eMedicine Specialties > Emergency Medicine > Trauma & Orthopedics

Pneumothorax, Tension and Traumatic: Treatment & Medication

Author: Jeffrey Glenn Bowman, MD, MS, Consulting Staff, Highfield MRI, Columbus, Ohio
Contributor Information and Disclosures

Updated: Feb 5, 2009

Treatment

Prehospital Care

Attention to the ABCs is mandatory for all patients with thoracic trauma. Evaluate the patency of the airway and the adequacy of the ventilatory effort. Assess the circulatory status and the integrity of the chest wall.

  • Failure of the emergency medical service personnel and medical control physician to make a correct diagnosis of tension pneumothorax and to promptly perform needle decompression in the prehospital setting can result in rapid clinical deterioration and cardiac arrest.
  • However, if an incorrect diagnosis of tension pneumothorax is made in the prehospital setting, the patient's life is endangered by unnecessary invasive procedures. Close cooperation and accurate communication between the emergency department and the emergency medical service personnel is of paramount importance.
  • To prevent reentry of air into the pleural cavity after needle thoracostomy and decompression in the prehospital setting, a one-way valve should be attached to the distal end of the Angiocath. If available, a Heimlich valve may be used. If a commercially prepared valve is not available, attach a finger condom or the finger of a rubber glove with its tip removed to serve as a makeshift one-way valve device.
  • Clothing covering a wound that communicates with the chest cavity can play a role in producing a one-way valve effect, allowing air to enter the pleural cavity but hindering its exit. Removing such clothing items from the wound may facilitate decompression of a tension pneumothorax.
  • A tension pneumothorax is a contraindication to the use of military antishock trousers.

In a preliminary 2006 study from Norway, Busch evaluated the feasibility of using portable ultrasound in an air rescue setting.5 Concluding that prehospital ultrasonography could provide diagnostic and therapeutic benefit when conducted by a proficient examiner who used goal-directed and time-sensitive protocols. Further study in this area may help to determine the indications and role of prehospital sonography.

Emergency Department Care

For all patients with thoracic injury, immediate and careful attention to the ABCs is vital. Fully assess the patency of the airway and adequacy of the ventilatory effort. Carefully evaluate the cardiovascular system because a tension pneumothorax and a pericardial tamponade can cause similar findings.

  • If a tension pneumothorax is suspected, immediately administer 100% oxygen, and evaluate the patient for evidence of respiratory compromise, hemodynamic instability, or clinical deterioration. Place large-bore catheters, because hemothorax can be associated with pneumothorax, and the patient may, therefore, require immediate intravenous infusion. Upright positioning, if not inappropriate due to cervical spine or trauma concerns, may be beneficial.
  • Immediately perform needle thoracostomy or chest tube placement (see Procedures) if the clinical condition warrants such action. Once a needle thoracostomy has been performed, chest tube insertion must follow.
  • If a hemothorax is associated with the pneumothorax, additional chest tubes may be needed to assist drainage of blood and clots. If the hemopneumothorax requires insertion of a second chest tube, the second tube should be directed inferiorly and should be posterior to the diaphragm.
  • Chest tubes are attached to a vacuum apparatus that continually removes air from the pleural cavity. The collapsed lung reexpands and heals, thereby preventing continued air leakage. After air leaks have ceased for 24 hours, the vacuum may be decreased and the chest tube removed.
  • The process of lung reexpansion and healing is not immediate and may be complicated by pulmonary edema; therefore, a chest tube is usually left in place for at least 3 days unless the clinical condition warrants a longer placement.
  • In general, traumatic pneumothoraces should be treated with insertion of a chest tube, particularly if the patient cannot be closely observed.  
    • A subset of patients who have a small (<15-20%), minimally symptomatic pneumothorax may be admitted, observed closely, and monitored by using serial chest radiographs.
    • In these patients, administration of 100% oxygen promotes resolution by speeding the absorption of gas from the pleural cavity into the pulmonary vasculature.

Hernandez et al noted that ultrasonography is the only radiographic modality allowing patients with nonarrhythmogenic cardiac arrest to continue undergoing resuscitation while searching for easily reversible causes of asystole or PEA.6 Their proposal is for further investigation into a protocol (using the acronym C.A.U.S.E. for cardiac arrest ultrasound exam) in which cardiac arrest patients, concurrent with resuscitation, receive bedside ultrasonography to look for cardiac tamponade, massive pulmonary embolus, severe hypovolemia, and tension pneumothorax. Their hope is that the eventual adoption of ultrasonography in this setting may allow increased "real-time" diagnostic acumen, decreasing the time required to receive appropriate condition-related therapy.

Consultations

  • Treatment of tension pneumothorax should commence immediately after diagnosis, without waiting for further consultation and/or evaluation.
  • A trauma or general surgeon should evaluate patients with trauma, and the patient should be admitted for observation.

Medication

A tension pneumothorax requires treatment with procedural modalities. Anesthetics and analgesics should be used if the patient is not in distress. Medication may be necessary to treat the pulmonary disorder that caused the pneumothorax. For example, intravenous antibiotics are included in the treatment of a pneumothorax that developed as a sequela of staphylococcal pneumonia. Also, studies suggest that the administration of prophylactic antibiotics after chest tube insertion may reduce the incidence of complications such as emphysema.

More on Pneumothorax, Tension and Traumatic

Overview: Pneumothorax, Tension and Traumatic
Differential Diagnoses & Workup: Pneumothorax, Tension and Traumatic
Treatment & Medication: Pneumothorax, Tension and Traumatic
Follow-up: Pneumothorax, Tension and Traumatic
Multimedia: Pneumothorax, Tension and Traumatic
References
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References

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Further Reading

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Contributor Information and Disclosures

Author

Jeffrey Glenn Bowman, MD, MS, Consulting Staff, Highfield MRI, Columbus, Ohio
Disclosure: Nothing to disclose.

Medical Editor

Joseph A Salomone, III, MD, Associate Professor, Department of Emergency Medicine, Truman Medical Center, University of Missouri at Kansas City School of Medicine
Joseph A Salomone, III, MD is a member of the following medical societies: American Academy of Emergency Medicine, Society for Academic Emergency Medicine, and Southern Medical Association
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

Managing Editor

Eric Legome, MD, Chair, Department of Emergency Medicine, St Vincent's Hospital, Manhattan
Eric Legome, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Emergency Medicine, American College of Emergency Physicians, Council of Emergency Medicine Residency Directors, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

CME Editor

John D Halamka, MD, MS, Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical Center
John D Halamka, MD, MS is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Chief Editor

Rick Kulkarni, MD, Medical Director, Assistant Professor of Surgery, Section of Emergency Medicine, Yale-New Haven Hospital
Rick Kulkarni, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Emergency Medicine, American College of Emergency Physicians, American Medical Association, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine
Disclosure: WebMD Salary Employment

 
 
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