35. Pneumothorax, pleural effusion, thoracocentesis

Question 1

35. Pneumothorax, pleural effusion, thoracocentesis

Answer 1

Trauma-associated pleural space injuries
-pneumothorax
-hemothorax
-chylothorax
-diaphragmatic hernia
-pleural effusion–a buildup of fluid in the pleural
space(many causes;in case of blood or chyle–possibly caused by trauma)

Pneumothorax
-accumulation of air in the pleural space
-one of the most common trauma-associated thoracic injuries
-open/closed(closed more common)
-diagnosis:clinical examination/auscultation→thoracocentesis (U/S?)
-radiography contraindicated in clinically significant cases!
-treatment:thoracocentesis,oxygen!,AB (open),thoracostomy tube placement if necessary,surgery(open/recurrent pneumothorax 3-4
days or suspected tracheal avulsion/rupture)

Pleural effusion (possibly hemo- or
chylothorax)

Hemothorax
-the accumulation of blood within the pleural space,results from disruption of vasculature of the chest wall, lungs,or mediastinal structures including the great vessels
-uncommonly clinically significant
-diagnosis:clinical examination/auscultation→thoracocentesis only if
necessary(guided by U/S if possible)
-radiography contraindicated in clinically significant cases!
-treatment:thoracocentesis,oxygen!,analgesia,thoracostomy tube
placement if necessary, possible blood transfusion, surgery
(persistent ongoing hemorrhage or penetrating injury)
-hemorrhagic exudate->trauma

Chylothorax
-chyle is composed of lymph and chylomicrons(triglycerids)
-traumatic(rare)chylothorax may occur secondary to rupture of the thoracic duct(uncommon)
-not a peracute manifestation of thoracic trauma but is usually noted
within days of the traumatic event
-diagnosis:examination/auscultation→thoracocentesis
-radiography contraindicated in clinically significant cases!
-treatment:thoracocentesis,oxygen!,thoracostomy tube place-
ment if necessary,surgery usually not necessary (performed if
fails to resolve over 2 weeks)
-chylous exudate->more than 35 g/L protein->trauma

Thoracocentesis
-equipment
>syringe,3-way stopcock,IV extension tubing
>19-21 g butterfly needle or 18-22 g needle(18-22 g catheter)
-sternal recumbency
-clip and prepare area(often bilateral),use aseptic technique
-insert needle dorsally for pneumothorax,ventrally for effusion
-stay close to the cranial edge of the rib while advancing though the skin(pneumothorax–9th-11th intercostal space,hemothorax– 5th-8th space)
-guided by ultrasound if possible
-aspirate
-effusion–collect fluid(assess clotting first–should not clot) for analysis