Tension pneumothorax--time for a re-think. Emerg Med J. 2005;22:8-16. [PMID: 15611534 DOI: 10.1136/emj.2003.010421]

Iatrogenic pneumothorax related to mechanical ventilation

Pneumothorax is a potentially lethal complication associated with mechanical ventilation. Most of the patients with pneumothorax from mechanical ventilation have underlying lung diseases; pneumothorax is rare in intubated patients with normal lungs. Tension pneumothorax is more common in ventilated patients with prompt recognition and treatment of pneumothorax being important to minimize morbidity and mortality. Underlying lung diseases are associated with ventilator-related pneumothorax with pneumothoraces occurring most commonly during the early phase of mechanical ventilation. The diagnosis of pneumothorax in critical illness is established from the patients’ history, physical examination and radiological investigation, although the appearances of a pneumothorax on a supine radiograph may be different from the classic appearance on an erect radiograph. For this reason, ultrasonography is beneficial for excluding the diagnosis of pneumothorax. Respiration-dependent movement of the visceral pleura and lung surface with respect to the parietal pleura and chest wall can be easily visualized with transthoracic sonography given that the presence of air in the pleural space prevents sonographic visualization of visceral pleura movements. Mechanically ventilated patients with a pneumothorax require tube thoracostomy placement because of the high risk of tension pneumothorax. Small-bore catheters are now preferred in the majority of ventilated patients. Furthermore, if there are clinical signs of a tension pneumothorax, emergency needle decompression followed by tube thoracostomy is widely advocated. Patients with pneumothorax related to mechanical ventilation who have tension pneumothorax, a higher acute physiology and chronic health evaluation II score or PaO₂/FiO₂ < 200 mmHg were found to have higher mortality.

Clinical manifestations of tension pneumothorax: protocol for a systematic review and meta-analysis

BACKGROUND

Although health care providers utilize classically described signs and symptoms to diagnose tension pneumothorax, available literature sources differ in their descriptions of its clinical manifestations. Moreover, while the clinical manifestations of tension pneumothorax have been suggested to differ among subjects of varying respiratory status, it remains unknown if these differences are supported by clinical evidence. Thus, the primary objective of this study is to systematically describe and contrast the clinical manifestations of tension pneumothorax among patients receiving positive pressure ventilation versus those who are breathing unassisted.

METHODS/DESIGN

We will search electronic bibliographic databases (MEDLINE, PubMed, EMBASE, and the Cochrane Database of Systematic Reviews) and clinical trial registries from their first available date as well as personal files, identified review articles, and included article bibliographies. Two investigators will independently screen identified article titles and abstracts and select observational (cohort, case-control, and cross-sectional) studies and case reports and series that report original data on clinical manifestations of tension pneumothorax. These investigators will also independently assess risk of bias and extract data. Identified data on the clinical manifestations of tension pneumothorax will be stratified according to whether adult or pediatric study patients were receiving positive pressure ventilation or were breathing unassisted, as well as whether the two investigators independently agreed that the clinical condition of the study patient(s) aligned with a previously published tension pneumothorax working definition. These data will then be summarized using a formal narrative synthesis alongside a meta-analysis of observational studies and then case reports and series where possible. Pooled or combined estimates of the occurrence rate of clinical manifestations will be calculated using random effects models (for observational studies) and generalized estimating equations adjusted for reported potential confounding factors (for case reports and series).

DISCUSSION

This study will compile the world literature on tension pneumothorax and provide the first systematic description of the clinical manifestations of the disorder according to presenting patient respiratory status. It will also demonstrate a series of methods that may be used to address difficulties likely to be encountered during the conduct of a meta-analysis of data contained in published case reports and series. PROSPERO registration number: CRD42013005826.

Improvement in the prehospital recognition of tension pneumothorax: the effect of a change to paramedic guidelines and education

INTRODUCTION

An audit of ambulance service clinical records from 2001 to 2002 in Melbourne, Australia revealed 10 patients with tension pneumothorax on arrival at hospital which had been undetected or untreated by paramedics. The clinical practice guideline for paramedic recognition of tension pneumothorax was subsequently changed to emphasise heightened clinical suspicion of a tension pneumothorax in the setting of chest trauma, especially when patients were managed with positive pressure ventilation. This study was undertaken to determine whether the number of undetected or untreated tension pneumothoraces had decreased after the new clinical practice guideline and associated education program; if there were unintended consequences arising from earlier paramedic intervention; and what effect, if any, this change had on subsequent hospital treatment.

METHODS

Retrospective case note review of all patients requiring intercostal catheter (ICC) insertion at The Alfred Hospital, Melbourne, Australia, using records from Ambulance Victoria, the Alfred Trauma Registry and the National Coronial Information System.

RESULTS

In 2001-2002 paramedics treated 22 patients with suspected tension pneumothorax before transport to the Alfred Hospital. In 2006-2007 this number had increased to 81. There was a decrease from ten to four in the number of unrecognised or untreated tension pneumothoraces between the two time periods. No unintended or adverse consequences of prehospital needle decompression could be found. However, there was an increase in the number of patients who had prehospital needle decompression that needed further treatment for tension pneumothorax on arrival at hospital. This need for further treatment was associated with use of shorter cannulas and unilateral needle decompression by paramedics.

CONCLUSION

A small change in clinical practice guidelines, supported by an education and audit program, led to a reduction in unrecognised untreated tension pneumothoraces by paramedics without an increase in complications. Paramedics should be aware that a shorter cannula may fail to reach the pleural space and that both sides of the chest may require decompression.

Diagnosis and treatment of pneumothorax

Many diagnostic and therapeutic options exist for the evaluation and treatment of patients with pneumothorax. Guidelines from US and European professional societies and individual expert opinions differ in the approach to patient care. Advances in diagnostic techniques, such as real-time thoracic ultrasound, have added to the evaluation strategy. It is important for medical trainees and providers to become familiar with techniques utilized worldwide as they may be encountered in clinical practice. We review current evidence, expert recommendations, and compare professional society guidelines discussing the various diagnostic and management options for patients with pneumothorax to assist physicians and trainees involved in the care of hospitalized and outpatient adults who have primary, secondary, and traumatic iatrogenic pneumothorax. Management of traumatic non-iatrogenic pneumothorax is beyond the scope of this article, thus, not reviewed here.

Tension pneumothorax, is it a really life-threatening condition?

BACKGROUND

Tension pneumothorax is a life-threatening occurrence that is infrequently the consequence of spontaneous pneumothorax. The aim of this study was to identify the risk factors for the development of tension pneumothorax and its effect on clinical outcomes.

METHODS

We reviewed patients who were admitted with spontaneous pneumothorax between August 1, 2003 and December 31, 2011. Electronic medical records and the radiological findings were reviewed with chest x-ray and high-resolution computed tomography scans that were retrieved from the Picture Archiving Communication System.

RESULTS

Out of the 370 patients included in this study, tension pneumothorax developed in 60 (16.2%). The bullae were larger in patients with tension pneumothorax than in those without (23.8 ± 16.2 mm vs 16.1 ± 19.1 mm; P = 0.007). In addition, the incidence of tension pneumothorax increased with the lung bulla size. Fibrotic adhesion was more prevalent in the tension pneumothorax group than in that without (P = 0.000). The bullae were large in patients with fibrotic adhesion than in those without adhesion (35.0 ± 22.3 mm vs 10.4 ± 11.5 mm; P = 0.000). On multivariate analysis, the size of bullae (odds ratio (OR) = 1.03, P = 0.001) and fibrotic adhesion (OR = 10.76, P = 0.000) were risk factors of tension pneumothorax. Hospital mortality was 3.3% in the tension pneumothorax group and it was not significantly different from those patients without tension pneunothorax (P = 0.252).

CONCLUSIONS

Tension pneumothorax is not uncommon, but clinically fatal tension pneumothorax is extremely rare. The size of the lung bullae and fibrotic adhesion contributes to the development of tension pneumothorax.

Simultaneous bilateral spontaneous pneumothoraces in a patient with occupational asthma

Spontaneous pneumothoraces are relatively common; however, simultaneous bilateral spontaneous pneumothoraces (SBSP) have rarely been reported. This case report describes the presentation of SBSP in a 60-year-old man with occupational asthma. He was initially started on treatment for life-threatening asthma, but an early deterioration in symptoms prompted an urgent chest radiography that established the diagnosis of bilateral pneumothoraces. This was managed with bilateral needle thoracocentesis followed by stabilisation with intercostal chest drains. He was subsequently referred to the thoracic unit for minithoracotomy, bullectomy and talc pleurodesis. This case highlights the potential difficulties in diagnosing SBSP and advocates the necessity for prompt chest radiography when managing such presentations in the acute setting.

Boerhaave's syndrome and tension pneumothorax secondary to Norovirus induced forceful emesis

Boerhaave's syndrome or spontaneous esophageal perforation is a rare condition, with high mortality. We describe a case of Boerhaave's syndrome presenting with tension pneumothorax. The patient was infected with Norovirus and developed Boerhaave's syndrome, initially thought to be gastroenteritis but later developing with tension pneumothorax, and mediastinitis caused by esophageal perforation. The patient was treated with thoracotomy with primary suture and oesophageal stent placement. He had a long period of recovery and was discharged after 98 days. Boerhaaves syndrome is often delayed and must be considered in any patient with respiratory symptoms and a recent history of vomiting.

Algorithm for the resuscitation of traumatic cardiac arrest patients in a physician-staffed helicopter emergency medical service

Survival rates following traumatic cardiac arrest (TCA) are known to be poor but resuscitation is not universally futile. There are a number of potentially reversible causes to TCA and a well-defined group of survivors. There are distinct differences in the pathophysiology between medical cardiac arrests and TCA. The authors present some of the key differences and evidence related to resuscitation in TCA, and suggest a separate algorithm for the management of out-of-hospital TCA attended by a highly trained physician and paramedic team.

Evolved design makes ThoraQuik safe and user friendly in the management of pneumothorax and pleural effusion

Background

We have previously described the utility of ThoraQuik, a device designed to be fit for purpose for aspirations of pneumothorax and pleural effusions. We evaluated the safety, efficacy and operator handling of the evolved prototype, ThoraQuik II, which has a lesser profile and a spring loaded Veres needle for added safety.

Methods

A prospective, observational clinical trial with ethics and MHRA approval was conducted in a single centre. Patients with diagnosed pneumothorax (including tension pneumothorax) and pleural effusion were consented and recruited. The ease of device introduction, penetration and ease of use were evaluated. Clinical and radiological improvements were the clinical endpoints and operator feedback was analysed.

Results

20 procedures were performed on patients (mean age: 63.4 years (range: 30–90 years) with 75% male subjects) recruited between September 2008 and August 2009. Nine patients had pneumothorax (tension pneumothorax n=4) and 11 had pleural effusions. 19 patients completed the study with symptomatic and radiological resolution. One patient was withdrawn due to poor pain threshold disproportionate to the procedure. No complications were encountered. 68% had complete clinical and radiological resolution and 32% had partial resolution (these patients needed a definitive drain and hence were not aspirated to completion). The operator feedback in the study rated the device as very good or excellent in 90% patients.

Conclusions

Our study found the use of ThoraQuik II to be safe and easy in draining pneumothorax and pleural effusions. The changes to ThoraQuik II made it more user friendly.

Development of a simple algorithm to guide the effective management of traumatic cardiac arrest

BACKGROUND

Major trauma is the leading worldwide cause of death in young adults. The mortality from traumatic cardiac arrest remains high but survival with good neurological outcome from cardiopulmonary arrest following major trauma has been regularly reported. Rapid, effective intervention is required to address potential reversible causes of traumatic cardiac arrest if the victim is to survive. Current ILCOR guidelines do not contain a standard algorithm for management of traumatic cardiac arrest. We present a simple algorithm to manage the major trauma patient in actual or imminent cardiac arrest.

METHODS

We reviewed the published English language literature on traumatic cardiac arrest and major trauma management. A treatment algorithm was developed based on this and the experience of treatment of more than a thousand traumatic cardiac arrests by a physician - paramedic pre-hospital trauma service.

RESULTS

The algorithm addresses the need treat potential reversible causes of traumatic cardiac arrest. This includes immediate resuscitative thoracotomy in cases of penetrating chest trauma, airway management, optimising oxygenation, correction of hypovolaemia and chest decompression to exclude tension pneumothorax.

CONCLUSION

The requirement to rapidly address a number of potentially reversible pathologies in a short time period lends the management of traumatic cardiac arrest to a simple treatment algorithm. A standardised approach may prevent delay in diagnosis and treatment and improve current poor survival rates.

Three-step management of pneumothorax: time for a re-think on initial management

Pneumothorax is a common disease worldwide, but surprisingly, its initial management remains controversial. There are some published guidelines for the management of spontaneous pneumothorax. However, they differ in some respects, particularly in initial management. In published trials, the objective of treatment has not been clarified and it is not possible to compare the treatment strategies between different trials because of inappropriate evaluations of the air leak. Therefore, there is a need to outline the optimal management strategy for pneumothorax. In this report, we systematically review published randomized controlled trials of the different treatments of primary spontaneous pneumothorax, point out controversial issues and finally propose a three-step strategy for the management of pneumothorax. There are three important characteristics of pneumothorax: potentially lethal respiratory dysfunction; air leak, which is the obvious cause of the disease; frequent recurrence. These three characteristics correspond to the three steps. The central idea of the strategy is that the lung should not be expanded rapidly, unless absolutely necessary. The primary objective of both simple aspiration and chest drainage should be the recovery of acute respiratory dysfunction or the avoidance of respiratory dysfunction and subsequent complications. We believe that this management strategy is simple and clinically relevant and not dependent on the classification of pneumothorax.

Multidetector computed tomography of chest trauma: indications, technique and interpretation

Background

Chest traumas are a significant cause of mortality and morbidity, especially in the younger population.MethodsDiagnostic imaging plays a key role in their management. Multidetector computed tomography (MDCT) is the most important imaging method in this field. Its advantages include especially high speed and high geometric resolution in any plane.ResultsThe method allows us to view large parts of the body with minimal motion artifacts and to create accurate multiplanar and three-dimensional (3D) reformations, which make the diagnosis significantly more accurate. Because of its advantages MDCT has become the first-choice method in high-energy traumas.ConclusionThis article summarises the position of MDCT in the diagnostic algorithm of chest injuries, technical aspects of the examination and imaging findings in traumas of the individual chest compartments.

Teaching Points

• Diagnostic imaging plays a key role in the management of high-energy chest trauma.

• MDCT is the most important imaging method in this kind of injury, as detailed information can be acquired in a short acquisition time.

• Multiplanar and three-dimensional (3D) reformattings make the diagnosis significantly more accurate.

Needle Thoracostomy by Non-Medical Law Enforcement Personnel: Preliminary Data on Knowledge Retention

Introduction:

Tension pneumothorax is the second leading cause of preventable combat death. Although relatively simple, the management of tension pneumothorax is considered an advanced life support skill set. The purpose of this study was to assess the ability of non-medical law enforcement personnel to learn this skill set and to determine long-term knowledge and skill retention.

Methods:

After completing a pre-intervention questionnaire, a total of 22 tactical team operators completed a 90-minute-long training session in recognition and management of tension pneumothorax. Post-intervention testing was performed immediately post-training, and at one- and six-months post-training.

Results:

Initial training resulted in a significant increase in knowledge (pre: 1.3 ±1.35, max score 7; post: 6.8 ±0.62, p < 0.0001). Knowledge retention persisted at one- and six-months post-training, without significant decrement.

Conclusions:

Non-medical law enforcement personnel are capable of learning needle decompression, and retain this knowledge without significant deterioration for at least six months.

Incidence of Tension Pneumothorax in Police Officers Feloniously Killed in the Line of Duty: A Ten-Year Retrospective Analysis

Background: According to US military data, tension pneumothorax (TPx) is the second leading cause of possibly preventable combat death after isolated extremity hemorrhage. The purpose of this study was to determine whether TPx similarly represents a significant cause of possibly preventable death in police officers.

Methods: FBI data for the years 1998 through 2007 were reviewed. Cases were included if officers were on-duty at the time of fatal injury, and died within one hour from time of wounding from penetrating torso trauma. After case identification, letters were sent to the departments of victim officers requesting autopsy reports.

Results: One hundred and eight victim officers met inclusion criteria. Four charts were excluded due to inability to re-identify officers. Departmental response rate was 83.7%. Autopsy reports were provided for 60 officers (57.7%). All officers died from gunshot wounds. No coroner specifically identified TPx as either a direct cause of death or a contributing factor (95% CI, 0.00%-5.96%).

Conclusion: In contrast to the military experience, TPx appears to be a rare cause of possibly preventable death in police officers. Further study of non-fatal “near miss” events will be required to determine the actual need for law enforcement-specific medical training in the recognition and management of TPx.

High-pressure intrapleural chemotherapy: feasibility in the pig model

Background

The usual treatments for pleural malignancies are mostly palliative. In contrast, peritoneal malignancies are often treated with a curative intent by cytoreductive surgery and intraperitoneal chemotherapy. As pressure has been shown to increase antitumor efficacy, we applied the concept of high-pressure intracavitary chemotherapy to the pleural space in a swine model.

Methods

Cisplatin and gemcitabine were selected because of their antineoplasic efficacy in vitro in a wide spectrum of cancer cell lines. The pleural cavity of 21 pigs was filled with saline solution; haemodynamic and respiratory parameters were monitored. The pressure was increased to 15-25 cm H₂O. This treatment was associated with pneumonectomy in 6 pigs. Five pigs were treated with chemotherapy under pressure.

Results

The combination of gemcitabine (100 mg/l) and cisplatin (30 mg/l) was highly cytotoxic in vitro. The maximum tolerated pressure was 20 cm H₂0, due to haemodynamic failure. Pneumonectomy was not tolerated, either before or after pleural infusion. Five pigs survived intrapleural chemotherapy associating gemcitabine and cisplatin with 20 cm H₂O pressure for 60 min.

Conclusions

High-pressure intrapleural chemotherapy is feasible in pigs. Further experiments will establish the pharmacokinetics and determine whether the benefit already shown in the peritoneum is also obtained in the pleura.

Evaluation of performance of two different chest tubes with either a sharp or a blunt tip for thoracostomy in 100 human cadavers

BACKGROUND

Emergent placement of a chest tube is a potentially life-saving procedure, but rate of misplacement and organ injury is up to 30%. In principle, chest tube insertion can be performed by using Trocar or Non-trocar techniques. If using trocar technique, two different chest tubes (equipped with sharp or blunt tip) are currently commercially available. This study was performed to detect any difference with respect to time until tube insertion, to success and to misplacement rate.

METHODS

Twenty emergency physicians performed five tube thoracostomies using both blunt and sharp tipped tube kits in 100 fresh human cadavers (100 thoracostomies with each kit). Time until tube insertion served as primary outcome. Complications and success rate were examined by pathological dissection and served as further outcomes parameters.

RESULTS

Difference in mean time until tube insertion (63 s vs. 59 s) was statistically not significant. In both groups, time for insertion decreased from the 1st to the 5th attempt and showed dependency on the cadaver's BMI and on the individual physician. Success rate differed between both groups (92% using blunt vs. 86% using sharp tipped kits) and injuries and misplacements occurred significantly more frequently using chest tubes with sharp tips (p = 0.04).

CONCLUSION

Data suggest that chest drain insertion with trocars is associated with a 6-14% operator-related complication rate. No difference in average time could be found. However, misplacements and organ injuries occurred more frequently using sharp tips. Consequently, if using a trocar technique, the use of blunt tipped kits is recommended.

Needle decompression for tension pneumothorax in Tactical Combat Casualty Care: do catheters placed in the midaxillary line kink more often than those in the midclavicular line?

BACKGROUND

Tactical Combat Casualty Care (TCCC) is a system of prehospital trauma care designed for the combat environment. Needle decompression (ND) is a critical TCCC intervention, because previous data suggest that up to 33% of all preventable deaths on the battlefield result from tension pneumothoraces. There has recently been increased interest in performing ND at the fifth intercostal space in the midaxillary line to prevent complications associated with landmarking second intercostal space in the midclavicular line site. We developed a model to assess whether catheters placed in the midaxillary line for decompressing tension pneumothoraces are more prone to kinking than those placed in the midclavicular line because of adducted arms during military transport.

METHODS

To simulate ND, we secured segments of porcine chest walls over volunteer soldiers' chests and placed 14-gauge, 1.5-inch angiocatheters through the porcine wall segments which were affixed to either the midaxillary or midclavicular location on the volunteers. We then assessed for occlusion and kinking by flow of normal saline (NS) through the angiocatheter in situ. The angiocatheter was then transduced using standard arterial line manometry, and the opening pressures required to initiate flow through the catheters were measured. The opening pressures were then converted to mm Hg. We also assessed for catheter occlusion after the physical manipulation of the patient, by simulated patient transport.

RESULTS

We observed that there was a significant pressure difference required to achieve free flow through the in situ angiocatheter between the fifth intercostal space midaxillary line versus the second intercostal space midclavicular line site (13.1 ± 3.6 mm Hg vs. 7.9 ± 1.8 mm Hg).

CONCLUSIONS

This study suggests that the 14-gauge, 1.5-inch angiocatheter used for ND in the midaxillary line may partially and temporarily occlude in patients who will be transported on military stretchers. The pressure of 12.8 mm Hg has been documented in animal models as the pressure at which hemodynamic instability develops. This may contribute to the reaccumulation of tension pneumothoraces and ultimate patient deterioration in military transport.

Initial management and resuscitation of severe chest trauma

Severe chest trauma, blunt or penetrating, is responsible for up to 25% of traumatic deaths in North America. Respiratory compromise is the most frequent dramatic presentation in blunt trauma, while injuries to the heart and great vessels pose the greatest risk of immediate death following penetrating trauma. More than 80% of patients will be managed with interventions that can be performed in the emergency department. This article reviews the presentation, diagnosis, and management of the most important thoracic injuries. A structured approach to the acutely unstable patient is proposed to guide resuscitation decisions.

Spontaneous tension pneumothorax and CO₂ narcosis in a near fatal episode of chronic obstructive pulmonary disease exacerbation

Exacerbation of chronic obstructive pulmonary disease (COPD) is a disease pattern frequently seen in emergency medical services and intensive care units. Usually, exacerbations of COPD are of infectious origin, and an acute vital threat may take several days to develop. Tension pneumothorax in patients with COPD is a rare and often unexpected cause of acute vital threat. To the best of our knowledge, this is a unique case of CO2 narcosis after spontaneous tension pneumothorax in a patient with COPD. We describe the rapid development of respiratory insufficiency and near fatal pulmonary failure in a 65-year-old female patient with COPD due to spontaneous tension pneumothorax. The patient was in respiratory failure and comatose upon arrival of the emergency service. Before mechanical ventilation, coma could be confirmed to be due to CO2 narcosis caused by exorbitant arterial hypercapnia (PCO2, 193 mm Hg). Pneumothorax was diagnosed in the hospital by chest x-ray and resolved after pleural drainage. The patient could be extubated early and discharged without sequelae. In conclusion, we want to report the occurrence of a tension pneumothorax as an important and potentially overseen condition in patients with COPD with acute respiratory failure.

Barotrauma developed during intra-hospital transfer -A case report-

A 74-year-old male patient receiving ventilatory support due to aspiration pneumonia developed bilateral pneumothorax, pneumopericardium, pneumomediastinum, pneumo-retroperitoneum, and subcutaneous emphysema, after manual ventilation while being transferred from the intensive care unit (ICU) to the operating room (OR). These complications were assumed to be secondary to inappropriate manual ventilation of the intubated patient. In addition, it is likely that the possible migration of an already marginally acceptable endotracheal tube (ETT) position during transport was the cause of these complications. Finally, aggravation of a latent pneumothorax might have contributed to these complications.

Thoracic needle decompression for tension pneumothorax: clinical correlation with catheter length

BACKGROUND

Tension pneumothorax requires emergent decompression. Unfortunately, some needle thoracostomies (NTs) are unsuccessful because of insufficient catheter length. All previous studies have used thickness of the chest wall (based on cadaver studies, ultrasonography or computed tomography [CT]) to extrapolate probable catheter effectiveness. The objective of this clinical study was to identify the frequency of NT failure with various catheter lengths.

METHODS

We evaluated the records of all patients with severe blunt injury who had a prehospital NT before arrival at a level-1 trauma centre over a 48-month period. Patients were divided into 2 groups: helicopter (4.5-cm catheter sheath) and ground ambulance (3.2 cm) transport. Success of the NT was confirmed by the absence of a large pneumothorax on subsequent thoracic ultrasonography and CT.

RESULTS

Needle thoracostomy decompression was attempted in 1.5% (142/9689) of patients. Among patients with blunt injuries, the incidence was 1.4% (101/7073). Patients transported by helicopter (74%) received a 4.5-cm sheath. The remainder (26% ground transport) received a 3.2-cm catheter. A minority in each group (helicopter 15%, ground 28%) underwent immediate chest tube insertion (before thoracic ultrasound) because of ongoing hemodynamic instability. Failure to decompress the pleural space by NT was observed via ultrasound and/or CT in 65% (17/26) of attempts with a 3.2-cm catheter, compared with only 4% (3/75) of attempts with a 4.5-cm catheter (p < 0.001).

CONCLUSION

Tension pneumothorax decompression using a 3.2-cm catheter was unsuccessful in up to 65% of cases. When a larger 4.5-cm catheter was used, fewer procedures (4%) failed. Thoracic ultrasonography can be used to confirm NT placement.

Subacute tension hemopneumothorax with novel electrocardiogram findings

This case report describes a patient with a subacute right-sided tension hemopneumothorax following an occult stab. The patient's electrocardiogram (ECG), performed as part of a standardized triage process, demonstrated significant abnormalities that misguided initial resuscitation, but resolved following evacuation of the tension hemopneumothorax. Tension pneumothorax is typically regarded as an immediately life-threatening condition that requires emergent management with needle or tube thoracostomy. However, we believe that subacute tension pneumothorax may be a rarely observed clinical phenomenon and may lead to unique ECG findings. We believe that the ECG changes we observed provided an early clue to the eventual diagnosis of a subacute tension pneumothorax and have not been previously described in this setting. .

High-risk chief complaints I: chest pain--the big three

Chest pain is one of the most frequently seen chief complaints in patients presenting to emergency departments, and is considered to be a "high-risk" chief complaint. The differential diagnosis for chest pain is broad, and potential causes range from the benign to the immediately life-threatening. Although many (if not most) emergency department patients with chest pain do not have an immediately life-threatening condition, correct diagnoses can be difficult to make, incorrect diagnoses may lead to catastrophic therapies, and failure to make a timely diagnosis may contribute to significant morbidity and mortality. Several atraumatic "high-risk" causes of chest pain are discussed in this article, including myocardial infarction and ischemia, thoracic aortic dissection, and pulmonary embolism. Also included are brief discussions of tension pneumothorax, esophageal perforation, and cardiac tamponade.

Bilateral tension pneumothorax and tension pneumoperitoneum secondary to tracheal tear in a patient with relapsing polychondritis

Relapsing polychondritis (RP) is a rare disease that is characterized by recurrent inflammation and destruction of cartilage and connective tissues. RP can have significant airway pathology that may require procedures to maintain airway patency and thus may have serious implications for anesthesiologists. Anesthesiologists must be prepared to deal with the possible complications that may occur during airway manipulation in patients with RP. Here, we present a case of life-threatening bilateral tension pneumothorax and tension pneumoperitoneum that developed after a tracheal tear during Montgomery T-tube insertion in a patient with tracheal stenosis due to RP. Correct diagnosis was delayed due to a misdiagnosis of airway obstruction. As a result, we emphasize that bilateral tension pneumothorax should be considered during refractory cardiac arrest in patients with increased airway pressure. A high index of suspicion and adequate management are mandatory for patients to survive these life-threatening complications.

Bilateral tension pneumothoraces during minimally invasive parathyroidectomy: A case report

Minimally invasive parathyroidectomy, a new technique for the surgical management of parathyroid disease, is gaining popularity. The smaller incision in the neck results in better cosmetic results and patient satisfaction. Despite a low incidence of complications, the anesthesiologist should be aware and prepared to manage life saving situations. We describe a case of bilateral tension pneumothoraces during minimally invasive parathyroidectomy.

Iatrogenic tension pneumothorax in children: two case reports

Introduction

Two cases of iatrogenic tension pneumothorax in children are reported.

Case presentations

Case 1: A 2-year-old boy with suspected brain death after suffering multiple trauma suddenly developed intense cyanosis, extreme bradycardia and generalized subcutaneous emphysema during apnea testing. He received advanced cardiopulmonary resuscitation and urgent bilateral needle thoracostomy. Case 2: A diagnostic-therapeutic flexible bronchoscopy was conducted on a 17-month-old girl, under sedation-analgesia with midazolam and ketamine. She very suddenly developed bradycardia, generalized cyanosis and cervical, thoracic and abdominal subcutaneous emphysema. Urgent needle decompression of both hemithoraces was performed.

Conclusion

In techniques where gas is introduced into a child's airway, it is vital to ensure its way out to avoid iatrogenic tension pneumothorax. Moreover, the equipment to perform an urgent needle thoracostomy should be readily available.

Bilateral tension pneumothorax resulting from a bicycle-to-bicycle collision

Bilateral tension pneumothorax occurring as a result of recreational activity is exceedingly rare. A 10-year-old boy with no previous respiratory symptoms was involved in a bicycle-to-bicycle collision during play. He was the only one hurt. A few hours later, he was rushed to the general casualty unit of the emergency department of our institution with respiratory distress, diminished bilateral chest excursions and diminished breath sounds. The correct diagnosis was made after a chest radiograph was obtained in the course of resuscitation at the casualty unit. Pleural space needle decompression was suggestive of tension only on the right. Bilateral tube thoracostomies provided effective relief. He was discharged from hospital after a week in excellent health. This case illustrates the need for children to have safety instruction to reduce the risks of recreational bicycling. Chest radiography may be needed to establish the diagnosis of bilateral tension pneumothorax. Needle thoracostomy decompression is not always effective.

[Tension pneumothorax in intensive care units]

<zakljucak> Najcesci uzrok pneumotoraksa u jedinicama intenzivne nege je barotrauma. Pojava, rana dijagnostika i brzo i efikasno lecenje tenzijskog pneumotoraksa kod bolesnika na mehanickoj ventilaciji predstavljaju i veliki izazov. Kod bolesnika koji su ventilisani pod pozitivnim pritiskom, u slucaju pojave bilo kakvog poremecaja treba obavezno posumnjati na tenzijski pneumotoraks i preduzeti sve mere da se on potvrdi ili iskljuci. Kasno utvrdjena dijagnoza tenzijskog pneumotoraksa i neblagovremeno sprovedeno adekvatno lecenje predstavljaju veliki rizik od smrtnog ishoda.

Pre-hospital and in-hospital thoracostomy: indications and complications

INTRODUCTION

Pleural drainage with chest tube insertion for thoracic trauma is a common and often life-saving technique. Although considered a simple procedure, complication rates have been reported to be 2-25%. We conducted a prospective cohort observational study of emergency pleural drainage procedures to validate the indications for pre-hospital thoracostomy and to identify complications from both pre- and in-hospital thoracostomies.

PATIENTS AND METHODS

Data were collected over a 7-month period on all patients receiving either pre-hospital thoracostomy or emergency department tube thoracostomy. Outcome measures were appropriate indications, errors in tube placement and subsequent complications.

RESULTS

Ninety-one chest tubes were placed into 52 patients. Sixty-five thoracostomies were performed in the field without chest tube placement. Twenty-six procedures were performed following emergency department identification of thoracic injury. Of the 65 pre-hospital thoracostomies, 40 (61%) were for appropriate indications of suspected tension pneumothorax or a low output state. The overall complication rate was 14% of which 9% were classified as major and three patients required surgical intervention. Twenty-eight (31%) chest tubes were poorly positioned and 15 (17%) of these required repositioning.

CONCLUSIONS

Pleural drainage techniques may be complicated and have the potential to cause life-threatening injury. Pre-hospital thoracostomies have the same potential risks as in-hospital procedures and attention must be paid to insertion techniques under difficult scene conditions. In-hospital chest tube placement complication rates remain uncomfortably high, and attention must be placed on training and assessment of staff in this basic procedure.

Pleural decompression and drainage during trauma reception and resuscitation

This review examines pleural decompression and drainage during initial hospital adult trauma reception and resuscitation, when it is indicated for haemodynamically unstable patients with signs of pneumothorax or haemothorax. The relevant historical background, techniques, complications and current controversies are highlighted. Key findings of this review are that: 1. Needle thoracocentesis is an unreliable means of decompressing the chest of an unstable patient and should only be used as a technique of last resort. 2. Blunt dissection and digital decompression through the pleura is the essential first step for pleural decompression, as decompression of the pleural space is a primary goal during reception of the haemodynamically unstable patient with a haemothorax or pneumothorax. Drainage and insertion of a chest tube is a secondary priority. 3. Techniques to prevent tube thoracostomy (TT) complications include aseptic technique, avoidance of trocars, digital exploration of the insertion site and guidance of the tube posteriorly and superiorly during insertion. 4. Whenever possible, blunt thoracic trauma patients should undergo definitive CT imaging after TT to check for appropriate tube position.