RESPIRATORY EMERGENCY

PNEUMOTHORAKS
P E MB I MB I N G :
D R . A L I H A E D A R , S P E M
Bobby Laksana
Wahyu Wulandari
Rayu Sili D.
DEFINITION
The accumulation of air under pressure in the
pleural space lung collapse because of the
pressure.
EPIDEMIOLOGY
America 180,000 people died from lung
problems such as thoracic trauma, either as
direct or indirect.

United States:
primary spontaneous pneumothorax in each
year: men was 7.4 cases per 100,000 people
and female was 1.2 cases per 100,000 people
secondary spontaneous pneumothorax in
each year: men was 6.3 cases per 100,000
people and female was 2.0 women per 100,000
people


ETIOLOGY
Pneumothorax
Spontaneus
Primary Secondary
Traumatic
Iatrogenic
Interventional
Procedures
Positive
Pressure
Ventilation
Non Iatrogenic
Penetrating
Trauma
Blunt Trauma
RISK FACTOR
Age
Genetics
History
of
pneumo
thorax
Playing
hard
sport
Sex
Lung
disease
Smoking
Mechanic
ventilation
Changes in
atmospheric
pressure
History
of
fighting/
accident
HOW TO DIAGNOSE
Anamnesis
Physical
examination
Imaging
studies
Assessment
ANAMNESIS
Sudden chest pain
Shortness of breath
PHYSICAL EXAMINATION
Suppressed respiratory sounds
Impaired chest mobility
Hypersonoric percussion sounds
Tachycardia
Hypotension
Signs of injury
Tachypneu
IMAGING STUDIES
Chest x-ray
Chest computed
tomography
scanning
Chest
ultrasonography
MANAGEMENT
Non
Surgical
Needle
compression
Chest tube
Pleurodesis
Surgical
Sewing
blisters
closed
Lobectomy
Many people who have had one
pneumothorax can have another,
usually within one to two years of the
first. Air may sometimes continue to
leak if the opening in the lung won't
close. Surgery may eventually be
needed to close the air leak.
TENSION PNEUMOTHORAX
S I G N A N D S Y M P T O M M A N A G E M E N T
Immediate
treatment
needle
compression
Next step is the
same way as
another
pneumothorax
(for example:
insertion chest
tube)
Although laboratory and imaging
studies help determine a diagnosis,
tension pneumothorax primarily is a
clinical diagnosis based on patient
presentation.
ABG analysis does not replace
physical diagnosis, nor should
treatment be delayed while awaiting
results if symptomatic pneumothorax
is suspected
REMEMBER

A tension pneumothorax is an
emergency that requires urgent
treatment
CASE REPORT
17
PATIENTS IDENTITY
Name : Mr. S
Gender : male
Age : 66 years old
Address : Poncokusumo
Occupation : Unemployment
Reg. number : 1118xxxx
Body weight : 60 kg

Patient came to the emergency
department on June 9th, 2014.
Patient came to the emergency department due to chest
pain in right side which occurred about eight hours ago.
He also complain about the shortness of breath, open
wound at right lateral chest, right foot and head due to a
traffic accident. The patient was hit by a motorcycle while
walking and his head hit the streets. Nausea (-) vomit (-)
loss of consciousness (-).
History of past illness: there is no history of past illness,
including the lung disease.
SUMMARY OF CASE
Family history : unknown
History of medication : the patient not
taking any medication or herb
History of injury: Traffic accidents hit by
motorcycle while walking with his head
hit the road on the 9th June at 08.00 and
arrives at 15:30 o'clock
Upon the arrival at the emergency department, the patient
had chest pain in the right side with GCS 456, asymetric
chest wall when breathing, decreasing breathing sound
pulmo dextra, hyperresonance percussion thorax dextra,
open wound at right AAL, decreasing blood pressure (90/30
mmHg), increasing respiratory rate (28 times per minute),
increasing pulse rate (114 times per minute), cold and
clammy acral, CRT > 2 , increasing JVP (R+5 cmH2O), open
fracture cruris dextra and deformity digiti II sinistra

The patient was then placed at P1 and got O
2
10 lpm via
NRBM, needle decompression, sterile dressing with three
side taped for open wound in right chest, double IV lines with
line I IVFD NaCl 0,9 % 20cc/kgbw/h and line II IVFD NaCl 0,9
% 20cc/kgbw/h. Patient got fixation and splinting for his open
fracture at cruris dextra
From physical examination after initial treatment,
it was found that the patient looked stable with
relief chest pain, increased of blood pressure,
decreased of respiratory rate, pulse rate and
JVP. We also found vulnus appertum at
supraorbital with size 2x1 cm and at occipital
with size 3x1 cm, deformity digiti II sinistra,
splinted cruris dextra, and we still found
asymetrical in chest wall expansion,
decreased of breathing sound and
hyperresonance percussion on thorax dextra.

Then we did further diagnostic evaluation: ECG,
laboratory (complete blood count, faal
haemostatic, serum electrolyte, blood gas
analysis), and radiology (manus sinistra and
cruris dextra x-ray).
After performed the primary survey and
gave initial treatment for the patient, we
did secondary survey wich included
anamnesis, physical examination and
also further diagnostic evaluation.

From the summary of the case, we suspect
that the cause of the chest pain at right
side in this patient is due to tension
pneumothorax dextra.
PRIMARY SURVEY
A : patent, no additional breath sound, AVPU : alert
B : asymetric, respiratory rate 28 times per minute, ronki (-)
wheezing (-), decreased breathing sound pulmo dextra,
hyperresonance on percussion of thorax dextra
C: blood pressure 90/30 mmHg, pulse rate 114 times per
minute, cold and clammy acral, CRT > 2, JVP R+5
cmH20
D : GCS 456
E : open wound at right anterior axillary line, open fracture
cruris dextra, deformity digiti II sinistra

Patient then placed at P1

INITIAL TREATMENT
A : -
B : Oksigen NRBM 10 lpm, needle decompression
C : Line I : NaCl 0,9% 20cc/kgbw/h 1200cc/h
Line II : NaCl 0,9% 20cc/kgbw/h 1200cc/h
D : Sterile dressing with three side tape for open wound
at right chest, fixation and splinting cruris dextra
26
According to the theory, we initially treated
the patient in critical care area (P1) with
ECG, vital sign and O2 saturation
monitoring.
Patient with tension pneumothorax should
be given the initial treatment including
oxygenation, and the most important is
needle decompression. Sterile dressing with
three side taped also should be given to
prevent increasing the trapped air into the
pleural cavity


MANAGEMENT OF TENSION
PNEUMOTHORAX
At first, we distinguish whether the condition is tension
pneumothorax or not tension pneumothorax. So we can
suspect the patient to certain diagnosis with:
1. Presenting symptom of patient: chest pain in right
side after traffic accident and the shortness of breath
2. Physical examination: supressed respiratory sound,
impaired chest mobility, sign of injury, tachypneu,
tachycardia, hypersonoric percussion sound,
hypotension, increased jugular vein pressure
3. Imaging examination:
4. Monitoring: ECG, pulse oximetry, VS every 15-30 min.

MANAGEMENT OF TENSION
PNEUMOTHORAX
ECG
29
SINUS RHYTHM, HEART RATE 100 BPM
PR INTERVAL : 0,12
QRS COMPLEX : 0,08
QT INTERVAL : 0,4
FRONTAL AXIS : NORMAL
HORIZONTAL AXIS : CLOCKWISE ROTATION
CONCLUSION : NORMAL ECG WITH SINUS
RHYTHM 100 BPM
HASIL LABORATORIUM
HEMATOLOGI FAAL HEMOSTASIS
Hb 14,60
13,1-17,2 g/dl PPT
Pasien
INR

11,00
0,96

11,1 11,6
detik
0,8 1,30
Eritrocyte 5020 4000-5500/L
APTT
Pasien

21,40

28,9 30,6
detik
Leukocyte 22.310
4300-11.300/L
METABOLISME KARBOHIDRAT
Hematokrit 44,70 40 47 % GDS 168 < 200 mg/dL
Platelet 260.000 142.000-424.
000/L
SERUM ELECTROLYTE
MCV 69,00 80-93 fL Natrium 130
136-145
mmol/L
MCH 29,10 27-31 pg Kalium 4,06
3,5-5,5 mmol/L
Eo/Ba/Neu/
Lim/Mo
0,3/0,2/89,6/
6,4/3,5
0-4/0-1/51-67/25-
33/2-5 %
Klorida 111
96-106 mmol/L
30
BLOOD GAS ANALYSIS (NRBM 10 lpm)
pH 7,26 7,35-7,45
pCO2 41,0 35-45 mmHg
pO2 161,3 80-100 mmHg
Bikarbonat (HCO3) 18,5 21-28 mmol/L
Kelebihan basa (BE) -8,8 (-3) (+3) mmol/L
Saturasi O2 99,2 % > 95%
Hb 14,6 g/dL
Suhu 37,0 C
31
FOTO MANUS
32
FOTO CRURIS
33
Immediate Management tension pneumothorax:
1. IV access
2. Apply oxygen to maintain SPO2 94%
3. Do the needle decompression
4. Close the open chest wound with three side taped
sterile dressing
After performed the primary survey and gave initial
treatment for the patient, we did SECONDARY
SURVEY which include anamnesis, physical
examination and also further diagnostic evaluation.
From the summary of the case that patient have chest
pain with shortness of breath after the traffic
accident and open wound at right anterior axillary
line.
So, we did further diagnostic evaluation such as chest
x-ray after we gave urgent treatment like needle
decompression for his pneumothorax.

ASSESSMENT
Open fracture cruris dextra
Tension Pneumothorax dextra


Dispose to surgery departement
36
FOTO THORAX
37
AP position, symmetric,
trachea shift to the right,
enough KV, less
inspiration, bone and
soft tissue normal, left
and right
hemidiaphragm
domeshaped, left and
right phrenico costalis
angle was sharp, pulmo
was normal, aorta
sclerosis, no infiltrate,
BVP right side was
increase and BVP left
side was normal, cor
size, site and shape was
normal, CTR 66%.
Conclussion :
SPECIAL TIPS FOR GP
Always consider the diagnosis of tension
pneumothorax in a patient with signs of simple
pneumothorax, haemodynamic instability,
severe respiratory distress and neck vein
distension.
Immediately perform needle thoracostomy,
preferably with a large bore 14/16 G IV venula at
the 2nd intercostal space midclavicular line.
A delay in performing this procedure will cause
the patient to die! A wrong diagnosis will at
most cause patient to have chest tube insertion
but will not kill a patient!
Guide to the Essentials in Emergency Medicine, 2004
39