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Snapshot
  • A 34-year-old man arrives at the emergency department by ambulance following an altercation at the local bar. He was arguing with a man when all of a sudden he pulled out a knife and stabbed the patient in the chest. He complains of difficulty breathing and extreme chest pain. Vital signs are within normal limits. A physical examination demonstrates a penetrating chest wound and a “sucking” sound during inspiration. 
Introduction
  • Clinical definition
    • abnormal collection of air in the pleural space between the lung and the chest wall secondary to an opening or passageway at the chest wall
    • often a result of blunt or penetrating chest wall trauma
  • Epidemiology
    • demographics
      • more common in urban centers due to higher rates of interpersonal violence
    • risk factors  
      • penetrating chest trauma (e.g., stab or bullet wounds)
      • motor vehicle accidents
  • Pathogenesis
    • opening at the chest wall allows for air movement into the pleural space as the atmospheric pressure and intrathoracic pressure equilibrates
    • the air in the pleural space compresses the lung and leads to super-atelectasis and dyspnea
  • Associated conditions
    • rib fractures
    • pulmonary contusion
    • hemothorax
    • pericardial tamponade
    • tracheobronchial injury
    • esophageal injury
    • aortic injury
Presentation
  • Symptoms 
    • dyspnea  
    • pleuritic chest pain
  • Physical exam
    • vital sign abnormalities (e.g., hypotension)
    • diminished or absent breath sounds
    • hyper-resonance
    • sucking” (sometimes audible) chest wound 
Studies
  • Diagnostic testing
    • diagnostic approach
      • following initial resuscitation and trauma surveys, patients are often diagnosed clinically and later confirmed via chest radiograph
    • imaging
      • chest radiograph
        • best initial test  
        • ideally posterior-anterior view during maximal inspiration
        • allows for evaluation of other conditions associated with blunt or penetrating chest trauma (e.g., aortic dissection)
      • ultrasound (e.g., FAST exam)
        • often part of the initial trauma evaluation but is limited by the operator
        • may be more sensitive than chest radiograph in the identification of pneumothorax
      • chest computed tomography (CT)
        • most sensitive test but is not necessary for the diagnosis  
Differential
  • Tension pneumothorax 
    • distinguishing factor
      • clinical features such as unstable vitals and jugular venous distension
  • Flail chest 
    • distinguishing factor
      • will see a paradoxical movement of the chest wall 
Treatment
  • Management approach
    • initial management consists of stabilization (e.g., oxygen) with close monitoring for early signs of respiratory compromise
    • prompt application of occlusive dressing with thoracostomy is the mainstay of treatment and prevents progression to tension pneumothorax
  • First-line:
    • High flow oxygen and monitoring
    • thoracostomy/chest-tube insertion
      • allows for removal of air and re-expansion of the lung
    • an occlusive dressing (taped on 3 sides)
    • surgical closure of chest wall wound
    • analgesic for pain management
    • fluid management to limit pulmonary edema 
Complications
  • Tension pneumothorax  
    • medical emergency that requires immediate needle thoracostomy
  • Pulmonary edema
    • often follows lung re-expansion
  • Bronchopulmonary fistula
  • Empyema
  • Pneumomediastinum/pneumopericardium
 

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