Morning Report: 11/27/2012 - The Original Kings of County

Back from the Thanksgiving Holiday with another edition of Morning Report! Here’s Dr. Kazzi with today’s topic:

Pneumothorax / Hemothorax :

(EMPGU 2012)

Definition = Air in the pleural cavity

Types:

1) Spontaneous

– Primary (no underlying lung disease)

– Secondary (Underlying lung disease)

2) Traumatic

Classification:

Occult: Not seen on CXR but seen on CT scan
Small: < 2 cm at level of Hilum
Large: > 2 cm at level of Hilum
Tension: Progressive build up of pressure in pleural cavity causing lateral displacement of mediastinum, compromise of venous return, clinical deterioration and possible cardiac arrest.

Diagnosis:

Ultrasound: Absence of lung sliding, identification of transition point, M-mode showing “stratosphere” sign instead of seashore sign. More sensitive than CXR
E-FAST will identify fluid consistent with hemothorax in trauma

CXR

CT scan: most sensitive modality

Management:
a) Discharge
b) Observation
c) Needle aspiration
d) Tube Thoracostomy

Traumatic Pneumothorax / HTX:

Surgical intervention if
Initial Drainage > 1000 mL
Drainage of > 150 – 200 mL/hr over 2 – 4 hours
Repeated transfusions to maintain hemodynamic stability

(EAST Guidelines 2011)
Patient physiology rather than absolute numbers of initial or persistent output should guide decision making.
1500 mL via chest tube in any 24 hour period should prompt surgical exploration

All hemothoraces should be considered for drainage.
Tube thoracostomy (36 Fr – 40 Fr) should be placed.
If initial chest tube does not drain HTX then VATS (Video Assisted Thorascopic Surgery) not a second chest tube, is indicated

Occult pneumothorax can be observed, even in the setting of Positive Pressure Ventilation.

Tension Pneumothorax:

Mid-clavicular line is more lateral than commonly assumed. Clavicle ends at shoulder. Most EM docs place catheter more medial than is correct.

Insert angiocatheter at 5th intercostal space along the mid-axillary line similar to the location of the chest tube. Avg chest wall thickness was 3.5 +/- 0.9 cm at 5th ICS vs. 4.5 cm +/- 1.1 cm at mid-clavicular 2nd ICS.
Successful needle thoracostomy placement was 100% at 5th ICS vs. 58% at 2nd ICS.
Use at least a 5 cm angiocatheter. Traditional angiocatheters are 3 cm. CVC angiocatheters are 6.3 cm.

Spontaneous Pneumothorax:
Primary – no underlying lung pathology
Secondary – yes underlying lung pathology (COPD usually)

Management:
Oxygen 100% NRB
Needle Aspiration
– As effective (14-16 gauge) as large bore (> 20 Fr) chest drains. Do not repeat a
needle aspiration.
– Unsuccessful aspiration is followed by Chest tube (< 14 Fr) not another attempt

Suction should be avoided due to potential for reexpansion pulmonary edema

Small spontaneous primary PTX without breathlessness → 6 hour CXR → ? DC
Large Spontaneous primary PTX > 2 cm → Needle aspiration
Small secondary spontaneous PTX < 1 cm → Observe
Secondary Spontaneous PTX 1 – 2 cm → Needle Aspiration
Secondary Spontaneous PTX > 2 cm → Chest tube < 14 Fr

Thanks Dr. Kazzi!

The views expressed on this blog are the author's own and do not reflect the views of their employer. Please read our full disclaimer here. Any references to clinical cases refer to patients treated at a virtual hospital, Janus General Hospital.

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Jay Khadpe MD

Editor in Chief of "The Original Kings of County" Assistant Professor of Emergency Medicine Assistant Residency Director SUNY Downstate / Kings County Hospital