Developing Tension Pneumo or Cardiac Tamponade?

[jaksasquatch]

Interesting patient I had the other day. Dispatched for a stabbing you arrive on scene to find one 29 y/o male patient sitting in the middle of a cow pasture. He appears to be in mild distress (anxious), breathing approx 22 times per minute and notes that he was stabbed once in the chest with a 4 inch knife. It is covered by a t shirt and after this is lifted you see a 1 inch diameter wound located in the left mid-clavicular at the 2nd-3rd intercostal space. The patient currently denies shortness of breath but notes that his chest hurts. His skin is pale, cool, diaphoretic. Your initial auto-pressure is 112/69, HR 90 with a strong radial, SpO2 95% on room air and 100% on 15 lpm NRB. An occlussive dressing was applied in the form of a defibrillator pad. He notes that the assailant used the knife to penetrate in a downward direction. The patient is CAO X 4 but continues to be very anxious and refuses to answer the deputies questions regarding the assailant. The patient denies drug/alcohol use at this time but due to the location you highly suspect a drug deal was going on (numerous call outs to this area for overdoses etc...). Initial lung sounds reveal diminished in the left lower and 5 min later diminished upper on the left as well. The patient continues to deny shortness of breath. The patient's ETCO2 is 33 mmHg with a normal plateau. No JVD or tracheal deviation is present. Heart sounds were unable to be assessed due to the background noise

Now this patient obviously has a pneumothorax and is also at risk for cardiac tamponade/greater vessel injury. He continued to deny shortness of breath and spoke in full sentences and I held off on needle decompression. The pressure dropped to 97/64 mmHg, SpO2 100% on NRB, and HR rose to 120 bpm. The flight crew who arrived 10 min later also held off after I gave them report with the next pressure at 87/64 mmHg. Looking back on this call I'm upset with myself that I didn't decompress (dressing would not burp) as the shock and diminished lung sounds are an obvious indication. Reason I held off was the denial of shortness of breath and the lack of hypoxia. I've yet to receive followup but I'm more inclined to say that his signs and symptoms were caused by hemorrhagic shock due to vessel injury or a developing tamponade with a developing tension pneumothorax. I had the mid-axilary area marked and was preparing to decompress at the first sign of hypoxia and subjective complaint of shortness of breath. Our flight medics are usually jam up and I'm very surprised that they didn't decompress in the back of our unit as they usually do so before loading. What is everyone's opinion on this patient and the care he received?

 

[StCEMT]

How did the EtCO2 trend during your time with him? Get a rhythm strip to see if there were signs of electrical alternans? Any signs of pulsus paradoxus?

 

[GMCmedic]

Im leaning towards a developing hemothorax

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[VentMonkey]

After (briefly) reading through your scenario I just have one question- Why decompress the patients chest?

The patient appeared stable for the time being. @StCEMT the set of vital signs that the OP provided is most likely indicative of pulsus paradoxus. With that said, why do anything now for a seemingly otherwise stable patient? Oh, and where exactly on the chest was this patient stabbed?

Perhaps some judicious fluids in-flight, but aside from that this sounds to me to be the perfect candidate who meets the need for rapid transport more than anything that could be done in the field.

A clinician always trumps a technician, IMO. An adequate SPO2, no acute dyspnea, and someone who could/ would most likely remain stable throughout the flight with simple fluid bumps titrated to keep their end organs perfused most likely does not need to be decompressed right then and there. I think you're overthinking this one, OP.

 

[StCEMT]

@VentMonkey, possibly/probably. However, if I have 10 minutes to wait for a flight crew, I'd check those off my list just because I have the time.

 

[VFlutter]

Is a defib pad your only option for an occlusive dressing? You don't have actual chest seals?

Signs of shock with suspected pneumothorax gets decompressed immediately regardless of hypoxia. Even if he is denying SOB he is anxious and tachypenic. In this case if burping the dressing isn't effective then what is the downside? He is getting a chest tube regardless.

Vessel injury is definitely possible but a cardiac tamponade is less likey. Most patients whom develop tamponade with penetrating chest trauma die quickly there after.

 

[jaksasquatch]

Is a defib pad your only option for an occlusive dressing? You don't have actual chest seals?

Signs of shock with suspected pneumothorax gets decompressed immediately regardless of hypoxia. Even if he is denying SOB he is anxious and tachypenic. In this case if burping the dressing isn't effective then what is the downside? He is getting a chest tube regardless.

Vessel injury is definitely possible but a cardiac tamponade is less likey. Most patients whom develop tamponade with penetrating chest trauma die quickly there after.

No formal asherman seal. Defib pad is the only option. Looking back I agree with you Chase this patient was a candidate for decompression. An odd one in that he wasn't yet hypoxic but one nonetheless

 

[jaksasquatch]

How did the EtCO2 trend during your time with him? Get a rhythm strip to see if there were signs of electrical alternans? Any signs of pulsus paradoxus?

ETCO2 remained 33 mmHg. No signs of electrical alternans

 

[jaksasquatch]

After (briefly) reading through your scenario I just have one question- Why decompress the patients chest?

The patient appeared stable for the time being. @StCEMT the set of vital signs that the OP provided is most likely indicative of pulsus paradoxus. With that said, why do anything now for a seemingly otherwise stable patient? Oh, and where exactly on the chest was this patient stabbed?

Perhaps some judicious fluids in-flight, but aside from that this sounds to me to be the perfect candidate who meets the need for rapid transport more than anything that could be done in the field.

A clinician always trumps a technician, IMO. An adequate SPO2, no acute dyspnea, and someone who could/ would most likely remain stable throughout the flight with simple fluid bumps titrated to keep their end organs perfused most likely does not need to be decompressed right then and there. I think you're overthinking this one, OP.

The patient was stabbed in the left anterior chest midclavicular line 2nd/3rd IF. The decompression would have been to essentially stay ahead of the game rather than wait for the hypoxia to develop. I chose the conservative route during the call and it's interesting to hear everyone's thoughts on this one in retrospect

 

[Akulahawk]

Frankly I'm leaning toward hemothorax. The fact that he's anxious is a sign that he's already compromised. Burping the chest isn't going to work because his chest isn't filling with air, it's filling with blood. I would think starting a couple of relatively large-bore locks (18g or bigger) would be a priority and once that's done, consider decompressing the chest at the left anterior axillary line. If you do, be ready for blood to come pouring out. The highest priority is to get him to a trauma center. Anything else that needs to be done should be done while en-route. I'm not too worried about hearing heart sounds in this guy. I want to hear what his chest sounds like when I percuss... if I can hear lung sounds, I should be able to hear the results of percussing his chest. If you were able to percuss his chest while it was still quiet enough, you might have heard/noted dullness in that lower left chest early...

 

[DesertMedic66]

Kinda hard to develop a cardiac tamponade from a stab wound to the heart that has to pierce the pericardial sac to reach the heart.

 

[Brandon O]

Kinda hard to develop a cardiac tamponade from a stab wound to the heart that has to pierce the pericardial sac to reach the heart.

This is extremely possible. The pericardial lesion is not often not enough to drain the space.

 

[VFlutter]

This is extremely possible. The pericardial lesion is not often not enough to drain the space.

As well as clot formation that commonly occurs blocking the pericardial defect but not the source of the bleeding.

 

[E tank]

Frankly I'm leaning toward hemothorax. The fact that he's anxious is a sign that he's already compromised. Burping the chest isn't going to work because his chest isn't filling with air, it's filling with blood....

^^^ !

 

[TomB]

I would not personally decompress without signs of significant air hunger and hypoxia. On both occasions I have witnessed an actual developing tension pneumothorax there was jugular venous engorgement, asymmetrical chest (best viewed from the feet looking toward the head), absent breath sounds on the affected side, hyperresonance to percussion, and subcutaneous emphysema. Notably absent from the physical exam was tracheal deviation although it was clearly visible on CXR -- don't necessarily expect to see it because the "turn" can happen below the sternal notch. I have reviewed a lot of reports over the years where the chest was "decompressed" but the physical exam did not warrant it. Just because it happens a lot does not mean it was indicated. I agree with others who suggest the more likely diagnosis is hemothorax although I understand why you were concerned with a dropping blood pressure.

 

[jaksasquatch]

Just received the followup on this patient. Flight crew had the patient finally complain of shortness of breath and show more signs of air hunger. Patient received a chest tube either with them or at the trauma center (followup is from the trauma center not the flight service) and on arrival to trauma center the patient was found to have a pneumothorax. No hemothorax or other injuries to report. Patient is currently in the step-down ICU with a chest tube in good spirits expected to make a full recovery.

 

[VFlutter]

I would not personally decompress without signs of significant air hunger and hypoxia. On both occasions I have witnessed an actual developing tension pneumothorax there was jugular venous engorgement, asymmetrical chest (best viewed from the feet looking toward the head), absent breath sounds on the affected side, hyperresonance to percussion, and subcutaneous emphysema. Notably absent from the physical exam was tracheal deviation although it was clearly visible on CXR -- don't necessarily expect to see it because the "turn" can happen below the sternal notch. I have reviewed a lot of reports over the years where the chest was "decompressed" but the physical exam did not warrant it. Just because it happens a lot does not mean it was indicated. I agree with others who suggest the more likely diagnosis is hemothorax although I understand why you were concerned with a dropping blood pressure.

To play Devil's Advocate I have personally seen a few patients with significant pneumothorax, and one tension, that were not hypoxic. A young healthy patient on a NRB can accumulate a lot of air, potentially enough to compress vessels and cause hemodynamic compromise, before saturations deteriorate.

 

[EpiEMS]

@Chase, what's your decision rule for decompressing on young, healthy patients like the one you describe?

 

[VFlutter]

Wouldn't say there is a hard rule it is an overall presentation but in this case the patient has penetrating chest trauma so a pneumo is on top of the differential until proven otherwise. He is anxious, tachypneic, with decreased breath sounds and signs of shock. Personally I feel that lack of hypoxia does not rule out tension when the mechanism and other symptoms fit. He may very well become hypoxic at the point he is pre-arrest. If it was blunt trauma I would be more prudent but the patient already has an open penetrating chest wound, he is getting a chest tube. I think decompressing when it may not have been necessary is better than missing a tension pneumo having him arrest.

 

[EpiEMS]

@Chase, so in this case, it sounds like you'd decompress from the start, even if he's more or less in a compensatory shock (I suppose)?