Penetrating Chest Wounds, Pneumothorax, Tension Pneumothorax

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Penetrating Chest Wounds, Pneumothorax, Tension
Pneumothorax and Hemothorax

• Gary L. Weinstein M.D.
• Director of Pulmonary and Critical Care Medicine
• Presbyterian Hospital of Dallas
• September 14, 2006

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Normal Physiology

• Breathing
• Inspiration
• The diaphragm contracts and moves downward
  enlarging the chest cavity
• And the rib muscles contract, widening the chest
  cavity causing air to fill the lungs through
  suction.
• Expiration- The diaphragm and rib muscles then
  relax, decreasing the chest size and forcing air
  out of the lungs.

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Normal Physiology

• Chest Wall
• Pleura
• Pleural Space
• Diaphragm

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Penetrating Chest Wounds

• Anything that disrupts these normal relationships
  can cause problems
• A hole in the chest, lets air collect in the
  pleural space

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Causes
Causes
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Causes
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Causes
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Causes
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Pneumothorax

• Pleura
• Diaphragm

Pleura
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Pneumothorax

• Pneumothorax - air gets between your lungs and
  your chest wall and the lung collapses.
• Normally, two thin layers of tissue (pleura)
  separate the lung and chest wall.
• Any air that leaks into this space (pleural
  space) will cause the lung to collapse..

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Pneumothorax

• Air can collect inside the chest for many
  reasons, such as
• An injury that damages the chest wall, such as a
  stab or gunshot wound
• A broken rib that punctures the lung

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Pneumothorax

• Signs and symptoms of a pneumothorax include
• Sudden, sharp chest pain
• Shortness of breath
• Chest tightness
• Rapid pulse
• Rapid, shallow breaths

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Pneumothorax

• A pneumothorax is a serious condition that can be
  life-threatening.

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Tension Pneumothorax
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Tension Pneumothorax

• If air continues to enter the pleural space, a
  tension pneumothorax occurs.
• The air may compress the heart and cause a fall
  in B.P.
• This is life-threatening and requires immediate
  treatment to release the pressure.
• Treatment can life-saving.

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Tension Pneumothorax

• Symptoms of a tension pneumothorax may include
• Shift of the trachea
• Loss of consciousness
• Sweating
• Gasping
• Shock
• Rapid HR

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Hemothorax

• Blood can also collect in the pleural space and
  cause all the same signs and symptoms and
  problems as a pneumothorax including a tension
  hemothorax

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Classical physical examination findings
The size of the injury, and position of the
patient will affect the clinical findings. For
example, a small hemothorax may have no clinical
signs at all. A moderate hemothorax will be dull
to percussion with absent breath sounds at the
bases in the erect patient, whereas signs will be
posterior in the supine patient. This is also
reflected in chest X-ray findings.
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Assesment of patient with Blunt or Penetrating
chest trauma

• Look
• Determine the respiratory rate and depthLook for
  chest wall asymmetry. Paradoxical chest wall
  motion Look for bruising, seat belt or steering
  wheel marks, penetrating wounds
• Feel
• Feel the trachea for deviationAssess whether
  there is adequate and equal chest wall
  movementFeel for chest wall tenderness or rib
  'crunching' indicating rib fracturesFeel for
  subcutaneous emphysema
• Listen
• Listen for normal, equal breath sounds on both
  sides.Listen especially in the apices and
  axillae and at the back of the chest (or as far
  as you can get while supine).
• Percuss
• Percuss both sides of the chest looking for
  dullness or resonance (more difficult to
  appreciate in the trauma room).

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Physical Exam in Chest Trauma

• Trachea Chest expansion Breath
  Sounds Percussion
• Tension Away Decreased Diminished
  or Hyper-resonant
• Pnuemothorax Chest may be absent
• fixed in
• hyperexpansion
• Simple Midline Decreased May be May be
  hyper-
• Pneumothorax diminished resonant Usually
• normal
• Hemothorax Midline Decreased Diminished
  if Dull, especially
• large Normal posteriorly
• if small
• Pulmonary Midline Normal Normal May Normal
• Contusion have crackles
• Lung Collapse/ Towards Decreased May be
  Normal
• Atelectasis reduced

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Hemothorax, supine
Hemothorax, upright
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Simple Pneumothorax
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Tension Pneumothorax
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Examples
Stab wounds to back
Open pneumothorax
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Treatment

• Needle decompression
• Simple large-bore needle
• Mid, anterior chest
• 2nd or 3rd rib space
• NOT right next to Sternum

The Magic Triangle
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Treatment

• Asherman chest seal for Sucking Chest Wounds

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Treatment

• Asherman chest seal convert sucking chest
  wounds to simple pneumo/hemothorax

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Treatment

• Needle decompression
• Cook Pneumothorax set

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Treatment

• Chest tube
• Standard
• Standard with Heimlich valve

Chest tube
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Chest Tubes
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Suction Systems
A - Suction Port/Connection C - Water Seal Fill
Port G - Suction Setting I - J - Collection
Chamber K - Suction Indicator L - Chest Tube
Connector
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Take Home Points

• Simple Pneumothorax/Hemothorax should be expected
  with penetrating chest wounds and rarely kills
• Tension pneumothorax can occur rapidly
• Tension pneumothorax can KILL rapidly
• Treatment SAVES lives
• Needle decompression will never harm and may
• SAVE A LIFE!!

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Questions?????
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to take whatever they want!!!!