Developing Tension Pneumo or Cardiac Tamponade?

[Akulahawk]

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.

I have read where tracheal deviation is actually visible but missed during physical exam because the trachea is deviated only by a few mm.

 

[Akulahawk]

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.

This is a little surprising, but not unexpected given the info we were given earlier. In any event, in my mind, the description given still would make me lean toward decompressing the chest, by chest tube if I'm authorized to do it. If he doesn't yet meet criteria, I'd be very closely observant to see if he develops sufficient signs/symptoms that trigger the thoracostomy tube insertion.

 

[VentMonkey]

I have read where tracheal deviation is actually visible but missed during physical exam because the trachea is deviated only by a few mm.

Yes, this was sort of along the lines something an instructor of mine once emphasized.

Basically, it was present on CXR (minimal mid-line shift upon physical exam) upon ED arrival, however, this was why tracheal deviation being visibly obvious and present in front of EMS is emphasized as being considered a late sign, and requires immediate decompression.

 

[zzyzx]

Tracheal deviation usually isn't visible on physical exam. But Google some chest x-ray images of tension pneumos and you'll see how obvious it is on a CXR.

 

[MackTheKnife]

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?

You obviously treated the pt and not the numbers- GOOD. His systolic dropped between readings but not his diastolic. With TP or CT, the diastolic usually increases as the pulse pressure narrows. This didn't happen. You did right. Don't second guess yourself.