Open pneumothorax

Question 1

What is an open pneumothorax?

Answer 1

defect in the chest wall creating a communication between the pleural space and the external environment. if air is greater than 2/3 the diameter of the trachea, air will preferentially pass through the defect on inspiration following the path of least resistance to equilibrate atmospheric and intrathoracic pressures

Question 2

What size of defect in open pneumothorax is required to lead to cause air to preferentially pass through the defect on inspiration?

Answer 2

if opening is greater than two thirds the diameter of the trachea

Question 3

What type of mechanism of injury tends to cause an open pneumothorax?

Answer 3

penetrating chest wall trauma, e.g. gunshot wound (GSW) or stabbing

Question 4

What are the clinical features of open pneumothorax?

Answer 4

as for simple pneumothorax (SOB, pleuritic chest pain, subcutaneous emphysema, tenderness, crepitus, reduced chest movement, hyperresonance, wheeze)

+ penetrating chest wall injury which may be bubbling

Question 5

What must you remember to do in the assessment of a patient with potential open pneumothorax?

Answer 5

check back of patient to avoid missing any wounds

Question 6

What are the investigations of open pneumothorax? 3 key things

Answer 6

as for simple pneumothorax:

1. Emergency department ultrasoound
2. CXR
3. CT scan

Question 7

What on emergency department ultrasound suggests pneumothorax?

Answer 7

absent lung sliding or absent cornet tails suggest possibiliy

Question 8

What are 6 aspects of the management of open pneumothorax?

Answer 8

1. close defect with a commercial device e.g. Asherman chest seal or three-sided dressing
2. insertion of chest drain remove from wound
3. observe closely to identify any developing tension pneumothorax
4. IV antbiotics as prophylaxis for wound infection
5. senior surgical review of patient
6. definitive cardiothoracic surgery to close chest wall defect and identify any intrathoracic injury

Question 9

How do commercial devices initially used to close the wound in open pneumothorax work?

Answer 9

Asherman chest seal or three sided dressing allow a flutter valve effect so the dressing will occlude the wound during inhalation, but during exhalation air can escape from the pleural space

Question 10

What is the definitive management of open pneumothorax?

Answer 10

definitive cardiothoracic surgery to close the chest wall defect and identify any intrathoracic injury