The management of major injuries
Ashley W. Blom, David Warwick, Michael R. Whitehouse in Apley and Solomon’s System of Orthopaedics and Trauma, 2017
Positive-pressure ventilation is likely to accelerate the conversion of a simple pneumothorax into a tension pneumothorax. If the casualty is intubated and ventilated and a pneumothorax suspected, a simple, open thoracostomy is made in the fifth intercostal space, anterior to the midaxillary line. This allows a tension pneumothorax to decompress; however, the lung can still be inflated as the casualty is being ventilated and so this procedure can be performed bilaterally if indicated. A thoracostomy is made by making a 3 cm horizontal incision immediately above the sixth rib, just anterior to the midaxillary line, dissecting the subcutaneous tissues with large, straight Spencer Wells forceps until the chest cavity is entered. A finger is used to open up the thoracostomy and ensure no vital structures are felt.
Pediatric abdominal trauma
David E. Wesson, Bindi Naik-Mathuria in Pediatric Trauma, 2017
Management of children with diaphragmatic trauma is operative, but in hemodynamically stable patients initial resuscitation and appropriate intervention for accompanying injuries should precede the surgical exploration. Nasogastric tube placement can allow for gastric decompression and maintain adequate lung expansion until the operation. Chest tube placement should be avoided if at all possible. There is a risk of injury to abdominal organs with tube thoracostomy. Diaphragmatic repair can be approached laparoscopically or via an open laparotomy depending on the operator’s comfort level. A thorough examination of the abdomen should be undertaken at the time of repair. For most injuries, direct suture repair is appropriate after debridement of devitalized tissue. In the setting of extensive destruction when a direct repair would result in tension on the suture line, a muscle flap or prosthetic mesh can be utilized. Obstruction, intestinal necrosis, sepsis, and death may all be sequelae of diaphragmatic hernia if it is missed.
Congenital malformations of the lung
Prem Puri in Newborn Surgery, 2017
If identified prenatally, postnatal excision is recommended. This can generally be done between 4 and 6 months of age.63 However, acute respiratory decompensation from a large tense bronchogenic or lung cyst may necessitate needle or chest tube thoracostomy as a temporizing measure. Preexisting pneumonias should be treated with preoperative antibiotics. Thereafter, patients can be treated with surgical resection, enucleation, or lobectomy.9 In patients with stable cysts, simple cystectomy should be performed with oversewing or stapling of any anomalous bronchial communications (Figure 42.7). If a bronchogenic cyst cannot be removed in its entirety, remaining portions of cyst wall may be destroyed with electrocautery. Generally, lateral thoracotomy or thoracoscopy is employed for management of these lesions, although median sternotomy may be appropriate for certain central lesions.62 The thoracoscopic approach has been used successfully in recent years and may be associated with shorter duration of thoracostomy drainage and hospital stay.50,63
An occult iatrogenic pneumothorax as a cosmetic procedure complication
Published in Baylor University Medical Center Proceedings, 2023
Alejandro José Quiroz Alfaro, Cara East, Iván Javier Rodríguez Acosta, Roberto Eduardo Quiroz Simanca
The next day, the patient presented with sudden-onset dyspnea, tachycardia, and mild mesogastric tenderness without peritoneal irritation. A chest x-ray showed bibasal alveolar-reticular infiltrates and right basal atelectasis (Figure 1a). Her oxygen saturation was 91%, and an arterial blood gas showed respiratory alkalosis with moderate hypoxemia on a 32% fraction of inspired oxygen (partial pressure of oxygen in the arterial blood, 56 mm Hg; ratio of arterial oxygen partial pressure to fractional inspired oxygen, 175); the D-dimer was 1167 ng/mL. The patient was immediately transferred to the intensive care unit. Pulmonary embolism protocol CT angiography showed a left-sided 35% pneumothorax, with no evidence of pulmonary embolism or fat embolism (Figure 1b). An abdominal ultrasound was normal. A left-sided chest tube was inserted, and the marked hypoxemia and acute respiratory failure resolved. After 48 hours, chest CT showed small residual pneumothorax with complete left lung reexpansion. The thoracostomy tube was removed, and the patient was discharged.
Complications from Needle Thoracostomy: Penetration of the Myocardium
Published in Prehospital Emergency Care, 2021
Arielle Thomas, K. Hope Wilkinson, Kevin Young, Timothy Lenz, Jillian Theobald
Needle thoracostomy is a potentially life-saving intervention performed when there is suspicion of a tension pneumothorax. A tension pneumothorax occurs when air rapidly accumulates in the extra-pleural space, which can result in respiratory distress and eventual cardiopulmonary arrest (1). Patients are usually treated based on a mechanism capable of causing a pneumothorax and the clinical picture of unequal breath sounds, decreased compliance during ventilation, and in more serious cases, hypotension (2, 3). The standard intervention is a 14-gauge angiocatheter that is placed in the second intercostal space at the MCL, however some teach placement in a lateral position, at the AAL at the 4th rib space, similar to tube thoracostomy. Needle thoracostomy is a temporizing procedure which must be exchanged for tube thoracostomy at the soonest availability.
Bilateral pneumatoceles resulting in spontaneous bilateral pneumothoraces and secondary infection in a previously healthy man with COVID-19
Published in Baylor University Medical Center Proceedings, 2021
Piruthiviraj Natarajan, James Skidmore, Olufemi Aduroja, Vamsi Kunam, Dan Schuller
The patient presented 2 days later with worsening dyspnea, increasing oxygen requirement, and hemoptysis. Chest film revealed a large left tension pneumothorax, small right pneumothorax, pneumomediastinum, and subcutaneous emphysema (Figure 2). He underwent an emergent left thoracostomy tube placement. Subsequent CT scan of the chest showed resolving pneumothoraces, extensive bilateral necrotizing pneumonia with pneumatoceles, and large cysts with air fluid levels (Figure 1b). The sputum culture grew K. aerogenes and P. aeruginosa; the antimicrobials were narrowed to cefepime. He subsequently underwent two separate left-sided chemical pleurodesis at the bedside with intrapleural doxycycline 4 days apart, as the first attempt resulted only in partial resolution. He was discharged home after a 16-day hospital stay to complete a total of 3 weeks of IV cefepime and was subsequently switched to oral ciprofloxacin for 3 months until near complete radiological resolution of the air fluid levels in the pneumatoceles (Figure 1c). Several months from his initial presentation, the patient is still convalescent at home and requires supplemental oxygen with minimal activity. Repeat CT of the chest during an outpatient visit is shown in Figure 1d.
Related Knowledge Centers
- Contraindication
- Incision & Drainage
- Latissimus Dorsi Muscle
- Thoracentesis
- Thoracic Wall
- Thoracotomy
- Pleural Cavity
- Pneumothorax
- Incision & Drainage
- Chest Tube
- Coagulopathy