Updated: 12/22/2021

Open Pneumothorax

Review Topic
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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
  • 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
    • Diagnostic testing
      • diagnostic approach
        • following initial resuscitation and trauma surveys, patients are often diagnosed clinically and later confirmed via chest radiograph
  • 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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