Tension pneumothorax and the "forbidden CXR"

Occult tension pneumothorax discovered following imaging for adult trauma patients in the modern major trauma system: a multicentre observational study

BACKGROUND

Tension pneumothorax following trauma is a life-threatening emergency and radiological investigation is normally discouraged prior to treatment in traditional trauma doctrines such as ATLS. Some trauma patients may be physiologically stable enough for diagnostic imaging and occult tension pneumothorax is discovered radiologically. We assessed the outcomes of these patients and compared them with those with clinical diagnosis of tension pneumothorax prior to imaging.

METHODS

A multicentre civilian-military collaborative network of six major trauma centres in the UK collected observational data from adult patients who had a diagnosis of traumatic tension pneumothorax during a 33-month period. Patients were divided into 'radiological' (diagnosis following CT/CXR) or 'clinical' (no prior CT/CXR) groups. The effect of radiological diagnosis on survival was analysed using multivariable logistic regression that included the covariates of age, gender, comorbidities and Injury Severity Score.

RESULTS

There were 133 patients, with a median age of 41 (IQR 24-61); 108 (81%) were male. Survivors included 49 of 59 (83%) in the radiological group and 59 of 74 (80%) in the clinical group (p=0.487). Multivariable logistic regression showed no significant association between radiological diagnosis and survival (OR 2.40, 95% CI 0.80 to 7.95; p=0.130). There was no significant difference in mortality between the groups.

CONCLUSION

Radiological imaging may be appropriate for selected trauma patients at risk of tension pneumothorax if they are considered haemodynamically stable. Trauma patients may be physiologically stable enough for radiological imaging but have occult tension pneumothorax because they did not have the typical clinical presentation. The historical dogma of the 'forbidden scan' no longer applies to such patients.

Tension Pneumothorax as a Complication of Inadvertent Pleural Tears During Posterior Spinal Surgery

OBJECTIVE

To review and expose the occurrences of tension pneumothorax as a result of pleural tear during posterior spinal surgery.

METHODS

Intraoperative reports were retrospectively reviewed for 2 patients who underwent posterior spinal fusion and experienced pleural tear and subsequent tension pneumothorax. Surgical decisions for recognition and treatment were also reviewed.

RESULTS

Unrecognized pleural tearing led to the formation of tension pneumothorax in both patients studied. Onset of respiratory signs and symptoms were delayed, occurring in the recovery room for the first patient and intraoperatively for the second. Both patients were successfully treated with conversion to open pneumothorax and placement of chest tubes.

CONCLUSIONS

Tension pneumothorax is a complication that can arise during posterior thoracic spinal surgery as a result of an inadvertent pleural tear. Awareness of this potentially fatal complication will greatly help in the timely recognition and treatment of this condition if this situation occurs. The authors recommend a low threshold for chest tube placement in patients with known or suspected pleural tears or in patients with undiagnosed respiratory failure undergoing posterior thoracic spine surgery.

Pre-hospital pleural decompression and chest tube placement after blunt trauma: A systematic review

Pre-hospital insertion of chest tubes or decompression of air within the pleural space is one of the controversial topics in emergency medical care of trauma patients. While a wide variety of opinions exist medical personnel on the scene require guidance in situations when tension pneumothorax or progressive pneumothorax is suspected. To ensure evidence based decisions we performed a systematic review of the current literature with respect to the diagnostic accuracy in the pre-hospital setting to identify patients with (tension) pneumothorax, the efficacy and safety of performing pleural decompression in the field and the choice of method and technique for the procedure. The evidence found is presented and discussed and recommendations are drawn from the authors' perspective.