4E3626?page=19) - [ ] 12Q: [Rib Fractures](x-devonthink-item://EE0B8625-5F19-46CF-8208-56D79DC48BC5?page=5) -- [Answer](x-devonthink-item://6F751245-A36C-447A-8AE7-599AD5871C71?page=11) - [ ] 13Q: [Chest Trauma](x-devonthink-item://73409C77-B2FA-4E0A-AEB3-5EB284457F0C?page=7) -- [Answer](x-devonthink-item://5A848952-80E3-4184-B553-368412A69917?page=6) -- [prop](x-devonthink-item://2A1F4A99-92AE-4C8E-B325-AE448BD46AC6?page=2) ## penetrating chest trauma - [ ] 6Q: [Knitting needle to chest](x-devonthink-item://554C45F7-8661-4467-BD61-8A79B6ECABF4?page=11) -- [Answer](x-devonthink-item://554C45F7-8661-4467-BD61-8A79B6ECABF4?page=13) - [ ] 7Q: [Shotgun wounds](x-devonthink-item://CA0CC973-6102-4C33-AB59-A43A87724DF0?page=10) -- [Answer](x-devonthink-item://9F437E5A-02D4-43FC-B795-5386EDE954F3?page=8) -- [prop](x-devonthink-item://281EC7A9-8E5A-461A-AA34-3FF490AA0EC2?page=2) - [ ] 8Q: [Chest stabbing](x-devonthink-item://2CB6E202-E7C1-46E8-B49F-435AB6C937F0?page=3) -- [Answer](x-devonthink-item://78503782-404C-41A2-A3AE-B1A26F578DF5?page=3) - [ ] 9Q: [Penetrating chest trauma](x-devonthink-item://F0498813-9350-484C-AD5B-6FF7C3AE9015?page=48) -- [Answer](x-devonthink-item://A491A3F6-FD6D-492F-BCBE-7F7BAE101EDF?page=52) - [ ] 10Q: [Penetrating chest trauma](x-devonthink-item://A8F2D7A0-9A26-4012-AF42-19D640D674B4?page=2) -- [Answer](x-devonthink-item://A10DE51E-92FA-42D1-8AA0-7AE68C2FA743?page=1) -- [prop](x-devonthink-item://B864660E-6598-4555-ACA9-B87F41ED4C3A?page=2) - [ ] 11Q: [Local Bar Shenanigans](x-devonthink-item://40F10AFA-5F29-4EE4-B149-300627B498B0?page=1) -- [Answer](x-devonthink-item://2088AEED-9FCF-4CF0-B58D-E4279D4BCC76?page=20) -- [prop](x-devonthink-item://5F365535-E019-4C8D-8402-2E764B328988?page=5) ## pneumothorax - [ ] 12Q: [Pneumothorax](x-devonthink-item://4134DDB3-6E12-474A-9F6F-64135C0C6048?page=49) -- [Answer](x-devonthink-item://AC92B5F1-8EE6-461A-B03E-F70AE7DC1275?page=49) -- [prop](x-devonthink-item://68EA6F60-334D-4A94-8327-78286C5F1AED?page=12) - [ ] 13Q: [Pneumothorax ultrasound](x-devonthink-item://8A1FC024-FD4E-4202-A93D-77C4E8234DC5?page=18) -- [Answer](x-devonthink-item://7EEBE66F-C2B1-4EF7-B29C-FB52D469C8CD?page=17) -- [prop](x-devonthink-item://47692A18-39D4-4FDD-9F24-8F946DAF9CAB?page=1) - [x] DUPLICATE Q: [Pneumothorax Ultrasound](x-devonthink-item://8A1FC024-FD4E-4202-A93D-77C4E8234DC5?page=18) -- [Answer](x-devonthink-item://7EEBE66F-C2B1-4EF7-B29C-FB52D469C8CD?page=17) - [ ] 14Q: [Pneumothorax](x-devonthink-item://B9C99BB4-DAF8-4D15-BBD3-40E82B279902?page=13) -- [Answer](x-devonthink-item://DF848F67-27AB-450A-988B-159784B72957?page=13) -- [prop](x-devonthink-item://D2415799-57A6-4B32-BE9A-0120DF5500A1?page=2) - [ ] 15Q: [Pneumothorax](x-devonthink-item://5DD7C01C-AB9B-4F0E-9CC4-266700BD94E8?page=4) -- [Answer](x-devonthink-item://7CE81625-E4A6-40C1-BAEB-7E44C75B1E60?page=4) - [ ] 16Q: [Pneumothorax](x-devonthink-item://1A2C485F-D4AD-4821-AFF2-452BA753717F?page=4) -- [Answer](x-devonthink-item://FD716379-1A77-4B5B-B257-1154995ECA6E?page=1) -- [prop](x-devonthink-item://1A2C485F-D4AD-4821-AFF2-452BA753717F?page=61) - [ ] 17Q: [Decompression illness](x-devonthink-item://F0498813-9350-484C-AD5B-6FF7C3AE9015?page=32) -- [Answer](x-devonthink-item://A491A3F6-FD6D-492F-BCBE-7F7BAE101EDF?page=32) - [x] DUPLICATE Q: [Chest and Head Trauma](x-devonthink-item://834C484F-DDAA-4819-8DF0-84AE5E70DA1D?page=2) -- [Answer](x-devonthink-item://D46998FE-62E2-4A3A-860D-C32C94B86E42?page=0) - [x] DUPLICATE Q: [Penetrating chest trauma](x-devonthink-item://A8F2D7A0-9A26-4012-AF42-19D640D674B4?page=2) -- [Answer](x-devonthink-item://A10DE51E-92FA-42D1-8AA0-7AE68C2FA743?page=1) - [ ] 18Q: [Pneumothorax](x-devonthink-item://EE0B8625-5F19-46CF-8208-56D79DC48BC5?page=9) -- [Answer](x-devonthink-item://6F751245-A36C-447A-8AE7-599AD5871C71?page=13) -- [prop](x-devonthink-item://308BBEF4-A83E-4972-8F63-9249898FC8E8?page=10) - [x] DUPLICATE Q: [Chest Trauma](x-devonthink-item://2504F01B-CEAF-41E8-803B-B3AE1B07A49E?page=13) -- [Answer](x-devonthink-item://00427DF6-6D28-4FEB-A0CA-DF96DBBBCE97?page=28) ## tension pneumothorax - [ ] 20Q: [Chest Trauma](x-devonthink-item://1EA9311E-0B9E-49F7-8D6E-4C4187A838C4?page=58) -- [Answer](x-devonthink-item://B1CB2E8F-5D04-49EE-8274-043871389D28?page=38)