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Pneumothorax (Tension (Clinical presentation (SOB, Tacypnoea, Acute…

- - - - Distended neck veins
      - Tachycardia, low BP
      - Tracheal deviation
        (away from affected side)
      - Reduced chest expansion
        on affected side
      - Absent breath sounds
        on affected side
      - Hyper-resonant percussion
        on affected side
    - - Trauma
      - Iatrogenic cause
  - - - Decompression with IV cannula
        IV cannula (>16G) into 2nd intercostal space MCL
        Withdraw needle and listen for hiss of gas
        Tape cannula to chest wall
      - Axillary chest drain
        Insert ASAP
        Remove cannula and dress site
      - CXR
- - - - Lung disease
        
        COPD
        
        Asthma
        
        Lung Ca
        
        Infection
        (pneumonia, TB, abscess)
        
        CF
      - CT disease
        (Marfan's, Ehler-Danlos)
  - - - Radiation
        Nil
      - Associated symptoms
        SOB, cough
      - Character
        Pleuritic (worse on inspiration)
      - Timing
        Constant
      - Onset
        Sudden
      - Exacerbating/relieving factors
        Exacerbating: inspiration
        Relieving: stillness
      - Site
        Unilateral chest
      - Severity
        Severe
  - - - Respiratory
        
        Tachypnoea
        
        Reduced breath sounds
        on affected side
        
        Increased percussion note
      - Cardiovascular
        
        Tachycardia
        
        Hamman's sign
        (rare; systolic crunch
        at L parasternal edge)
    - - Bedside
        
        ECG
        (sinus tachy, other non-specific e.g.
        R axis deviation, T wave inversion)
        
        Obs
        (sats may be low)
      - Bloods
        (ABG [hypoxia], FBC, CRP,
        U+E, troponins, amylase)
      - Imaging
        
        CXR
        Rim of dark lung edge
        Small <2cm, large >2cm
  - - - Secondary
        
        Not breathless and/or
        rim of air <2cm on CXR
        
        Aspiration
        Admit to hospital for 24h
        Discharge with FU
        
        Breathless and/or
        rim of air >2cm on CXR
        
        Intercostal drain
        Axillary approach (cosmesis)
        Suture tube in place, CXR
        Remove 24h after re-expansion/cessation of air leak
        
        Referral
        Chest physician >48h
        Thoracic surgeon >3d
      - Primary
        
        Not breathless and/or
        rim of air <2cm on CXR
        
        Consider discharge and FU
        
        Breathless and/or
        rim of air >2cm on CXR
        
        1. Aspiration
        LA (e.g. 1% lidocaine)
        16G cannula in 2nd intercostal space MCL
        Remove needle and add 3-way tap,
        aspirate air with 50mL syringe
        
        2. Repeat aspiration
        
        3. Intercostal drain
        Axillary approach (cosmesis)
        Suture tube in place, CXR
        Remove 24h after re-expansion/cessation of air leak
        
        4. Referral
        Chest physician <48h Thoracic surgeon >5d
    - - Primary
        Some may be discharged after aspiration
        if stable, with early chest clinic FU
      - Secondary
        Admit all irrespective of tx
- - - - Surgical emphysema
      - Reduced air entry
        on affected side
      - Hyperresonance on
        affected side
      - Reduced chest expansion
        on affected side
      - Tachycardia, tachypnoea
      - Sats - hypoxia
    - - Erect CXR
        Erect shows lung contour
        Dark rim around edge of lung
        Hyperinflation of hemithorax and depressed hemidiaphragm
        Double contour of hemidiaphragm
        Basal hyperlucency
        Surgical emphysema
      - CT thorax
      - Bloods
        ABG
  - - - Blunt inury
        (assoc rib fracture)
      - Penetrating injury
        (gunshot, knife)
    - - CVA line