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 ETIOLOGY 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 DIAGNOSIS 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