Traumatic Pneumothorax: Updates in Diagnosis and Management in the Emergency Department - Trauma EXTRA Supplement (Trauma CME) -

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Publication Date: April 2022 (Volume 24, Supplement 04)

CME Credits: 4 AMA PRA Category 1 Credits™. CME expires 04/15/2025. This course is included with an Emergency Medicine Practice subscription

Specialty CME Credits: Included as part of the 4 credits, this CME activity is eligible for 4 Trauma CME credits, subject to your state and institutional approval.

Authors

Peer Reviewer

Trauma EXTRA Guest Editor-in-Chief

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?

Accreditation:

EB Medicine is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians.