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Mayahara T, Katayama T, Higashi Y, Asano J, Sugimoto T. Position-Dependent Symptoms of Pneumothorax During Mechanical Ventilation: A Case Report. Cureus 2023; 15:e50820. [PMID: 38249264 PMCID: PMC10797467 DOI: 10.7759/cureus.50820] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/20/2023] [Indexed: 01/23/2024] Open
Abstract
A 54-year-old male with severe hypoxia was transferred to our hospital after choking on a mochi. Chest computed tomography revealed negative pressure pulmonary edema without pneumothorax. Endotracheal intubation was performed, and pressure-controlled ventilation was initiated. Following admission to the intensive care unit, his respiratory condition was stable in both the supine and left decubitus positions. However, every time he was placed in the right decubitus position, the tidal volume decreased by half, and SpO₂ dropped rapidly to 80%, which recovered soon after returning to the supine position. Chest radiography was performed the following day, revealing grade II right pneumothorax, and a chest tube placement stabilized his respiratory status in the right decubitus position. Air leakage ceased within a few hours. Extubation was successful on the fifth hospital day, and the chest tube was removed on the eighth hospital day. To our knowledge, there are no previous reports on position-dependent symptoms of pneumothorax during mechanical ventilation. Clinicians should consider the possibility of pneumothorax on that same side when respiratory deterioration is observed only in one lateral decubitus position during mechanical ventilation.
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Affiliation(s)
- Taku Mayahara
- Emergency Medicine, Kōbe Ekisaikai Hospital, Kobe, JPN
| | | | - Yuki Higashi
- Emergency Medicine, Kōbe Ekisaikai Hospital, Kobe, JPN
| | - Jun Asano
- Emergency Medicine, Kōbe Ekisaikai Hospital, Kobe, JPN
| | - Takashi Sugimoto
- Emergency Medicine, Kobe University Graduate School of Medicine, Kobe, JPN
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2
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Ki S, Choi B, Cho SB, Hwang S, Lee J. Unexpected Tension Pneumothorax Developed during Anesthetic Induction Aggravated by Positive Pressure Ventilation: A Case Report. MEDICINA (KAUNAS, LITHUANIA) 2023; 59:1631. [PMID: 37763751 PMCID: PMC10535224 DOI: 10.3390/medicina59091631] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/09/2023] [Revised: 08/23/2023] [Accepted: 09/07/2023] [Indexed: 09/29/2023]
Abstract
Background and Objectives: Tension pneumothorax is a life-threatening emergency condition that requires immediate diagnosis and intervention. However, due to the non-specific symptoms and the rarity of its occurrence during surgery, anesthesiologists encounter difficulties in promptly diagnosing tension pneumothorax when it arises intraoperatively. Diagnosing tension pneumothorax can become even more challenging in unexpected situations in patients with normal preoperative evaluation for general anesthesia. Materials and Methods, Results: We report the case of a 66-year-old woman who underwent general anesthesia for oblique lateral interbody fusion surgery of her lumbar spine. Though she did not have any respiratory symptoms prior to the induction of anesthesia, auscultation following endotracheal intubation indicated decreased breathing sound in the left hemithorax of the chest. Subsequently, her vital signs showed tachycardia, hypotension, and hypoxemia, and the ventilator indicated a gradual increase in the airway pressure. We verified the proper depth of the endotracheal tube to exclude one-lung ventilation, and, in the meantime, learned that there had been unsuccessful attempts at left subclavian venous catheterization by the surgical department on the previous day. Tension pneumothorax was diagnosed through portable chest radiography in the operating room, and needle thoracostomy and chest tube insertion were performed immediately, which in turn stabilized her vital signs and airway pressure. The surgery was uneventful, and the chest tube was removed one week later after evaluation by the cardiothoracic department. The patient was discharged from hospital on postoperative day 14 without known complications. Conclusions: Anesthesiologists should be aware of the conditions and risk factors that may cause tension pneumothorax and remain vigilant for signs of its development throughout surgery, even for patients who show normal preoperative assessments. An undetected small pneumothorax without any symptoms can progress to tension pneumothorax through positive pressure ventilation during general anesthesia, posing a life-threatening situation. If a tension pneumothorax is highly suspected through clinical assessments, its prompt differentiation and timely diagnosis are crucial, allowing for rapid intervention to stabilize vital signs.
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Affiliation(s)
| | | | | | | | - Jeonghan Lee
- Department of Anesthesiology and Pain Medicine, Busan Paik Hospital, Inje University College of Medicine, Busan 47392, Republic of Korea; (S.K.); (B.C.); (S.B.C.); (S.H.)
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3
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Quantitative Measurement of Pneumothorax Using Artificial Intelligence Management Model and Clinical Application. Diagnostics (Basel) 2022; 12:diagnostics12081823. [PMID: 36010174 PMCID: PMC9406694 DOI: 10.3390/diagnostics12081823] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2022] [Revised: 07/16/2022] [Accepted: 07/26/2022] [Indexed: 11/23/2022] Open
Abstract
Artificial intelligence (AI) techniques can be a solution for delayed or misdiagnosed pneumothorax. This study developed, a deep-learning-based AI model to estimate the pneumothorax amount on a chest radiograph and applied it to a treatment algorithm developed by experienced thoracic surgeons. U-net performed semantic segmentation and classification of pneumothorax and non-pneumothorax areas. The pneumothorax amount was measured using chest computed tomography (volume ratio, gold standard) and chest radiographs (area ratio, true label) and calculated using the AI model (area ratio, predicted label). Each value was compared and analyzed based on clinical outcomes. The study included 96 patients, of which 67 comprised the training set and the others the test set. The AI model showed an accuracy of 97.8%, sensitivity of 69.2%, a negative predictive value of 99.1%, and a dice similarity coefficient of 61.8%. In the test set, the average amount of pneumothorax was 15%, 16%, and 13% in the gold standard, predicted, and true labels, respectively. The predicted label was not significantly different from the gold standard (p = 0.11) but inferior to the true label (difference in MAE: 3.03%). The amount of pneumothorax in thoracostomy patients was 21.6% in predicted cases and 18.5% in true cases.
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4
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Kim KH. Tension Pneumothorax after Attempting Insertion of a Central Venous Catheter. Acute Crit Care 2019; 33:280-281. [PMID: 31723898 PMCID: PMC6849031 DOI: 10.4266/acc.2017.00598] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2017] [Revised: 04/21/2018] [Accepted: 08/17/2018] [Indexed: 11/30/2022] Open
Affiliation(s)
- Ki Hoon Kim
- Department of Surgery, Inje University Haeundae Paik Hospital, Inje University College of Medicine, Busan, Korea
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5
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Devia Jaramillo G, Torres Castillo J, Lozano F, Ramírez A. Ultrasound-guided central venous catheter placement in the emergency department: experience in a hospital in Bogotá, Colombia. Open Access Emerg Med 2018; 10:61-65. [PMID: 29872354 PMCID: PMC5973354 DOI: 10.2147/oaem.s150966] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Introduction The use of central venous catheters (CVCs) in the emergency room (ER) is a valuable tool for the comprehensive management of critically ill patients; however, the positioning of these devices is not free of complications. Currently, the use of ultrasound is considered a useful and safe tool to carry out these procedures, but in Colombia, the number of emergency departments providing this tool is scarce and there is no literature describing the experience in our country. Objective The objective of this study was to describe the experience regarding placement of ultrasound-guided CVCs by emergency physicians in an institution in Bogotá, as well as the associated complications. Materials and methods This is a descriptive cross-sectional retrospective study. Medical records of 471 patients requiring insertion of CVCs in the resuscitation area from January 2014 to December 2014 were reviewed. Insertion site and complications are described. Results For 471 total cases, the average age of patients was 68.6 years, the most frequent diagnosis was sepsis (30.7%), the preferred route of insertion was the right internal jugular vein, and insertion was successful at the first attempt in 85.9% of patients. Pneumothorax was the most common complication (1.2%), followed by extensive hematoma and infection. Conclusion Insertion of ultrasound-guided CVCs by emergency physicians is a safe procedure that involves complications similar to those reported in the literature; it is necessary to expand the use of ultrasound-guided CVCs in ERs.
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Affiliation(s)
- German Devia Jaramillo
- Emergency Medicine Department, Universidad del Rosario, Resuscitation Unit, Hospital Universitario Mayor Méderi, Bogotá, Colombia
| | - Jenny Torres Castillo
- Emergency Medicine Department, Universidad del Rosario, Resuscitation Unit, Hospital Universitario Mayor Méderi, Bogotá, Colombia
| | - Freddy Lozano
- Resuscitation Unit, University Hospital Mayor Méderi, Bogotá, Colombia
| | - Angélica Ramírez
- Resuscitation Unit, University Hospital Mayor Méderi, Bogotá, Colombia
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6
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Colì L, Donati G, Galaverni M, Golfieri R, Raimondi C, Cianciolo G, Comai G, Piccari M, Rossi C, Stefoni S. Jugular Vein-Mammary Artery Fistula after Catheterism for Hemodialysis: Case Report. J Vasc Access 2018. [DOI: 10.1177/112972980700800209] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
The demographic characteristics of hemodialysis (HD) patients increase the need for the tunneled cuffed permanent catheter (TCC) as a definitive vascular access (VA) for HD. The internal jugular vein is increasingly being used as a route for TCC or temporary catheter placement and can be associated with serious complications. Among them other authors have described arteriovenous fistula (AVF) creation between the common carotid artery and the right jugular vein. We describe a case of an AVF between the right internal jugular vein and the right internal mammary artery. The fistula was detected during the TCC placement in a patient who underwent several jugular and subclavian catheterisms for HD in her clinical history.
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Affiliation(s)
- L. Colì
- Nephrology Dialysis and Renal Transplantation Unit, S. Orsola University Hospital, Bologna - Italy
| | - G. Donati
- Nephrology Dialysis and Renal Transplantation Unit, S. Orsola University Hospital, Bologna - Italy
| | | | - R. Golfieri
- Radiology Unit, Malpighi Hospital, Bologna - Italy
| | - C. Raimondi
- Nephrology Dialysis and Renal Transplantation Unit, S. Orsola University Hospital, Bologna - Italy
| | - G. Cianciolo
- Nephrology Dialysis and Renal Transplantation Unit, S. Orsola University Hospital, Bologna - Italy
| | - G. Comai
- Nephrology Dialysis and Renal Transplantation Unit, S. Orsola University Hospital, Bologna - Italy
| | - M. Piccari
- Nephrology Dialysis and Renal Transplantation Unit, S. Orsola University Hospital, Bologna - Italy
| | - C. Rossi
- Department of Radiology, S. Orsola University Hospital, Bologna - Italy
| | - S. Stefoni
- Nephrology Dialysis and Renal Transplantation Unit, S. Orsola University Hospital, Bologna - Italy
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7
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Cavatorta F, Zollo A, Galli S, Mij M, Dolla D. Ultrasound-Guided Cannulation and Endocavitary Electrocardiography Placement of Internal Jugular Vein Catheters in Uremic Patients: The Importance of Routine Chest X-Ray Evaluation. J Vasc Access 2018; 2:37-9. [PMID: 17638257 DOI: 10.1177/112972980100200202] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
The NKF-DOQI guidelines recommend performing chest-X-ray(CXR) after subclavian and internal jugular vein insertion prior to catheter use. This is to exclude complications such as a pneumothorax before starting hemodialysis. Indication of a central venous dialysis catheter was based on the historic use of the subclavian vein for placement of these catheters and upon the reported incidence of pneumothorax after this approach of between 1% to 12.4%. In contrast, the incidence of these complications using the internal jugular vein (IJV) is much lower (< 1%). We report our experience in ultrasound-guided cannulation of the right IJV for dialysis vascular access in 527 uremic patients and central catheter placement by endocavitary electrocardiography (EC-ECG). Fluoroscopy was not utilized. In the first hundred cases, all patients underwent CXR. Subsequently, because of total absence of complications and catheter tip malpositioning, the CXR control was carried out only in selected cases (repeated cannulation of the jugular vein or absence of P wave). We believe that only in selected cases should a pCXR be performed before starting hemodialysis sessions, and that our method using the right IJV, ultrasound-guided puncture of the vessel, and catheter placement by EC-ECG is a safe and simple technique that avoids the need for CXR control.
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Affiliation(s)
- F Cavatorta
- Department of Nephrology and Dialysis, General Hospital, Imperia - Italy
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8
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Cavatorta F, Zollo A, Galli S, Dolla D. Real-Time Ultrasound and Endocavitary Electrocardiography for Venous Catheter Placement. J Vasc Access 2018; 2:40-4. [PMID: 17638258 DOI: 10.1177/112972980100200203] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
The authors report on their experience with internal jugular vein catheterization with temporary and tunnelled cuffed hemodialysis catheters in 527 patients from 1991 to 2001, using ultrasound guidance and monitoring of catheter placement by endocavitary electrocardiography. The incidence of successful puncture and cannulation using ultrasound was 99.62%. The majority of patients had catheters inserted on the first pass (93%) and fewer attempts were required (range, 2 to 5). In the first year of the procedure in 1991, we observed two cases of accidental puncture of the carotid artery because of an error in ultrasound localization of the neck vessel. Arrhythmias were not observed during this procedure. Right atrial electrocardiography was successful on 504 occasions (96.83%), and correct catheter placement was confirmed by plain chest-X-ray in the first 100 patients. The results confirm that real-time ultrasound guidance for catheter insertion is superior to traditional techniques relying on anatomic landmarks and should be adopted as the standard of care. Ultrasound guidance and EC-ECG improves both the success and the safety of internal jugular catheter insertion. The authors propose that EC-ECG be validated as a technique in compliance with recent Food and Drug Administration guidelines regarding the location of central venous catheter tips.
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Affiliation(s)
- F Cavatorta
- Department of Nephrology and Dialysis, General Hospital, Imperia - Italy
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9
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Giacomini M, Iapichino G, Armani S, Cozzolino M, Brancaccio D, Gallieni M. How to avoid and manage a pneumothorax. J Vasc Access 2018; 7:7-14. [PMID: 16596523 DOI: 10.1177/112972980600700103] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023] Open
Abstract
Pneumothorax is one of the most frequent complications during percutaneous central vascular cannulation. When choosing a site for central vascular access, the internal jugular vein is preferable to other vessels, for the lower frequency of related complications, including pneumothorax. This review intends to summarize the current state of the art on how to avoid and, if it occurs, to manage this rare but relevant complication. In order to prevent pneumothorax, as well as other relevant complications of central vein cannulation, it is advisable to use ultrasound guidance whenever possible. If pneumothorax occurs, it is important to recognize its signs and symptoms. To exclude the presence of asymptomatic pneumothorax, in the normal clinical routine a chest X-ray should be obtained within 4 hours from the procedure of central vein cannulation of subclavian and internal jugular veins. If promptly recognized, pneumothorax can be managed quickly and in a relatively easy way. Depending on its size and symptoms, and in particular when a tension pneumothorax is supected, treatment can vary from simple observation to a chest tube insertion or, in the latter case, to an emergency thoracentesis needle insertion in the pleural space.
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Affiliation(s)
- M Giacomini
- Anesthesia and Intensive Care Department, San Paolo Hospital, Milano; Universita' degli Studi di Milano, Italy
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10
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Siu AYC, Chung CH. Can Tension Haemopneumothorax Have Stable Haemodynamics? HONG KONG J EMERG ME 2017. [DOI: 10.1177/102490790301000109] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Tension pneumothorax or haemopneumothorax is a clinical diagnosis. Plain radiography is not advised to confirm the diagnosis and may delay definitive treatment. Unstable haemodynamics is one of the prerequisites for the diagnosis. We report a case in which the patient suffered from haemopneumothorax with all the typical radiological features of tension, but without any clinical sign of unstable haemodynamics. Close monitoring of patients suspected to have pneumothorax is recommended, especially in the radiology suite.
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Affiliation(s)
- AYC Siu
- North District Hospital, Accident and Emergency Department, 9 Po Kin Road, Sheung Shui, N.T., Hong Kong
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11
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Bensghir M, Moutaoukil M, Meziane M, Jaafari A, Hemmaoui B, Haimeur C. [Occult pneumothorax: Does it take drain before elective surgery?]. REVUE DE PNEUMOLOGIE CLINIQUE 2016; 72:259-263. [PMID: 27113614 DOI: 10.1016/j.pneumo.2015.12.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/16/2015] [Revised: 11/06/2015] [Accepted: 12/21/2015] [Indexed: 06/05/2023]
Abstract
Pneumothorax occult is defined by the presence of a non-visible to standard asymptomatic pneumothorax and pulmonary diagnosed only by X-ray computed tomography. The presence of this type of pneumothorax before planned surgery is a rare situation. What to do remains non-consensual. Through two clinic cases and a literature review, the authors discuss the modalities of management of this entity.
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Affiliation(s)
- M Bensghir
- Pôle anesthésie-réanimation, hôpital militaire Mohammed V, Rabat, Maroc; Université Mohammed V Souissi, Rabat, Maroc.
| | - M Moutaoukil
- Pôle anesthésie-réanimation, hôpital militaire Mohammed V, Rabat, Maroc; Université Mohammed V Souissi, Rabat, Maroc
| | - M Meziane
- Pôle anesthésie-réanimation, hôpital militaire Mohammed V, Rabat, Maroc; Université Mohammed V Souissi, Rabat, Maroc
| | - A Jaafari
- Pôle anesthésie-réanimation, hôpital militaire Mohammed V, Rabat, Maroc; Université Mohammed V Souissi, Rabat, Maroc
| | - B Hemmaoui
- Service d'ORL, hôpital militaire Mohammed V, Rabat, Maroc; Université Mohammed V Souissi, Rabat, Maroc
| | - C Haimeur
- Pôle anesthésie-réanimation, hôpital militaire Mohammed V, Rabat, Maroc; Université Mohammed V Souissi, Rabat, Maroc
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12
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Szarpak L, Mateo RG, Marchese G, Czyzewski L, Kurowski A, Smereka J, Truszewski Z. Ultrasonography as a tool for prehospital recognition of tension pneumothorax. Am J Emerg Med 2016; 34:1302-3. [DOI: 10.1016/j.ajem.2016.03.069] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2016] [Revised: 03/26/2016] [Accepted: 03/27/2016] [Indexed: 11/24/2022] Open
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13
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Vallabhajosyula S, Sundaragiri PR, Berim IG. Boerhaave Syndrome Presenting as Tension Pneumothorax: First Reported North American Case. J Intensive Care Med 2015; 31:349-52. [PMID: 26395053 DOI: 10.1177/0885066615606698] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2015] [Accepted: 08/27/2015] [Indexed: 11/16/2022]
Abstract
Tension pneumothorax is a rare and potentially life-threatening clinical complication. A 43-year-old Caucasian woman with type 1 diabetes mellitus presented with nausea and retching and examination revealed dehydration. Laboratory parameters were consistent with a diagnosis of diabetic ketoacidosis, which responded to therapy. Suddenly, 30 hours later, she developed cardiorespiratory compromise due to a tension pneumothorax. After emergent decompression and catheter placement, computerized tomographic scan of the chest demonstrated esophageal-pleural fistula confirming Boerhaave syndrome as the etiology for the pneumothorax. The patient underwent emergent esophagectomy with pleural washout with a subsequent gastric pull-up surgery. Boerhaave syndrome frequently presents atypically with chest pain, dyspnea, and nausea. It communicates with the left pleural space in 80% to 90% of cases, but <5% of cases involve the right pleural cavity. Unexplained and rapidly progressive pleural effusions have been associated with this entity. Only 4 cases of Boerhaave syndrome causing tension pneumothorax have been reported in the literature so far.
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Affiliation(s)
- Saraschandra Vallabhajosyula
- Division of Critical Care Medicine, Department of Internal Medicine, Mayo Clinic College of Medicine, Rochester, MN, USA
| | - Pranathi R Sundaragiri
- Division of Hospital Internal Medicine, Department of Internal Medicine, Mayo Clinic College of Medicine, Rochester, MN, USA
| | - Ilya G Berim
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Internal Medicine, Creighton University School of Medicine, Omaha, NE, USA
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Vinson DR, Ballard DW, Hance LG, Stevenson MD, Clague VA, Rauchwerger AS, Reed ME, Mark DG. Pneumothorax is a rare complication of thoracic central venous catheterization in community EDs. Am J Emerg Med 2015; 33:60-6. [DOI: 10.1016/j.ajem.2014.10.020] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2014] [Revised: 10/08/2014] [Accepted: 10/09/2014] [Indexed: 10/24/2022] Open
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15
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FRYKHOLM P, PIKWER A, HAMMARSKJÖLD F, LARSSON AT, LINDGREN S, LINDWALL R, TAXBRO K, ÖBERG F, ACOSTA S, ÅKESON J. Clinical guidelines on central venous catheterisation. Swedish Society of Anaesthesiology and Intensive Care Medicine. Acta Anaesthesiol Scand 2014; 58:508-24. [PMID: 24593804 DOI: 10.1111/aas.12295] [Citation(s) in RCA: 130] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/27/2014] [Indexed: 12/17/2022]
Abstract
Safe and reliable venous access is mandatory in modern health care, but central venous catheters (CVCs) are associated with significant morbidity and mortality, This paper describes current Swedish guidelines for clinical management of CVCs The guidelines supply updated recommendations that may be useful in other countries as well. Literature retrieval in the Cochrane and Pubmed databases, of papers written in English or Swedish and pertaining to CVC management, was done by members of a task force of the Swedish Society of Anaesthesiology and Intensive Care Medicine. Consensus meetings were held throughout the review process to allow all parts of the guidelines to be embraced by all contributors. All of the content was carefully scored according to criteria by the Oxford Centre for Evidence-Based Medicine. We aimed at producing useful and reliable guidelines on bleeding diathesis, vascular approach, ultrasonic guidance, catheter tip positioning, prevention and management of associated trauma and infection, and specific training and follow-up. A structured patient history focused on bleeding should be taken prior to insertion of a CVCs. The right internal jugular vein should primarily be chosen for insertion of a wide-bore CVC. Catheter tip positioning in the right atrium or lower third of the superior caval vein should be verified for long-term use. Ultrasonic guidance should be used for catheterisation by the internal jugular or femoral veins and may also be used for insertion via the subclavian veins or the veins of the upper limb. The operator inserting a CVC should wear cap, mask, and sterile gown and gloves. For long-term intravenous access, tunnelled CVC or subcutaneous venous ports are preferred. Intravenous position of the catheter tip should be verified by clinical or radiological methods after insertion and before each use. Simulator-assisted training of CVC insertion should precede bedside training in patients. Units inserting and managing CVC should have quality assertion programmes for implementation and follow-up of routines, teaching, training and clinical outcome. Clinical guidelines on a wide range of relevant topics have been introduced, based on extensive literature retrieval, to facilitate effective and safe management of CVCs.
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Affiliation(s)
- P. FRYKHOLM
- Department of Surgical Sciences; Anaesthesiology and Intensive Care Medicine; University Hospital; Uppsala University; Uppsala Sweden
| | - A. PIKWER
- Department of Clinical Sciences Malmö; Anaesthesiology and Intensive Care Medicine; Skåne University Hospital; Lund University; Malmö Sweden
| | - F. HAMMARSKJÖLD
- Department of Anaesthesiology and Intensive Care Medicine; Ryhov County Hospital; Jönköping Sweden
- Division of Infectious Diseases; Department of Clinical and Experimental Medicine; Faculty of Health Sciences; Linköping University; Linköping Sweden
| | - A. T. LARSSON
- Department of Anaesthesiology and Intensive Care Medicine; Gävle-Sandviken County Hospital; Gävle Sweden
| | - S. LINDGREN
- Department of Anaesthesiology and Intensive Care Medicine; Institute of Clinical Sciences; Sahlgrenska Academy; University of Gothenburg; Gothenburg Sweden
| | - R. LINDWALL
- Department of Clinical Sciences; Division of Anaesthesiology and Intensive Care Medicine; Karolinska Institute; Danderyd University Hospital; Stockholm Sweden
| | - K. TAXBRO
- Department of Anaesthesiology and Intensive Care Medicine; Ryhov County Hospital; Jönköping Sweden
| | - F. ÖBERG
- Department of Anaesthesiology and Intensive Care Medicine; Karolinska University Hospital Solna; Stockholm Sweden
| | - S. ACOSTA
- Department of Clinical Sciences Malmö; Vascular Centre; Skåne University Hospital; Lund University; Malmö Sweden
| | - J. ÅKESON
- Department of Clinical Sciences Malmö; Anaesthesiology and Intensive Care Medicine; Skåne University Hospital; Lund University; Malmö Sweden
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Gauss A, Tugtekin I, Georgieff M, Dinse-Lambracht A, Keipke D, Gorsewski G. Incidence of clinically symptomatic pneumothorax in ultrasound-guided infraclavicular and supraclavicular brachial plexus block. Anaesthesia 2014; 69:327-36. [DOI: 10.1111/anae.12586] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/29/2013] [Indexed: 12/21/2022]
Affiliation(s)
- A. Gauss
- Department of Anaesthesiology; University of Ulm; Ulm Germany
| | - I. Tugtekin
- Department of Anaesthesiology; University of Ulm; Ulm Germany
| | - M. Georgieff
- Department of Anaesthesiology; University of Ulm; Ulm Germany
| | | | - D. Keipke
- Department of Anaesthesiology; University of Ulm; Ulm Germany
| | - G. Gorsewski
- Department of Anaesthesiology; University of Ulm; Ulm Germany
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17
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Hasegawa I, Heinemann A, Tzikas A, Vogel H, Püschel K. Criminal gunshot wound and iatrogenic tension pneumothorax detected by post-mortem computed tomography. Leg Med (Tokyo) 2014; 16:154-6. [PMID: 24630902 DOI: 10.1016/j.legalmed.2014.02.005] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2014] [Revised: 02/12/2014] [Accepted: 02/13/2014] [Indexed: 01/23/2023]
Abstract
Post-mortem imaging at autopsy is gradually increasing in popularity among forensic practitioners. The objective of the present paper was to demonstrate that it is essential to survey the cadaver using computed tomography (CT) before autopsy. This case report presents an iatrogenic tension pneumothorax caused by left subclavian vein puncture undertaken during treatment for a gunshot-related wound. The victim, a 64-year-old woman, was shot by her husband at home, and transferred to the hospital emergency unit. Before surgical procedures were carried out, left subclavian vein puncture was performed; however, during the operation, the victim experienced sudden cardiac arrest. Subsequent intensive resuscitation was unsuccessful. The clinical cause of death was recorded as traumatic shock caused by the gunshot injury. However, before the legal autopsy took place, CT clarified the existence of tension pneumothorax not on the same side as the gunshot wound, but on the side of the iatrogenic subclavian vein puncture. Because of this information gained prior to legal dissection, a typical dissection procedure for tension pneumothorax could be performed. Post-mortem imaging prior to regular dissection is essential as an adjunct diagnostic tool.
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Affiliation(s)
- Iwao Hasegawa
- Department of Legal Medicine, University Medical Center Hamburg-Eppendorf, 22529 Hamburg, Germany.
| | - Axel Heinemann
- Department of Legal Medicine, University Medical Center Hamburg-Eppendorf, 22529 Hamburg, Germany
| | - Antonios Tzikas
- Department of Legal Medicine, University Medical Center Hamburg-Eppendorf, 22529 Hamburg, Germany
| | - Hermann Vogel
- Department of Legal Medicine, University Medical Center Hamburg-Eppendorf, 22529 Hamburg, Germany
| | - Klaus Püschel
- Department of Legal Medicine, University Medical Center Hamburg-Eppendorf, 22529 Hamburg, Germany
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Zaghal A, Khalife M, Mukherji D, El Majzoub N, Shamseddine A, Hoballah J, Marangoni G, Faraj W. Update on totally implantable venous access devices. Surg Oncol 2012; 21:207-15. [DOI: 10.1016/j.suronc.2012.02.003] [Citation(s) in RCA: 56] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2011] [Revised: 01/17/2012] [Accepted: 02/10/2012] [Indexed: 11/26/2022]
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Aukema TS, Beenen LFM, Hietbrink F, Leenen LPH. Initial assessment of chest X-ray in thoracic trauma patients: Awareness of specific injuries. World J Radiol 2012; 4:48-52. [PMID: 22423318 PMCID: PMC3304093 DOI: 10.4329/wjr.v4.i2.48] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2011] [Revised: 09/07/2011] [Accepted: 09/14/2011] [Indexed: 02/06/2023] Open
Abstract
AIM: To compare the reported injuries on initial assessment of the chest X-ray (CXR) in thoracic trauma patients to a second read performed by a dedicated trauma radiologist.
METHODS: By retrospective analysis of a prospective database, 712 patients with an injury to the chest admitted to the University Medical Center Utrecht were studied. All patients with a CXR were included in the study. Every CXR was re-evaluated by a trauma radiologist, who was blinded for the initial results. The findings of the trauma radiologist regarding rib fractures, pneumothoraces, hemothoraces and lung contusions were compared with the initial reports from the trauma team, derived from the original patient files.
RESULTS: A total of 516 patients with both thorax trauma and an initial CXR were included in the study. After re-evaluation of the initial CXR significantly more lung contusions (53.3% vs 34.1%, P < 0.001), hemothoraces (17.8% vs 11.0%, P < 0.001) and pneumothoraces (34.4% vs 26.4%, P < 0.001) were detected. During initial assessment significantly more rib fractures were reported (69.8% vs 62.3%, P < 0.001).
CONCLUSION: During the initial assessment of a CXR from trauma patients in the emergency department, a significant number of treatment-dictating injuries are missed. More awareness for these specific injuries is needed.
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Urgent findings on portable chest radiography: what the radiologist should know--review. AJR Am J Roentgenol 2011; 196:S45-61. [PMID: 21606235 DOI: 10.2214/ajr.09.7170] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
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An initial description of a sonographic sign that verifies intrathoracic chest tube placement. Am J Emerg Med 2010; 28:626-30. [PMID: 20579562 DOI: 10.1016/j.ajem.2009.04.010] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2008] [Revised: 03/27/2009] [Accepted: 04/16/2009] [Indexed: 11/20/2022] Open
Abstract
PURPOSE An initial description of a sonographic finding predictive of intrathoracic chest tube placement. METHODS This was a prospective observational study using unembalmed cadaveric models. Chest tubes were randomly placed intra- and extrathoracically and evaluated using ultrasound. Chest tube location was confirmed using blunt dissection followed by tactile and visual confirmation. Sonographers were blinded to chest tube position. Sonographic images obtained in a transverse orientation revealed a subcutaneous hyperechoic arc, created by the chest tube, at the insertion site. The path of the hyperechoic arc was followed cephalad. Disappearance of the hyperechoic arc signified intrathoracic chest tube placement. In contrast, continuation of a subcutaneous hyperechoic arc for the full length of the chest tube signified extrathoracic chest tube placement (the Disappearance/Intrathoracic, Continuation/Extrathoracic sign). RESULTS Ultrasound was used to evaluate 48 chest tube placements. All chest tube locations were identified correctly. In differentiating intra- vs extrathoracic chest tube placement, the Disappearance/Intrathoracic, Continuation/Extrathoracic sign revealed a sensitivity of 100% (95% confidence interval, 83%-100%) and a specificity of 100% (95% confidence interval, 83%-100%). CONCLUSIONS In this small study, bedside ultrasound appears to be highly sensitive and specific in differentiating intra- versus extrathoracic chest tube placement.
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Ball CG, Ranson K, Dente CJ, Feliciano DV, Laupland KB, Dyer D, Inaba K, Trottier V, Datta I, Kirkpatrick AW. Clinical predictors of occult pneumothoraces in severely injured blunt polytrauma patients: A prospective observational study. Injury 2009; 40:44-7. [PMID: 19131061 DOI: 10.1016/j.injury.2008.07.015] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2008] [Revised: 07/10/2008] [Accepted: 07/29/2008] [Indexed: 02/02/2023]
Abstract
INTRODUCTION The supine antero-posterior (AP) chest radiograph (CXR) is an insensitive test for detecting post-traumatic pneumothoraces (PTXs). Computed tomography (CT) often identifies occult pneumothoraces (OPTXs) that were not diagnosed on CXR. The purpose of this study was to prospectively determine the incidence, and validate previously identified clinical predictors, of OPTXs after blunt trauma. METHODS All severe blunt injured patients (injury severity score (ISS)>or=12) presenting to a level 1 trauma centre over a 17-month period were prospectively evaluated. Thoracoabdominal CT scans and corresponding CXRs were reviewed at the time of admission. Patients with OPTXs were compared to those with overt PTXs regarding incidence and previously identified predictive risk factors (subcutaneous emphysema, rib fractures, female sex and pulmonary contusion). RESULTS CT imaging was performed concurrent to CXR in 405 blunt trauma patients (ISS>or=12) during the study period. PTXs were identified in 107 (26%) of the 405 patients. Eighty-one (76%) of these were occult when CXRs were interpreted by the trauma team. Concurrent chest trauma predictive of OPTXs was limited to subcutaneous emphysema (p=0.003). Rib fractures, pulmonary contusions and female sex were not predictive. CONCLUSIONS OPTXs were missed in up to 76% of all seriously injured patients when CXRs were interpreted by the trauma team. This is higher than previously reported in retrospective studies and is likely based on the difficult conditions in which the trauma team functions. Subcutaneous emphysema remains a strong clinical predictor for concurrent OPTXs.
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Affiliation(s)
- Chad G Ball
- Department of Surgery, Grady Memorial Hospital, Atlanta, GA, USA
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Correlation between centrally versus peripherally transduced venous pressure in prone patients undergoing posterior spine surgery. Spine (Phila Pa 1976) 2008; 33:E643-7. [PMID: 18708916 DOI: 10.1097/brs.0b013e31817c6c2f] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Prospective clinical observational study. OBJECTIVE To evaluate the correlation and agreement between peripherally and centrally transduced venous pressures in prone spine surgery patients. SUMMARY OF BACKGROUND DATA In view of a variety of potential complications associated with the placement of central venous lines for the purpose of central venous pressure (CVP) monitoring, a number of authors have suggested that the use of peripherally transduced pressures (PVP) instead may yield similar results. Data confirming the validity of this technique for the purpose of intravascular fluid volume monitoring in prone patients undergoing spine surgery remain scarce. METHODS After protocol approval by the internal review board, we enrolled 40 patients who underwent spine surgery in the prone position. CVP and PVP were recorded simultaneously. The data pairs were analyzed for correlation. Bland and Altman plots were created to evaluate the degree of agreement between the 2 modes of venous pressure monitoring. RESULTS A total of 1275 data pairs were collected. The mean PVP was 17.55 mm Hg +/- 4.93 mm Hg and the mean CVP 15.52 mm Hg +/- 4.77 mm Hg (P < 0.001), thus yielding a mean difference of 2.04 mm Hg +/- 1.39 mm Hg. PVP and CVP correlated well over a wide range of pressures (r = 0.949, r = 0.920 [P < 0.001]). A high level of agreement was found between both methods of venous pressure measurement. CONCLUSION CVP and PVP correlate well under conditions associated with prone spine surgery. With a high level of agreement found in this study, PVP may represent an attractive alternative to CVP monitoring to assess fluid volume trends intraoperatively.
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Lee SH, Lee JW, Sohn JT, Lee HM, Shin IW, Lee HK, Chung YK. Delayed Tension Pneumothorax Detected 4 Days after Central Venous Catheterization - A case report -. Korean J Anesthesiol 2008. [DOI: 10.4097/kjae.2008.54.3.s59] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Affiliation(s)
- Seung Hwa Lee
- Department of Anesthesiology and Pain Medicine, Gyeongsang National University College of Medicine, Jinju, Korea
| | - Jae-Wan Lee
- Department of Anesthesiology and Pain Medicine, Gyeongsang National University College of Medicine, Jinju, Korea
| | - Ju-Tae Sohn
- Department of Anesthesiology and Pain Medicine, Gyeongsang National University College of Medicine, Jinju, Korea
- Institute of Health Sciences, Gyeongsang National University College of Medicine, Jinju, Korea
| | - Hyo Min Lee
- Department of Anesthesiology and Pain Medicine, Gyeongsang National University College of Medicine, Jinju, Korea
| | - Il-Woo Shin
- Department of Anesthesiology and Pain Medicine, Gyeongsang National University College of Medicine, Jinju, Korea
| | - Heon-Keun Lee
- Department of Anesthesiology and Pain Medicine, Gyeongsang National University College of Medicine, Jinju, Korea
| | - Young-Kyun Chung
- Department of Anesthesiology and Pain Medicine, Gyeongsang National University College of Medicine, Jinju, Korea
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Kusminsky RE. Complications of central venous catheterization. J Am Coll Surg 2007; 204:681-96. [PMID: 17382229 DOI: 10.1016/j.jamcollsurg.2007.01.039] [Citation(s) in RCA: 230] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2006] [Revised: 01/16/2007] [Accepted: 01/17/2007] [Indexed: 12/13/2022]
Affiliation(s)
- Roberto E Kusminsky
- Department of Surgery, West Virginia University, Robert C Byrd Health Sciences Center, Charleston Division and Charleston Area Medical Center, Charleston, WV 25304, USA
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Ball CG, Kirkpatrick AW, Laupland KB, Fox DI, Nicolaou S, Anderson IB, Hameed SM, Kortbeek JB, Mulloy RR, Litvinchuk S, Boulanger BR. Incidence, Risk Factors, and Outcomes for Occult Pneumothoraces in Victims of Major Trauma. ACTA ACUST UNITED AC 2005; 59:917-24; discussion 924-5. [PMID: 16374282 DOI: 10.1097/01.ta.0000174663.46453.86] [Citation(s) in RCA: 70] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND The supine anteroposterior chest radiograph (CXR) is an insensitive test for posttraumatic pneumothoraces (PTXs). Computed tomographic (CT) scanning often detects PTXs that were not diagnosed on CXR (occult PTXs [OPTXs]). The purpose of this study was to define the incidence, predictors, and outcomes for OPTXs after trauma. METHODS Thoracoabdominal CT scans and corresponding CXRs of all trauma patients entered into a regional database were reviewed. Patients with OPTXs were compared with those with overt, residual, and no PTXs regarding incidence, demographics, associated injuries, early resuscitative predictors, treatment, and outcomes. RESULTS Paired CXRs and CT scans were available for 338 of 761 (44%) patients (98.5% blunt trauma). One hundred three PTXs were present in 89 patients, 57 (55%) of which were occult; 6 (11%) were seen only on thoracic CT scan. Age, sex, length of stay, and survival were similar between all groups. OPTXs and PTXs were similar in comparative size index and number of images. Subcutaneous emphysema, pulmonary contusion, rib fracture(s), and female sex were independent predictors of OPTXs. Seventeen (35%) patients with OPTXs were ventilated, of whom 13 (76%) underwent thoracostomy. No complications resulted from observation, although 23% of patients with thoracostomy had tube-related complications or required repositioning. CONCLUSION OPTXs are commonly missed both by CXR and even abdominal CT scanning in seriously injured patients. Basic markers available early in resuscitation are highly predictive for OPTXs and may guide management before CT scanning. Further study of OPTX detection and management is required.
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Affiliation(s)
- Chad G Ball
- Department of Surgery, Foothills Medical Centre, Calgary, Alberta, Canada
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Abstract
This review examines the present understanding of tension pneumothorax and produces recommendations for improving the diagnostic and treatment decision process.
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Jantz MA, Sahn SA. Pleural Disease in the Intensive Care Unit. J Intensive Care Med 2000. [DOI: 10.1046/j.1525-1489.2000.00063.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Jantz MA, Sahn SA. Pleural Disease in the Intensive Care Unit. J Intensive Care Med 2000. [DOI: 10.1177/088506660001500201] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Pleural disease itself is an unusual cause for admission to the intensive care unit (ICU). Pleural complications of diseases and procedures in the ICU are common, however, and the impact on respiratory physiology is additive to that of the underlying cardiopulmonary disease. Pleural effusion and pneumothorax may be overlooked in the critically ill patient due to alterations in radiologic appearance in the supine patient. The development of a pneumothorax in a patient in the ICU represents a potentially life-threatening situation. This article reviews the etiologies, pathophysiology, and management of pleural effusion, pneumothorax, tension pneumothorax, and bronchopleural fistula in the critically ill patient. In addition, we review the potential complications of thoracentesis and chest tube thoracostomy, including re-expansion pulmonary edema.
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Affiliation(s)
- Michael A. Jantz
- From the Division of Pulmonary and Critical Care Medicine, Allergy and Clinical Immunology, Medical University of South Carolina, Charleston, SC
| | - Steven A. Sahn
- From the Division of Pulmonary and Critical Care Medicine, Allergy and Clinical Immunology, Medical University of South Carolina, Charleston, SC
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Abstract
We report a case of delayed pneumothorax, central venous catheter migration and iatrogenic hydrothorax in a 22-year-old female. The left subclavian central venous catheter initially transfixed the lung apex; pneumothorax occurred 24 h later following initiation of positive pressure ventilation. Lung collapse as a result of the pneumothorax caused catheter migration and hydrothorax. Catheter removal and chest drainage led to an uneventful recovery.
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Affiliation(s)
- C J Thomas
- Department of Anaesthesia and Intensive Care, Townsville General Hospital, Townsville, Queensland 4810, Australia
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Abstract
The diagnosis of tension pneumothorax has typically been taught as the presence of hemodynamic compromise with an expanding intrapleural space air mass. This may occur quickly or gradually, depending on the degree of lung injury and respiratory state of the patient. Experimentally, tension pneumothorax is a multifactorial event that manifests a state of central hypoxemia, compensatory mechanisms, and mechanical compression on intrathoracic structures. Studies using animal models suggest that over hypotension is a delayed finding that immediately precedes cardiorespiratory collapse. Recognition of early signs and symptoms associated with tension pneumothorax, e.g., progressive hypoxemia, tachycardia, and respiratory distress, can alert medical personnel to the need for rapid decompression before physiologic decompensation.
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Affiliation(s)
- E D Barton
- Department of Emergency Medicine, Brigham & Women's Hospital, Harvard Medical School, Boston, Massachusetts 02115, USA.
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