Hemothorax and Pneumothorax

Question 1

Disease/Illness:

Decreased breath sounds, dullness to percussion on affected side. Respiratory distress and hypotension. Can be penitrating injury caused or blood in space.

Answer 1

Hemothorax

Question 2

What is considered massive blood loss in a Hemorathorax injured patient?

Answer 2

Apon draining 1000ml or 250ml an hour.

Question 3

General Considerations:

• Injury to chest wall, great vessels, or lung can cause intra-pleural bleeding.
• Most commonly secondary to penetrating injury disrupting pulmonary or systemic blood vessels.
• In great vessel injury, 50% die immediately, 25% live 5-10 mins, and 25% live 30 mins or longer.
• Effect on respirations depends on blood loss
• Affected lung becomes collapsed

Answer 3

Hemothorax

Question 4

Physical Findings:

• Respiratory distress, tachypnea, variable degrees of hypoxia.
• Dullness to percussion, decreased breath sounds on affected side.
• Hypotension and flattened neck veins depending on degree of blood loss.
• Pulse pressure narrow.
• Smaller hemothorax difficult to detect in supine patients.
• Decreased breath sounds

Answer 4

Hemothorax

Question 5

Lab/Imaging Studies:

• Diagnosis confirmed by chest X-ray. Volumes of blood as low as 200-300mL may be seen on upright X-ray.
• Ultrasound - you can evaluate at bedside quickly.

Answer 5

Hemothorax

Question 6

Treatment:

• Ensure patient has an intact airway first
• Oxygen to correct hypoxia
• If the airway is not intact, provide suctioning and intubation if necessary
• Tube thoracostomy with a 36 or 40 French chest tube

Answer 6

Hemothorax

Question 7

Disposition:
MEDEVAC

Complications:
Hypovolemia due to blood loss

Answer 7

Hemothorax

Question 8

Essentials of Diagnosis:

Absent or decreased breath sound, hyper resonance to percussion on affected side. Air in lungs.

Answer 8

Pneumothorax

Question 9

General Considerations

• Pneumothorax is the abnormal collection of air within the pleural space.
• Classified as spontaneous (primary or secondary) or traumatic (chest trauma or iatrogenic).
• Primary spontaneous occurs in patients without clinically apparent lung disease.

Typically, young, tall, men age 20-40 who smoke? It is thought to occur from rupture of subapical blebs.

Answer 9

Pneumothorax

Question 10

General Considerations:

Secondary Dx occurs as a complication of preexisting underlying pulmonary disease.
* COPD
* Pneumonia
* CF
* Asthma
* TB
* Pneumocystis carina pneumonia infection.

Traumatic Dx is common.
* Always consider in trauma patients
* Consider after invasive procedures

-Subclavian line placement
-Thoracentesis
-Lung or pleural biopsies
-Barotrauma from positive pressure ventilation

Answer 10

Pneumothorax

Question 11

Physical Findings:

• Pleuritic chest pain, tachypnea, tachycardia
• Chest pain ranging from minimal to severe and dyspnea occur in almost all patients
• In small Dx (15% of one hemithorax or less) physical findings may be minimal
• In larger Dx, diminished breath sounds, decreased tactile fremitus, decreased chest movement, hyper resonance on affected side.

Answer 11

Pneumothorax

Question 12

Lab/Imaging Studies:

CXR will reveal
* Demonstration of a visceral pleural line is diagnostic, may only be seen on expiratory film.
* ABG can assist with assessment of respiratory insufficiency (Pco2, Po2) but is not usually necessary.
* Ultrasound - you can evaluate for lung sliding and if absent then diagnostic for pneumothorax.

Answer 12

Pneumothorax

Question 13

Treatment:

Ensure patient has an intact airway. If the airway is not intact, provide suctioning and intubation if necessary.

Treatment depends on size of the pneumothorax and the patient’s stability.

For stable patients:
* RR <24/min, HR 60-120/min, BP normal, O2 Sat >90%, able to talk in sentences
* Able to speak in sentences.
* Obtain chest X-ray in 3-6 hours and compare with arrival Chest X-ray

Many small sized pneumothorax resolve spontaneously as air is absorbed from the pleural space.

Supplemental oxygen may increase the rate of reabsorption.

For a large pneumothorax or unstable patients, re-expansion of the lung is necessary.
* Placement of a small-bore chest tube attached to a Heimlich valve may permit observation from home with close follow up.
* Large bore chest tube with water seal drainage and suction may be necessary for secondary, tension, severe symptoms, or pneumothorax on mechanical ventilation.

Treat symptomatically for cough and chest pain

Toridol 30mg
Codine T3

Answer 13

Pneumothorax

Question 14

Disposition:
Medical Evacuation (MEDEVAC)
Complications:
Tension Pneumothorax

Answer 14

Pneumothorax

Question 15

Stable patients with spontainious pnumothorax can be what?

Answer 15

Give oxygen and monitor and give them the boot