0071643192.pdf

■ If a patient with an untreated pneumothorax requires intubation, consider

chest tube placement prior to or immediately following intubation or

monitor carefully for signs of pneumothorax enlargement.

■ If the lung does not reexpand after chest tube placement and there is no

mechanical malfunction, consider the possibility of a large tear in lung

parenchyma or a bronchial injury.

■ If placement of a second chest tube doesn’t reinflate the lung then surgical

intervention is needed either via bronchoscopy or thoracotomy.

■ Stable asymptomatic patients with isolated chest injury and negative CXRs

for pneumothorax at 6 hours apart may be discharged.

Tension Pneumothorax

MECHANISMS

■ Caused by a one-way communication from lung parenchyma into pleural

space, allowing air into the space but not out (see Figure 3.10)

■ Progressive increase in air in the pleural space increases pressure of the

hemithorax, causing shifting of the mediastinum, compression of the vena

cava,obstruction of venous return, and decreased cardiac output.

SYMPTOMS/EXAM

■ Shortness of breath

■ Hypotension

■ Distended neck veins

■ Diminished/absent breath sounds on affected side

■ Tracheal deviation to opposite side

■ Hyperexpansion of chest wall on affected side

TRAUMA

FIGURE 3.9. Right-sided pneumothorax.

(Reproduced, with permission, from Stone CK, Humphries, RL. Current Emergency Diagnosis
and Treatment, 5th ed. New York: McGraw-Hill, 2004:232.)

Findings of hypotension with

distended neck veins may also

occur with cardiac

tamponade. The lung exam

and response to thoracostomy

should differentiate the two.