# Pneumothorax



## Ediron

I know hemothorax is blood in the the lungs
and pneumothorax, open pneumothorax, tension penumothorax, and cardiac contusion present with the same signs and symptoms

like decreased breath sounds and JVD

how do you differ them??? 
its frustrating

this is my only weak part

and im taking my national tomorrow


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## Shishkabob

Open Pneumo-- You can see it.  It has an open wound.

Pneumothorax-- Air in the pleural space of the chest cavity.  You'll have decreased / diminished breath sounds over that portion.

Tension pneumo-  A pneumo, either simple or open, that traps more air then it releases.  This trapped air eventually causes so much pressure in the chest that it collapses a lung and pushes against the heart, causing absent breath sounds and a decreasing blood pressure.  JVD can be caused because of decreased pre-load, so the excess blood is not being allowed to enter the heart and backs up.  Simplest explanation.  



Now, do you mean pulmonary contusion, or cardiac?


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## 18G

Its not always possible to diagnose all these specifically in the field. Linuss summed it up pretty good though. 

A pneumothorax you will have decreased or absent breath sounds with a history of chest trauma. Low SpO2, dyspnea, S/S of poor gas exchange. 

Tension pneumothorax - absent breath sounds with severe dyspnea and hemodynamic instability. Can see JVD. Trachial deviation is a rare find. 

Hemathorax - blood instead of air in the pleural space. Decreased air entry with crackles. A fair amount of blood can collect in the chest cavity so hemodynamics will be unstable. 

Don't just look at a subset of S/S... looking at the overall condition will clue you in. 

Cardiac contusion? Hx of chest trauma with EKG changes. PVC's, ST-segment changes, etc. 

Pulmonary contusion? Again, chest trauma with low Spo2 and other parameters indicating poor diffusion. 

This is all very condensed but hopefully will point ya in the right direction for thinking and differentiation.


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## Ediron

Linuss said:


> Open Pneumo-- You can see it.  It has an open wound.
> 
> Pneumothorax-- Air in the pleural space of the chest cavity.  You'll have decreased / diminished breath sounds over that portion.
> 
> Tension pneumo-  A pneumo, either simple or open, that traps more air then it releases.  This trapped air eventually causes so much pressure in the chest that it collapses a lung and pushes against the heart, causing absent breath sounds and a decreasing blood pressure.  JVD can be caused because of decreased pre-load, so the excess blood is not being allowed to enter the heart and backs up.  Simplest explanation.
> 
> 
> 
> Now, do you mean pulmonary contusion, or cardiac?




yea im sorry 
i meant cardiac contusion


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## 18G

Just to clarify, pneumothorax can have a non-traumatic etiology. I was assuming you wanted to know more about traumatic cause and recognition and wasnt 100% clear on that in my post.


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## Jeffrey_169

I have to agree with Linuss. Excellent job on the explanation.


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## kingsfan33

*Your thoughts please*

We had a patient last night with a spontaneous Tension Pneumothorax (as the ER later confirmed). 
She went into respiratory arrest immediately (she was walking in her kitchen and collapsed and immediately stopped breathing, as per family) and emt's were on scene within 2 minutes. BVM was not getting good chest rise/fall (with a good seal and with OPA and good head tilt). I believe the person who listened to lungs stated that one side was absent sounds and the other side he heard minimal air movement. is this normal for the tension pneumo?
Some color came back. She was initially blue, and then started to pink up. (leading me to believe maybe she was getting some air?)

she then lost a pulse after about 2 minutes. CPR initiated initiated, she regained a pulse after about 2 more minutes. (AED: "No shock advised" when she was pulseless). At this point ALS arrives. but it was very frustrating on scene. emt on scene noticed trachial deviation, advised the als units, but they just treat her being in arrest and ignore the trach deviation and lack of a patent airway.

They try tubing, failed on first try (hit the stimach). lost pulse again, then she regained it in ER. 

Last status check I heard she had BP of 110 systolic. Stable pulse, but on a vent. pupils fixed/non-reactive.

What are your thoughts on this? Could/Should ALS have done more?

Thanks!


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## Shishkabob

Can't tell by just your story alone on what was going through their minds.

Typically a tension pneumo is part of our Hs + Ts when trying to correct a cardiac arrest, so if they thought it was a tension pneumo causing a PEA, they would / should have darted her chest.


What did the hospital do to correct the situation?


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## kingsfan33

as far as the hospital interventions i believe they did a tracheotomy


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## LondonMedic

kingsfan33 said:


> as far as the hospital interventions i believe they did a tracheotomy


:unsure:


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## LondonMedic

Linuss said:


> Typically a tension pneumo is part of our Hs + Ts when trying to correct a cardiac arrest, so if they thought it was a tension pneumo causing a PEA, they would / should have darted her chest.


Crack on with bilat thoracotomies +/- convert to clamshell? B)


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## Shishkabob

kingsfan33 said:


> as far as the hospital interventions i believe they did a tracheotomy



A trach is a surgical incision in the trachea (neck).  A needle thoracostomy is what is used in the field for a tension pneumo... typically a 14ga IV catheter inserted into the affected side to let the excess air out.


So obviously there is more to the story, and to the patient, then you either know or are letting us know if the hospital "confired a tension pneumo" and used a trach to fix it.



LondonMedic said:


> Crack on with bilat thoracotomies +/- convert to clamshell? B)



And I got back to my response to you in the other thread:

What the heck did you just say?!  :wacko:


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## LondonMedic

Linuss said:


> And I got back to my response to you in the other thread:
> 
> What the heck did you just say?!  :wacko:


In traumatic arrest, we would intubate and get straight onto to doing bilateral anterolaterial thoracostomies (quick and dirty - scalpel and fingers) to relieve any potential tension pneumothorax. If that doesn't work, they'll convert the two thoracostomies by cutting through the intercostal tissue and sternum to create a clamshell thoracotomy so that any tamponade can be relieved.

http://emj.bmj.com/content/22/1/22.abstract
http://emj.bmj.com/content/19/6/587.extract

(I can send you full texts if you can't)


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## Shishkabob

Oh.  See, I knew the procedures, but I was confused by your lingo which I instantly assumed was Brit slang


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## VentMedic

A clamshell is one of the largest thoracotomy incision that opens up the entire thoracic cavity. It is a bilateral anterolateral thoracotomy combined with a transverse sternotomy. This is serious surgery. 

A trach will not fix a pneumothorax but may have been their option for a difficult or messed up intubation.

If an ED can do a trach, they should be able to insert chest tubes rather than doing a "clamshell".


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## LondonMedic

VentMedic said:


> If an ED can do a trach, they should be able to insert chest tubes rather than doing a "clamshell".


London HEMS do them to treat potential tamponade in traumatic arrest. Clamshell is done rather than a left extended anterolateral because it is quicker, easier and provides a better field of view to a non-surgeon.

Thoracostomies are used instead of chest tubes because they are easier and quicker in the I&V patient.


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## VentMedic

LondonMedic said:


> London HEMS do them to treat potential tamponade in traumatic arrest. Clamshell is done rather than a left extended anterolateral because it is quicker, easier and provides a better field of view to a *non-surgeon*.


 
Can you post the protocols (both the incision and anaesthesia) to that since the previous links you posted clearly stated this was done by a prehospital physician? 



> Thoracostomies are used instead of chest tubes because they are easier and quicker in the I&V patient.


When you do a chest tube, you generally do make a thoracostomy. It does not take that long and for several years, Paramedics (not a doctor) in the U.S. were taught to perform them  in the field. Now, a few rural services still have the protocols as do Flight and Specialty.


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## LondonMedic

VentMedic said:


> Can you post the protocols (both the incision and anaesthesia) to that since the previous links you posted clearly stated this was done by a prehospital physician?


To the best of my knowledge there's not a 'protocol' as such. The services, in- and out-of-hospital, that perform it teach their doctors to do it using the medicines, equipment and facilities that they have.

The incision, as was taught to me, is a 3cm incision made at the anterior axillary line, fifth intercostal space immediately above the sixth rib. Once the skin and subcut tissue is dissected, fingers or dissecting forceps can be used to get down to, and through, the pleura. That's normally it, a formal chest tube can be inserted and secured later.

To extend to a clamshell, insert a pair of shears (tuff cuts are a popular choice) into the thoracostomy and cut transversely until you (hopefully) meet up with the other thoracostomy. After that the thorax can be levered open.

Anaesthesia wise, it's a bog standard RSI with medications as appropriate for the patient and injury pattern chosen by the doctor.





> When you do a chest tube, you generally do make a thoracostomy. It does not take that long and for several years, Paramedics (not a doctor) in the U.S. were taught to perform them  in the field. Now, a few rural services still have the protocols as do Flight and Specialty.


It's something paramedics in this country wouldn't be able to do, they're limited to needle chest decompression.


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## VentMedic

A well trained EM physician or surgeon can do just about anything in the field.  With portable ECMO units, we can also get patients that would otherwise have died at a small rural hospital back to the trauma center.  

Interesting articles for thoracotomies and London HEMS:
http://www.jephc.com/uploads/990356TC1.pdf

Are doctors a routine part of their HEMS and fly each time?


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## LondonMedic

VentMedic said:


> A well trained EM physician or surgeon can do just about anything in the field.  With portable ECMO units, we can also get patients that would otherwise have died at a small rural hospital back to the trauma center.


Interesting, I have a little exposure to ECMO in neonatesand heard of it in grown-up critical care, never heard of it being used in pre-hospital care. Do you have any literature?




> Are doctors a routine part of their HEMS and fly each time?


In London, at least one doctor and one paramedic goes on each sortie whether in the aircraft or on the cars. The doctor will be a senior registrar or consultant (senior resident / attending) in anaesthetics, emergency medicine or surgery. The paramedic will be an experienced medic seconded from London Ambulance who will have recieved some top up training but we don't have formal 'flight paramedic' qualifications over here. Other services in other parts of the UK do their own thing, the use of doctors is increasing but I'm not sure I know of another service that sends doctors on _all_ sorties.


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## VentMedic

LondonMedic said:


> Interesting, I have a little exposure to ECMO in neonatesand heard of it in grown-up critical care, never heard of it being used in pre-hospital care. Do you have any literature?


 
ECMO is not initiated in the field but as I stated in my previous post, we can bring a doctor to initiate it in a local little general to get the patient back to a more advanced facility. H1N1 also brought about a renewed interest in ECMO with its flu associated ARDS.

Here is the Novalung that is getting a decent start in the U.S.   Medtronic is currently popular in the U.S.






Article:
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2811933/

Misc. Articles:

http://jtcs.ctsnetjournals.org/cgi/content/full/119/5/1015

Good article and several more listed:
http://jama.ama-assn.org/cgi/content/abstract/283/7/904

In the U.S., University of Michigan is the leader in ECMO/ECLS with Arkansas Children's ranking right behind them.

Now for the significance for EMS providers. It pays to get a strong educational background in the health sciences and don't skip the college level A&P, pharmacology, math and pathophysiology classes. Medicine is evolving and you will see many more VADs in the field as well as possibly having the opportunity someday to job a CCT, Flight or Specialty team that does do transports with advanced technology and high acuity patients. It involves a little more than just a speedy ride from point A to point B. These opportunities do exist and usually those that have gone the extra distance to enhance their education will be selected since these teams get an abundance of applications. Of course for every 200 applications, about 190 will barely meet the bare minimum to be a Paramedic.


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## EMTinNEPA

kingsfan33 said:


> We had a patient last night with a spontaneous Tension Pneumothorax (as the ER later confirmed).
> She went into respiratory arrest immediately (she was walking in her kitchen and collapsed and immediately stopped breathing, as per family) and emt's were on scene within 2 minutes. BVM was not getting good chest rise/fall (with a good seal and with OPA and good head tilt). I believe the person who listened to lungs stated that one side was absent sounds and the other side he heard minimal air movement. is this normal for the tension pneumo?
> Some color came back. She was initially blue, and then started to pink up. (leading me to believe maybe she was getting some air?)
> 
> she then lost a pulse after about 2 minutes. CPR initiated initiated, she regained a pulse after about 2 more minutes. (AED: "No shock advised" when she was pulseless). At this point ALS arrives. but it was very frustrating on scene. emt on scene noticed trachial deviation, advised the als units, but they just treat her being in arrest and ignore the trach deviation and lack of a patent airway.
> 
> They try tubing, failed on first try (hit the stimach). lost pulse again, then she regained it in ER.
> 
> Last status check I heard she had BP of 110 systolic. Stable pulse, but on a vent. pupils fixed/non-reactive.
> 
> What are your thoughts on this? Could/Should ALS have done more?
> 
> Thanks!



Tracheal deviation combined with the absent breath sounds should have warranted immediate needle decompression.  Tracheal deviation is a VERY late sign of a tension pneumothorax.  It sounds like this person had a spontaneous pneumo that developed into a tension pneumo.


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## EMTinNEPA

Ediron said:


> I know hemothorax is blood in the the lungs
> and pneumothorax, open pneumothorax, tension penumothorax, and cardiac contusion present with the same signs and symptoms
> 
> like decreased breath sounds and JVD
> 
> how do you differ them???
> its frustrating
> 
> this is my only weak part
> 
> and im taking my national tomorrow



Not quite.  A hemothorax is blood in the pleural cavity that puts pressure on the lung, causing it to partially or completely collapse.  An open pneumothorax is exactly as the name suggests... there will be a hole in the chest and you'll hear air rushing through it (sucking chest wound).  A simple pneumothorax is merely air in the pleural cavity that causes a partial collapse of the lung.  A tension pneumothorax causes complete collapse.

Hemothorax
S/S: Chest pain, anxiety, shortness of breath, cyanosis, decreased breath sounds, dull to percussion.
Treatment: The patient needs a chest tube.

Open Pneumothorax
S/S: Sucking chest wound, shortness of breath, cyanosis
Treatment: Cover the sucking chest wound with an occlusive dressing, leaving one side free.  Continuously reassess in case it develops into a tension pneumothorax.

Simple Pneumothorax
S/S: Shortness of breath, cyanosis (noticing a trend here?), decreased breath sounds, chest pain
Treatment: Chest tube.  Continuously reassess in case it develops into a tension pneumothorax.

Tension Pneumothorax
S/S: Shortness of breath, cyanosis, chest pain, absent breath sounds, tracheal deviation (on the opposite side of absent breath sounds), hyperresonance to percussion
Treatment: Needle Decompression

Cardiac contusion was described to us in class as basically a "traumatic heart attack".  The cardiac muscle is injured and the result is the same (you can even see EKG changes such as ST segment elevation in some cases).

This is just from memory, so double-check what I typed and review your book.  Best of luck with your test.


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## FLEMTP

LondonMedic said:


> London HEMS do them to treat potential tamponade in traumatic arrest. Clamshell is done rather than a left extended anterolateral because it is quicker, easier and provides a better field of view to a non-surgeon.
> 
> Thoracostomies are used instead of chest tubes because they are easier and quicker in the I&V patient.



Our agency does a pericardiocentesis on ANY trauma arrest victim... and anyone suspected or having a high suspicion of a pericardial tamponade. We also do a bilateral chest needle decompression... interesting that you would do a thoracotomy to treat them in the field.


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## LondonMedic

FLEMTP said:


> Our agency does a pericardiocentesis on ANY trauma arrest victim... and anyone suspected or having a high suspicion of a pericardial tamponade. We also do a bilateral chest needle decompression... interesting that you would do a thoracotomy to treat them in the field.


There's a joke about pericardiocentesis in trauma; "clot on both ends of the needle". 

Thoracotomy is a simple, lifesaving surgical procedure. When you consider how many they do a year, it's not that big a deal.

Needle chest decompression will only work, beyond the immediacy, if the flow into the pleural space is less than the flow out. How many needles have you got?


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## FLEMTP

as many as it takes.. we have 5 or 6 of the 3 inch 14 ga angio caths for chest decompressions.. and there might still be a couple of 10 ga needles still floating around!


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## mycrofft

*10 ga...almost a trochar!*

You'd think they would have a device to make it less potentially dangerous than jabbing a super sharp point into the chest then trying to keep from causing more harm. A scalpel then tube placement would almost be better.


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## Melclin

LondonMedic said:


> The incision, as was taught to me, is a 3cm incision made at the anterior axillary line, fifth intercostal space immediately above the sixth rib. Once the skin and subcut tissue is dissected, fingers or dissecting forceps can be used to get down to, and through, the pleura. That's normally it, a formal chest tube can be inserted and secured later.
> 
> To extend to a clamshell, insert a pair of shears (tuff cuts are a popular choice) into the thoracostomy and cut transversely until you (hopefully) meet up with the other thoracostomy. After that the thorax can be levered open.



:wacko: Bloody hell, mate. I've read a paper on thoractomies in the field by london HEMS, but I sure hope they're not "extending to a clamshell", wouldn't that be a sight to see, turning up to an arrest to assist and some blokes chest is talking to you haha.

Our Intensive care paramedics (as apposed to our basics), after a needle test and needle decompression with a 14g cannula, will insert "pnemo-caths". It's a relatively common procedure. 

An incision is made in the second intercostal space on the mid clavicular line, followed by the insertion of a catheter with a stylet and then the attachment of a a one way flutter valve and a few taps, etc. It sounds fairly similar to thoracotomy/chest tube with simplifications facilitated by clever equipment and location. Is this something people are familiar with? Anyone doing this?


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## LondonMedic

Melclin said:


> :wacko: Bloody hell, mate. I've read a paper on thoractomies in the field by london HEMS, but I sure hope they're not "extending to a clamshell", wouldn't that be a sight to see, turning up to an arrest to assist and some blokes chest is talking to you haha


Only a  couple of times a week.


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## EMS84

ahem

cardiac tamponade....


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## EMS84

VentMedic said:


> ECMO is not initiated in the field but as I stated in my previous post, we can bring a doctor to initiate it in a local little general to get the patient back to a more advanced facility. H1N1 also brought about a renewed interest in ECMO with its flu associated ARDS.
> 
> Here is the Novalung that is getting a decent start in the U.S.   Medtronic is currently popular in the U.S.
> 
> 
> 
> 
> 
> Article:
> http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2811933/
> 
> Misc. Articles:
> 
> http://jtcs.ctsnetjournals.org/cgi/content/full/119/5/1015
> 
> Good article and several more listed:
> http://jama.ama-assn.org/cgi/content/abstract/283/7/904
> 
> In the U.S., University of Michigan is the leader in ECMO/ECLS with Arkansas Children's ranking right behind them.
> 
> Now for the significance for EMS providers. It pays to get a strong educational background in the health sciences and don't skip the college level A&P, pharmacology, math and pathophysiology classes. Medicine is evolving and you will see many more VADs in the field as well as possibly having the opportunity someday to job a CCT, Flight or Specialty team that does do transports with advanced technology and high acuity patients. It involves a little more than just a speedy ride from point A to point B. These opportunities do exist and usually those that have gone the extra distance to enhance their education will be selected since these teams get an abundance of applications. Of course for every 200 applications, about 190 will barely meet the bare minimum to be a Paramedic.




















generally,ECMO is used in a clinical setting by an RT. wouldn't it be nice to have such a machine on unit?


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