Updated: 3/14/2019

Tension Pneumothorax

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Snapshot
  • A 56-year-old male with a history of chronic obstructive pulmonary disease presents with pleuritic chest pain and trouble breathing. Vital signs are significant for a blood pressure of 88/54 mmHg and a pulse of 115/min. On exam, there is jugular venous distension, decreased breath sounds on the right side, with wheezes. A chest radiograph is obtained.
 
Introduction
  • Tension pneumothorax results from positive pressure build-up secondary to a flap valve mechanism (or one-way valve) resulting in total lung collapse
    • tracheal shifting to opposite end
    • expansion of chest wall
  • Increased intrathoracic pressure restricts cardiac output
    • may result in shock and death
  • Etiologies include
    • penetrating and blunt chest trauma
    • infection
    • positive-pressure mechanical ventilation
    • iatrogenic
      • placement of central venous line
      • epidural thoracic catheter placement
Presentation
  • Symptoms
    • acute-onset, unilateral, pleuritic chest pain
    • dyspnea/acute respiratory distress
    • syncope
  • Physical exam
    • tachypnea and tachycardia
    • unilateral decreased or absent breath sounds  
    • hyperresonance
    • decreased or absent tactile fremitus
    • falling O2 saturation
    • deviated trachea
    • JVD
    • hypotension
    • subcutaneous emphysema
Evaluation
  • Ultrasound
    • fast with no radiation exposure
    • requires a bedside ultrasound readily available
    • guidance for tube placement
  • Chest radiography (CXR)
    • do not obtain CXR if tension pneumothorax is suspected - immediately decompress the pleural space
    • best observed in end-expiratory films
      • shows unilateral absence lung parenchyma
      • and contralateral mediastinal shift
Differential
  • Primary spontaneous pneumothorax, secondary pneumothorax, acute asthma, inhalation of foreign object, myocardial infarction, ruptured aortic aneurysm
Treatment/Management
  • Non-operative
    • do not resolve spontaneously
      • unlike small, simple pneumothoraces
    • supplemental O2 therapy
      • following operative intervention may be required
  • Operative
    • immediate needle decompression 
      • second intercostal space at the midclavicular line with 14 or 16-gauge needle
    • followed by chest tube placement  
Prognosis, Prevention, and Complications
  • Prognosis
    • shock and death will result if not immediately recognized and treated
  • Prevention
    • no preventive measures can be taken for initial insult
    • chest tube placement following needle decompression prevents recurrence
  • Complications
    • shock and death if left untreated
 

 

 

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Questions (2)
Lab Values
Blood, Plasma, Serum Reference Range
ALT 8-20 U/L
Amylase, serum 25-125 U/L
AST 8-20 U/L
Bilirubin, serum (adult) Total // Direct 0.1-1.0 mg/dL // 0.0-0.3 mg/dL
Calcium, serum (Ca2+) 8.4-10.2 mg/dL
Cholesterol, serum Rec: < 200 mg/dL
Cortisol, serum 0800 h: 5-23 μg/dL //1600 h:
3-15 μg/dL
2000 h: ≤ 50% of 0800 h
Creatine kinase, serum Male: 25-90 U/L
Female: 10-70 U/L
Creatinine, serum 0.6-1.2 mg/dL
Electrolytes, serum  
Sodium (Na+) 136-145 mEq/L
Chloride (Cl-) 95-105 mEq/L
Potassium (K+) 3.5-5.0 mEq/L
Bicarbonate (HCO3-) 22-28 mEq/L
Magnesium (Mg2+) 1.5-2.0 mEq/L
Estriol, total, serum (in pregnancy)  
24-28 wks // 32-36 wks 30-170 ng/mL // 60-280 ng/mL
28-32 wk // 36-40 wks 40-220 ng/mL // 80-350 ng/mL
Ferritin, serum Male: 15-200 ng/mL
Female: 12-150 ng/mL
Follicle-stimulating hormone, serum/plasma Male: 4-25 mIU/mL
Female: premenopause: 4-30 mIU/mL
midcycle peak: 10-90 mIU/mL
postmenopause: 40-250
pH 7.35-7.45
PCO2 33-45 mmHg
PO2 75-105 mmHg
Glucose, serum Fasting: 70-110 mg/dL
2-h postprandial:<120 mg/dL
Growth hormone - arginine stimulation Fasting: <5 ng/mL
Provocative stimuli: > 7ng/mL
Immunoglobulins, serum  
IgA 76-390 mg/dL
IgE 0-380 IU/mL
IgG 650-1500 mg/dL
IgM 40-345 mg/dL
Iron 50-170 μg/dL
Lactate dehydrogenase, serum 45-90 U/L
Luteinizing hormone, serum/plasma Male: 6-23 mIU/mL
Female: follicular phase: 5-30 mIU/mL
midcycle: 75-150 mIU/mL
postmenopause 30-200 mIU/mL
Osmolality, serum 275-295 mOsmol/kd H2O
Parathyroid hormone, serume, N-terminal 230-630 pg/mL
Phosphatase (alkaline), serum (p-NPP at 30° C) 20-70 U/L
Phosphorus (inorganic), serum 3.0-4.5 mg/dL
Prolactin, serum (hPRL) < 20 ng/mL
Proteins, serum  
Total (recumbent) 6.0-7.8 g/dL
Albumin 3.5-5.5 g/dL
Globulin 2.3-3.5 g/dL
Thyroid-stimulating hormone, serum or plasma .5-5.0 μU/mL
Thyroidal iodine (123I) uptake 8%-30% of administered dose/24h
Thyroxine (T4), serum 5-12 μg/dL
Triglycerides, serum 35-160 mg/dL
Triiodothyronine (T3), serum (RIA) 115-190 ng/dL
Triiodothyronine (T3) resin uptake 25%-35%
Urea nitrogen, serum 7-18 mg/dL
Uric acid, serum 3.0-8.2 mg/dL
Hematologic Reference Range
Bleeding time 2-7 minutes
Erythrocyte count Male: 4.3-5.9 million/mm3
Female: 3.5-5.5 million mm3
Erythrocyte sedimentation rate (Westergren) Male: 0-15 mm/h
Female: 0-20 mm/h
Hematocrit Male: 41%-53%
Female: 36%-46%
Hemoglobin A1c ≤ 6 %
Hemoglobin, blood Male: 13.5-17.5 g/dL
Female: 12.0-16.0 g/dL
Hemoglobin, plasma 1-4 mg/dL
Leukocyte count and differential  
Leukocyte count 4,500-11,000/mm3
Segmented neutrophils 54%-62%
Bands 3%-5%
Eosinophils 1%-3%
Basophils 0%-0.75%
Lymphocytes 25%-33%
Monocytes 3%-7%
Mean corpuscular hemoglobin 25.4-34.6 pg/cell
Mean corpuscular hemoglobin concentration 31%-36% Hb/cell
Mean corpuscular volume 80-100 μm3
Partial thromboplastin time (activated) 25-40 seconds
Platelet count 150,000-400,000/mm3
Prothrombin time 11-15 seconds
Reticulocyte count 0.5%-1.5% of red cells
Thrombin time < 2 seconds deviation from control
Volume  
Plasma Male: 25-43 mL/kg
Female: 28-45 mL/kg
Red cell Male: 20-36 mL/kg
Female: 19-31 mL/kg
Cerebrospinal Fluid Reference Range
Cell count 0-5/mm3
Chloride 118-132 mEq/L
Gamma globulin 3%-12% total proteins
Glucose 40-70 mg/dL
Pressure 70-180 mm H2O
Proteins, total < 40 mg/dL
Sweat Reference Range
Chloride 0-35 mmol/L
Urine  
Calcium 100-300 mg/24 h
Chloride Varies with intake
Creatinine clearance Male: 97-137 mL/min
Female: 88-128 mL/min
Estriol, total (in pregnancy)  
30 wks 6-18 mg/24 h
35 wks 9-28 mg/24 h
40 wks 13-42 mg/24 h
17-Hydroxycorticosteroids Male: 3.0-10.0 mg/24 h
Female: 2.0-8.0 mg/24 h
17-Ketosteroids, total Male: 8-20 mg/24 h
Female: 6-15 mg/24 h
Osmolality 50-1400 mOsmol/kg H2O
Oxalate 8-40 μg/mL
Potassium Varies with diet
Proteins, total < 150 mg/24 h
Sodium Varies with diet
Uric acid Varies with diet
Body Mass Index (BMI) Adult: 19-25 kg/m2
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(M2.PL.4827) A 27-year-old male presents to the emergency department after a motor vehicle collision. The patient was an unrestrained driver in a head-on collision. The patient appears intoxicated and is complaining of severe pain. He has a past medical history of cocaine, heroin, and MDMA use, and he is not currently taking any medications. His temperature is 99.5°F (37.5°C), blood pressure is 80/50 mmHg, pulse is 160/min, respirations are 15/min, and oxygen saturation is 95% on room air. An EKG is obtained as seen in Figure A. Laboratory values are ordered as below:

Serum:
Na+: 140 mEq/L
Cl-: 100 mEq/L
K+: 4.1 mEq/L
HCO3-: 24 mEq/L
BUN: 20 mg/dL
Glucose: 110 mg/dL
Creatinine: 1.1 mg/dL
Ca2+: 10.1 mg/dL

Hemoglobin: 10 g/dL
Hematocrit: 23%
Leukocyte count: 5,000 cells/mm^3 with normal differential
Platelet count: 150,000/mm^3

On physical exam the patient is notably short of breath. Cardiac exam is notable for a rapid rate and thready pulses as well as jugular venous distention (JVD). Pulmonary exam reveals unilateral breath sounds. A neurological exam is deferred due to patient non-compliance. Which of the following is the next best step in management? Review Topic

QID: 109455
FIGURES:
1

IV fluids

33%

(5/15)

2

Norepinephrine

7%

(1/15)

3

Needle decompression

53%

(8/15)

4

Cardioversion

0%

(0/15)

5

Defibrillation

0%

(0/15)

M2

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