Penetrating Chest Wounds, Pneumothorax, Tension

Pneumothorax and HemothoraxGary L. Weinstein M.D.Director of Pulmonary

and Critical Care Medicine

Presbyterian Hospital of Dallas

September 14, 2006

Normal Physiology

Breathing• Inspiration –

– The diaphragm contracts and moves downward enlarging the chest cavity

– And the rib muscles contract, widening the chest cavity causing air to fill the lungs through suction.

• Expiration- The diaphragm and rib muscles then relax, decreasing the chest size and forcing air out of the lungs.

Normal Physiology

Chest Wall

Pleura

Pleural Space

Diaphragm

Penetrating Chest Wounds

• Anything that disrupts these normal relationships can cause problems– A hole in the chest, lets

air collect in the pleural space

CausesCauses…

Causes…

Causes…

Causes…

                                                

Pneumothorax

Pleura

Diaphragm Pleura

Pneumothorax

• Pneumothorax - air gets between your lungs and your chest wall and the lung collapses.

• Normally, two thin layers of tissue (pleura) separate the lung and chest wall.

• Any air that leaks into this space (pleural space) will cause the lung to collapse..

Pneumothorax

• Air can collect inside the chest for many reasons, such as:– An injury that

damages the chest wall, such as a stab or gunshot wound

– A broken rib that punctures the lung

Pneumothorax

• Signs and symptoms of a pneumothorax include:– Sudden, sharp chest

pain – Shortness of breath – Chest tightness– Rapid pulse– Rapid, shallow breaths

Pneumothorax

• A pneumothorax is a serious condition that can be life-threatening.

Tension Pneumothorax

Tension Pneumothorax• If air continues to enter the

pleural space, a tension pneumothorax occurs.

• The air may compress the heart and cause a fall in B.P.

• This is life-threatening and requires immediate treatment to release the pressure.

• Treatment can life-saving.

Tension PneumothoraxSymptoms of a tension pneumothorax may include:

• Shift of the trachea•Loss of consciousness•Sweating•Gasping•Shock•Rapid HR

Hemothorax

• Blood can also collect in the pleural space and cause all the same signs and symptoms and problems as a pneumothorax including a tension hemothorax

Classical physical examination findings:

The size of the injury, and position of the patient will affect the clinical findings. For example, a small hemothorax may have no clinical signs at all. A moderate hemothorax will be dull to percussion with absent breath sounds at the bases in the erect patient, whereas signs will be posterior in the supine patient. This is also reflected in chest X-ray findings.

Assesment of patient with Blunt or Penetrating chest trauma

Look• Determine the respiratory rate and depth

Look for chest wall asymmetry. Paradoxical chest wall motion Look for bruising, seat belt or steering wheel marks, penetrating wounds

Feel• Feel the trachea for deviation

Assess whether there is adequate and equal chest wall movementFeel for chest wall tenderness or rib 'crunching' indicating rib fracturesFeel for subcutaneous emphysema

Listen• Listen for normal, equal breath sounds on both sides.

Listen especially in the apices and axillae and at the back of the chest (or as far as you can get while supine).

Percuss• Percuss both sides of the chest looking for dullness or resonance (more difficult to

appreciate in the trauma room).

Trachea Chest expansion Breath Sounds PercussionTension Away Decreased;Diminished or Hyper-resonant Pnuemothorax Chest may be absent

fixed inhyperexpansion

Simple Midline Decreased May be May be hyper- Pneumothorax diminishedresonant; Usually

normalHemothorax Midline Decreased Diminished if Dull, especially

large; Normal posteriorlyif small

Pulmonary Midline Normal Normal; May Normal Contusion have cracklesLung Collapse/ Towards Decreased May be Normal Atelectasis reduced

Physical Exam in Chest Trauma

Hemothorax, supine

Hemothorax, upright

Simple Pneumothorax

Tension Pneumothorax

Examples

Stab wounds to back Open pneumothorax

TreatmentNeedle decompression

– Simple large-bore needle• Mid, anterior chest• 2nd or 3rd rib space• NOT right next to Sternum

The “Magic Triangle”

TreatmentAsherman chest seal –

for “Sucking Chest Wounds”

TreatmentAsherman chest seal – convert

sucking chest wounds to simple pneumo/hemothorax

Treatment

Needle decompression– Cook Pneumothorax

set

Treatment

Chest tube•Standard•Standard with Heimlich valve

Chest tube

Chest Tubes

Suction Systems

A - Suction Port/Connection

C - Water Seal Fill Port

G - Suction Setting

I -

J - Collection

Chamber

K - Suction Indicator

L - Chest Tube Connector

Take Home Points

•Simple Pneumothorax/Hemothorax should be expected with penetrating chest wounds and rarely kills

•Tension pneumothorax can occur rapidly

•Tension pneumothorax can KILL rapidly

•Treatment SAVES lives

•Needle decompression will never harm and may

SAVE A LIFE!!

Questions?????

Drs Kumar and Weinmeister want everyone to come to their homes tonight for

Food,

Drink,

And to take whatever they want!!!!