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!!!!