SPONTANEOUS TENSION PNEUMOTHORAX

C. Gonzalez Maldonado, M. Diez Rodriguez b, M. Dent Rego b, R. Lucas of Lucas

Emergency Centre outpatient El Molar, SUMMA, 112, Madrid, Spain
b Family and Community Medicine, Equipment and Primary Care Management (EAP and
GAP), Casa de Campo, Madrid, Spain
Spontaneous pneumothorax. Diagnosis. Treatment.
Keywords
Spontaneous pneumothorax. Diagnosis. Therapy.
Summary
A catered clinical case is presented in a hospital emergency service spontaneous
pneumothorax tension. This is a relatively common condition that requires early
diagnosis and rapid therapeutic action of easy learning.
Abstract
Presented A clinical case of a patient is seen in the community emergency service due
to a spontaneous pneumothorax pressure. This is a frequent condition Relatively That
requires an early diagnosis and an easy-to-learn fast therapeutic action.
Article
Introduction
Tension pneumothorax is a clinical diagnosis that is often done in a dying patient with
severe cardiopulmonary compromise. The thoracostomy performed immediately
unpack needle prevents immediate death. This is a quick, simple and easy process to
learn.
In this case it is intended to emphasize the importance of suspecting this disease in a
community-acquired and know the material and the appropriate technique for the
toracostoma once diagnosed.
Clinical case
Male 29 years, no history of interest or known allergies. Habitual consumer of cannabis
(1cigarrillo / day), does not refer other toxic habits. Athletic habit (climbing usual
practitioner).
Attends the outpatient emergency center El Molar by sudden onset of chest pain and
shortness of breath. No history of trauma refers.
In-hospital Emergency Center El Molar have diagnostic tests (simple radiology
equipment, ultrasound and laboratory emergencies), 4 observation beds and 8 chairs
with monitoring, minor surgery operating room, critical room, delivery room / living
obstetrics and UVI for transfer.
History
Sudden onset of chest pain over an hour evolution, not oppressive, non-irradiated, with
associated vegetative symptoms. Dyspnea at rest. Refers consumption of a cannabis
cigarette a 4h before the pain. Clinical worse supine.
Initial exploration
conscious and oriented, mucocutaneous pallor, sweating; blood glucose: 120mg / dl;
TA 100 / 60mmHg; FC: 95 bpm; FR: 28rpm; basal O2 saturation: 96%.
isochoric and normorreactivas pupils, preserved cranial nerves.

 No jugular venous distension. Carotid rhythmic and isopulstiles. No tracheal

deviation.
Chest stable. Without subcutaneous emphysema. No run. AP: decreased breath
sounds in the left base. AC: rhythmic, without murmurs.
Abdomen without significant findings.
Good bilateral and symmetrical peripheral pulse; no edema in the lower limbs.
Additional tests
ECG: sinus rhythm without ST-segment abnormalities, unchanged repolarization, PR
and QT segment within the limits, without descent PR segment; striking voltage
decreased R precordial lead V5 and V6.
Analysis: blood count, biochemistry and venous gases without significant findings.
Cardiac enzymes within normal limits.
Chest X-ray (inspiration) (Figure 1.
Simple posteroanterior radiograph.
During the radiological study becomes more intense dyspnea; in the new examination
(15min to the arrival of the patient) is objective peripheral thready pulse, FC 120lpm,
34rpm FR, MT 80 / 40mmHg and abolition of breath sounds in all lung fields in the left
chest.
Therapeutic procedure
In view of the imaging and the clinical condition of the patient oxygen (100% oxygen
mask high flow) begins and proceeds to an intercostal disposable puncture
percutaneous chest tube kit (Pleurocath) (Figure 2) in the second intercostal space,
midclavicular line, after analgesia (fentanyl 150g slow iv bolus and local infiltration of
lidocaine 1%).
Image of the patient with tube thoracostomy already placed.
Evolution
After the procedure, the patient is stabilized hemodynamically immediately disappears
and clinical (both dyspnoea and pain).
On examination TA 110 / 70mmHg, FC 75 lpm, FR of 18rpm, and normocoloracin skin
and mucous observed.
He moves the patient in mobile reference hospital for definitive treatment UVI.
Discussion
Pneumothorax is one of the most frecuentes1 lung diseases. It may, according to their
etiology, spontaneous, traumatic or iatrogenic.
It is estimated that the incidence of spontaneous pneumothorax is 7.4 / 100,000 / year
in men and 1.2 / 100,000 / year in women2, although the true incidence is unknown,
because many patients do not consultan3 (mild or asymptomatic clinical ).
Primary spontaneous pneumothorax usually occurs in men (6: 1) young (16-24 years)
with asthenic habit and history of tabaquismo1. There is no direct connection with the
exercise (<10%) 5.

10-20% of spontaneous pneumothorax are asintomticos1. When there is clinical, the

most common symptoms are chest pain (deep, oppressive and is exacerbated by
respiratory movements) and disnea2, followed by dry irritating cough and hemoptysis.
Pneumothorax occurs tensin5 in approximately 3% of cases.
The diagnosis of tension pneumothorax is made by the clinic, along with physical and
radiolgica5 exploration.
In the exploration objective is tachypnea, cyanosis, hypotension and tachycardia, chest
bloat and decreased vocal vibrations, reduction or abolition of breath sounds in the
thorax, and engorgement of the veins of cuello4.
The typical radiological picture is that of "empty chest" (lack of vascular imaging of the
affected side) and the lung retracted only appears as a stain on the hilum. The
intercostal spaces are widened and sunk diaphragm. You can also observe the
mediastinal shift to the opposite side and the corresponding deflection trquea4.
electrocardiographic changes (right shift the axis of the middle frontal QRS, inversion of
the T wave in precordial and decreased amplitude or alternating QRS) may exist, but
not related to the degree of pneumothorax or severity of sntomas7.
The fundamental thing is to remember that the diagnosis of tension pneumothorax is
clinical and the delay in toraconcentesis can cause the death of paciente6, so
treatment should not be delayed for further diagnostic tests (p. Ex. X) 7.
The purpose of processing in any type of pneumothorax is the resolution of symptoms
by evacuating air from the pleural space and get re-expansion of the lung; in
spontaneous pneumothorax it is also intended to prevent recidivas2. Tension
pneumothorax is an emergency and when suspecting should start administering
oxygen and perform thoracostomy aguja7.
Needle thoracostomy
The safer, easier and more reliable to decompress tension pneumothorax point is the
2nd intercostal space on the line medioclavicular7. Povidone iodine is applied to the
site of insertion of the needle, the needle with the dominant hand wields it and inserted
perpendicular to the skin just above the upper edge of the 3rd rib (this prevents injury
neurovascular bundle); the needle is advanced to hear the air outlet and the drain is
introduced. The needle (check that none of the brands remain visible) is removed.
catheter cap is removed and the metal connector on the 3-way stopcock is introduced.
The catheter is attached to the skin and connected to a suction system (or aspires to
50ml syringe); if possible, a check valve (Heimlich) is inserted for transporte7,8.
Needle thoracostomy should be completed as soon as possible with a definitive
thoracostomy tube.
Conclusion
Tension pneumothorax is a medical emergency that requires prompt action
diagnosticoteraputica doctor for the patient to survive.
Received July 8, 2009
Accepted December 16, 2009