![]() ![]() Management of tension pneumothorax begins with its identification. This combination of insults to the cardio-respiratory system leads to dramatic hypoxia and obstructive shock. Eventually, the dramatic mediastinal shift leads to a deviation of the trachea away from the affected side. The mediastinal deviation and pressure work together to decrease venous return to the heart, dramatically dropping preload and leading to distention of the neck veins, weak pulses, and hypotension. Tension pneumothorax is a progressive condition that worsens as each breath increases the pressure inside the chest, further deflating the lung.Īs the pressure increases, the mediastinum is pushed to the opposite side. QUICK TIPS: Characteristic signs of a tension pneumothorax are: TENSION PNEUMOTHORAX: Is a true emergency, and results from a hole in the lung or chest wall acting as a one-way valve, allowing air to enter the thorax with inspiration and preventing it from exiting with expiration. Frequent re-assessment for the development of tension pneumothorax (hypotension, JVD, and decreased breath sounds) and blood loss ( headache, cold extremities, diaphoresis, and weak pulses) is paramount. Oxygen via non-rebreather, cardiac monitors, pulse oximetry, and end-tidal CO2 monitoring are indicated. The remainder of management is similar to an open pneumothorax. ![]() Pneumothorax can progress rapidly, requiring you to place a gloved hand over the wound until an occlusive dressing can be applied. Air can still accumulate if the lungs' visceral pleura is also damaged, lifting the dressing off of the wound temporarily will allow any developing tension pneumothorax to decompress. Management of open pneumothorax is focused around the placement of an "occlusive dressing." By placing the dressing, taping down three sides and leaving one end open to the air, you create a one-way valve that seals the chest upon inspiration but allows accumulated air and blood to leave the lung on expiration. This often results in the symptoms of mild to severe hemorrhage in addition to the expected symptoms of poor ventilation. Hemostasis may be impossible to maintain due to the inability to put pressure on the inner surface of the wound. These wounds have a high rate of conversion to tension pneumothorax and/or hemothorax. These wounds are almost exclusively secondary to penetrating trauma and are often called "sucking chest wounds" after the noises they make when blood leaving the circulation mixes with air being pulled into the wound as the patient inhales. OPEN PNEUMOTHORAX: Occurs when a hole in the chest wall and pleura allows air to collect in the pleural space, normally a hole greater than the size of a nickel. To rule out other complications of trauma, IV access should be obtained, patients should be placed on cardiac monitors, pulse oximetry, and in the rare case that positive pressure ventilation is needed, end-tidal CO2 monitoring. Management of a simple pneumothorax generally only requires the administration of oxygen via non-rebreather 12 to 15 LPM, as patients only have minor dyspnea. "Paper Bag Syndrome": Blunt trauma that occurs when a patient is holding their breath at full inspiration may also "pop" the pleura like a balloon as the alveolar pressure rises past what the pleura can contain, i.e., alveolar rupture. Holes in the pleura generally occur secondary to a fractured rib which directly lacerates the pleura or when a bleb in a patient with emphysema ruptures. SIMPLE PNEUMOTHORAX: Occurs when a hole in the visceral pleura allows air to escape the lung and collect in the pleural space, i.e., a hole in the lining over the lung. ![]() The three subtypes have unique elements of their presentations, management, and expected outcomes. Each involves the influx of air into the normally closed chest cavity with a resulting decrease in the ability for the affected lung to expand. Pneumothorax has three unique presentations: simple, open, and tension. This section will review the types, causes, and basic management of pneumothorax and hemothorax at the EMT level. They are common complications of blunt or penetrating trauma to the chest. Pneumothorax and Hemothorax are collections of abnormal material (air and blood, respectively) within the chest (thoracic) cavity, in the space normally occupied by the tissue of the lungs. ![]()
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