Iatrogenic pneumothorax

Question 1

A 57 year old man has a central line inserted into his right subclavian vein. Immediately after the insertion, he develops acute shortness of breath. How would you assess and manage him?

Answer 1

Impression
With the acute shortness of breath following central line insertion, I am worried about this having caused a pneumothorax. In particular, I would be concerned about the potential for this to develop into a tension pneumothorax and so would conduct an appropriate emergent assessment in view of this.

Other life-threatening differentials to consider as the cause of this presentation include;

• Tamponade
• ACS
• PE

Question 2

Iatrogenic pneumothorax - Initial assessment

Answer 2

Initial assessment
Given the critical nature of this presentation, I would call a MET call, and arrange for transfer to the ED for ongoing management and resus if required. I would take an A to E approach to initial assessment;
A - patent, maintaining, adjuncts?
B - RR, SP02, CXR at bedside for diagnosis and assessment of severity. consider eFAST scan at bedside as well. Consider resp examination findings consistent with pneumothorax (hyperresonance on percussion, reduced breath sounds). Consider providing supplemental oxygen if sats are reduced.
C - BP monitoring, ECG, IV access. consider requirement for fluids, transfusion if blood loss (haemothorax)
D - GCS
E - Secondary survey

Question 3

Iatrogenic pneumothorax - history

Answer 3

History

• sx: dyspnoea (improving vs worsening), pleuritic chest pain (SOCRATES), confusion, LOC
• Read operation/procedure report, read medical notes for further background history and relevant PMHx/meds/allergies

Question 4

Iatrogenic pneumothorax - Examination

Answer 4

Examination

• General obs + vital signs
• Respiratory exam: hyper resonance on percussion, reduced breath sounds, asymmetrical chest expansion

Question 5

iatrogenic pneumothorax - Investigations

Answer 5

Investigations

• Key/diagnostic: CXR, Lung ultrasound
• Bedside: VBG, ECG
• Bloods: FBC, coags,

Question 6

Iatrogenic pneumothorax - Management

Answer 6

Management
Depends on if tension or simple pneumothorax
- simple can be managed expectantly
- tension requires decompression

Supportive:

• High-flow 02 to maintain 02 sats
• analgesia
• regular nursing observations

Definitive
Decompression
- needle throacostomy - 2nd ISMCL
- chest drain insertion - 5th ISMAL (triangle of safety)
- repositioning of the CVC by IR once patient is stabilised