<<Emergency Trauma Care: Current Topics & Controversies Volume IV

Chapter 1: Traumatic Pneumothorax: Updates in Diagnosis and Management in the Emergency Department (Trauma CME)

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Pneumothorax, or air in the pleural space, is common in trauma, and has been found in up to 50% of severe polytrauma patients with chest injury. Although pneumothorax is traditionally diagnosed on plain film and confirmed with CT, the advent of portable ultrasonography has provided a way to rapidly diagnose pneumothorax, with a higher sensitivity than plain film. Patients with traumatic pneumothorax are typically treated with needle decompression or tube thoracostomy. However, recent literature has found that many patients can be managed conservatively via observation, or with a smaller thoracostomy such as a percutaneous pigtail catheter rather than a larger chest tube.

What components of a systematic approach aid in assessment for traumatic pneumothorax?

Which diagnostic studies should be utilized to identify signs of pneumothorax?

When should needle decompression, tube thoracostomy, pigtail catheter, or observation be utilized for appropriate management of pneumothorax?

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Table of Contents

 

1. Abstract
2. Case Presentation
3. Introduction
4. Anatomy and Pathophysiology
5. Emergency Department Evaluation
   1. Primary Survey
   2. Secondary Survey
6. Diagnostic Studies
   1. Chest X-Ray
   2. Ultrasonography
   3. Computed Tomography
7. Emergency Department Management
   1. Needle Decompression
   2. Chest Tube Insertion
   3. Observation
8. Controversies and Cutting Edge
   1. Positive-Pressure Ventilation
   2. Observation Versus Thoracostomy
   3. Chest Tube Sizing
9. Strategies for Management of Traumatic Pneumothorax
10. Summary
11. Case Conclusions
12. Clinical Pathway for Detection and Management of Pneumothorax in the Emergency Department
13. Tables and Figures
14. References

Abstract

Pneumothorax, or air in the pleural space, is common in trauma, and has been found in up to 50% of severe polytrauma patients with chest injury.¹ Findings associated with pneumothorax include dyspnea, chest pain, tachypnea, and absent breath sounds on lung auscultation. Although pneumothorax is traditionally diagnosed on plain film and confirmed with CT, the advent of portable ultrasonography has provided a way to rapidly diagnose pneumothorax, with a higher sensitivity than plain film.^2,3 Patients with traumatic pneumothorax are typically treated with needle decompression or tube thoracostomy. However, recent literature has found that many patients can be managed conservatively via observation, or with a smaller thoracostomy such as a percutaneous pigtail catheter rather than a larger chest tube.

Case Presentation

A 53-year-old man is brought in by EMS after he was involved in a pedestrian-versus-vehicle crash while hurrying across the street to get to a meeting at his office ...

• He is hemodynamically stable but complaining of difficulty breathing and pain along his right chest.
• Diagnostic workup with chest x-ray and CT reveals 2 nondisplaced rib fractures in his right fifth and sixth ribs, as well as a right-sided pneumothorax that measures 27 mm.
• When you discuss treatment options with him, he is adamant that he does not want a chest tube as he has heard from a family member that they are very painful. What are your recommendations for this patient, and how should you counsel him?

A 23-year-old woman who fell from her bicycle presents to the ED with discomfort in her left shoulder and back...

• She is sitting and conversing comfortably during your evaluation, and says that she feels fine other than her shoulder and back.
• You decide to obtain plain films to ensure that she has no fractures, and a small left-sided apical pneumothorax is found.
• You did not notice absence of breath sounds during your examination, and your patient says she feels good enough to go home. Does she need to be kept in the ED for observation, or considered for admission? For how long should she be monitored?

You are called to the trauma bay to evaluate an obese patient who sustained a single stab wound 1 cm below his left clavicle during an altercation…

• Per EMS, he complained of left-sided chest pain prior to becoming hemodynamically unstable and unresponsive en route.
• You consider whether you should confirm your suspected diagnosis with an eFAST examination or immediately place a needle in his anterior chest to decompress the possible tension pneumothorax. Or is another option the best next step?

Clinical Pathway for Detection and Management of Pneumothorax in the Emergency Department

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Tables and Figures

Key References

Following are the most informative references cited in this paper, as determined by the authors.

1. * Haynes D, Baumann MH. Management of pneumothorax. Semin Respir Crit Care Med. 2010;31(6):769-780. (Review)
2. Abdulrahman Y, Musthafa S, Hakim SY, et al. Utility of extended FAST in blunt chest trauma: is it the time to be used in the ATLS algorithm? World J Surg. 2015;39(1):172-178. (Blinded prospective study; 305 patients)
3. Ianniello S, Di Giacomo V, Sessa B, et al. First-line sonographic diagnosis of pneumothorax in major trauma: accuracy of e-FAST and comparison with multidetector computed tomography. Radiol Med. 2014;119(9):674-680. (Retrospective case series; 368 patients)
4. Mowery NT, Gunter OL, Collier BR, et al. Practice management guidelines for management of hemothorax and occult pneumothorax. J Trauma. 2011;70(2):510-518. (Guidelines)
5. * Rowan KR, Kirkpatrick AW, Liu D, et al. Traumatic pneumothorax detection with thoracic US: correlation with chest radiography and CT—initial experience. Radiology. 2002;225(1):210-214. (Prospective blinded study; 27 patients)
6. Ball CG, Kirkpatrick AW, Laupland KB, et al. Incidence, risk factors, and outcomes for occult pneumothoraces in victims of major trauma. J Trauma. 2005;59(4):917-924. (Multicenter retrospective chart review; 323 patients)
7. Blaivas M, Lyon M, Duggal S. A prospective comparison of supine chest radiography and bedside ultrasound for the diagnosis of traumatic pneumothorax. Acad Emerg Med. 2005;12(9):844-849. (Prospective single-blinded study; 176 patients)
8. Chan KK, Joo DA, McRae AD, et al. Chest ultrasonography versus supine chest radiography for diagnosis of pneumothorax in trauma patients in the emergency department. Cochrane Database Syst Rev. 2020;7:CD013031. (Systematic review and meta-analysis; 13 studies)

Keywords: pneumothorax, traumatic pneumothorax, dyspnea, chest pain, chest x-ray, CXR, pleural lines, ultrasound, eFAST, pleural interface, comet-tail artifact, lung sliding, computed tomography, CT, needle decompression, tube thoracostomy, TT, chest tube, pigtail catheter, primary survey, secondary survey, ATLS

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