Needle Decompression Complicated by Cardiac Injury in a Prehospital Environment.

Needle decompression is a mainstay intervention for tension pneumothorax in trauma medicine. It is used in combat and prehospital medicine when definitive measures are often not available or ideal. It can temporarily relieve increased intrathoracic pressure and treat a collapsed lung or great vessel obstruction. However, when done incorrectly, it can result in underlying visceral organ and vessel trauma. This is a case of an adult male who presented to the emergency department after sustaining multiple stab wounds during an altercation. On arrival, the patient had a 14-gauge angiocatheter inserted at the 4th intercostal space (ICS), left of the parasternal line traversing the right ventricle and interventricular septum and terminating in the left ventricle. The case emphasizes the importance of understanding the landmarks of performing needle decompression in increasing the procedure's efficacy and reducing iatrogenic complications.

Contralateral Tension Pneumothorax in One-Lung Ventilation: A Case Report and Systematic Review.

Contralateral tension pneumothorax is a rare but fatal complication of one-lung ventilation. The life-saving decompression of pleural space was frequently delayed by the difficult confirmation of diagnosis because of general anesthesia that masks specific clinical presentations when the patient is alert. We reported a case of tension pneumothorax in a patient who underwent thoracic spine instrumentation. There were no contralateral tension pneumothorax cases on file from the search of the Anesthesia Quality Institute Closed Claims Database from 2001 to 2017. We systematically searched PubMed, Ovid MEDLINE, Embase, and Google Scholar. Over the past 30 years, there were 21 single case reports and two case series were retrieved. It was a consensus that difficult confirmation of the diagnosis of contralateral tension pneumothorax is the culprit of delayed life-saving intervention. Difficulty of oxygenation with increasing inspiratory pressure was usually the first sign suggesting contralateral pneumothorax; however, earlier presentations of cardiovascular system failure than respiratory failure have significantly increased the incidence of cardiac arrest and death. It is paramount to maintain a high suspicion of tension pneumothorax. The application of esophageal stethoscope, lung ultrasound, and simulator training may improve the chance of early diagnosis and patient outcome.

Differentiating Giant Bullous Emphysema From Tension Pneumothorax: A Case Report.

Giant bullous emphysema (GBE) is a progressive disease that commonly presents with severe progressive dyspnea attributed to the progressive destruction of alveolar walls and the formation of large air pockets, resulting in impaired gas exchange. This presentation is most commonly seen in young, thin male smokers. GBE poses an interesting and unique clinical challenge due to its radiologic findings, which can be easily mistaken for tension pneumothorax. Despite the decreased acuity of GBE as compared to tension pneumothorax, inadequate treatment in a severe case can lead to spontaneous pneumothorax, infection, and/or respiratory failure. In this report, we highlight a case of severe GBE that presents similarly to tension pneumothorax in both symptomatology and radiologic findings. The case at hand is of a 50-year-old male patient with a history of chronic obstructive pulmonary disease (COPD) with complaints of dyspnea and subsequent findings of tachycardia, tachypnea, and hypoxemia with significantly decreased breath sounds in the right lung. Radiologic findings showed increased lucency of the right hemithorax and a mass effect with a mediastinal shift to the left. History and further imaging with CT led to an ultimate diagnosis of severe GBE and COPD exacerbations. The patient was treated with non-invasive medical management. With the challenges of overlapping presentations, landing on the correct diagnosis is imperative to accurately and adequately treat the patient since GBE and tension pneumothorax significantly differ in acuity and overall management, hence the need for a high level of suspicion based on the clinical picture and the use of high-resolution CT.

The need to suspect tension gastrothorax as a cause of obstructive shock in trauma care: A case report.

INTRODUCTION: Traumatic tension gastrothorax is a type of obstructive shock similar to tension pneumothorax. However, tension gastrothorax is not well known among emergency physicians, and no consensus has yet been reached on management during initial trauma care. We present a case of traumatic tension gastrothorax in which tube thoracostomy was performed based solely on clinical findings very similar to tension pneumothorax, followed by emergency laparotomy. PRESENTATION OF CASE: A 24-year-old male motorcyclist was brought to our emergency medical center after being struck by a motor vehicle. He was in respiratory failure and hypotensive shock with findings suggestive of pneumothorax. Although the physical findings were not fully in line with tension pneumothorax, we immediately performed finger thoracostomy. Subsequent radiography revealed left diaphragmatic rupture with hernia. After unsuccessful attempts to decompress the stomach with a nasogastric tube, immediate emergency laparotomy was performed. During the operation, the stomach, which had prolapsed through the ruptured diaphragm into the thoracic cavity, was manually returned to the abdominal cavity. The ruptured diaphragm was repaired with sutures. DISCUSSION: Although distinguishing between tension pneumothorax and tension gastrothorax based on physical examination alone is difficult, tension gastrothorax requires careful attention to avoid intrapleural contamination from gastric injury. In addition, relying solely on stomach decompression with a nasogastric tube or delaying laparotomy could lead to cardiac arrest. CONCLUSION: When tension pneumothorax is suspected during initial trauma care, tension gastrothorax should also be considered as a differential diagnosis and treated with immediate diaphragmatic repair once identified.

Medical and surgical management of pneumothorax in diving and hyperbaric chambers.

The presence of a pneumothorax within a pressurized chamber represents unique diagnostic and management challenges. This is particularly the case in the medical and geographic remoteness of many chamber locations. Upon commencing chamber decompression, unvented intrapleural air expands. If its initial volume and/or degree of chamber pressure reduction is significant enough, a tension pneumothorax will result. Numerous reports chronicle failure to diagnose and manage in-chamber pneumothorax with resultant morbidity and one fatal outcome. Such cases have occurred in both medically remote and clinically based settings. This paper reviews pneumothorax and tension pneumothorax risk factors and clinical characteristics. It suggests primary medical management using the principle of oxygen-induced inherent unsaturation in concert with titrated chamber decompression designed to prevent intrapleural air expanding faster than it contracts. Should this conservative approach prove unsuccessful, and surgical venting becomes necessary or otherwise immediately indicated, interventional options are reviewed.

Pneumothorax during manned chamber operations: A summary of reported cases.

In-chamber pneumothorax has complicated medically remote professional diving operations, submarine escape training, management of decompression illness, and hospital-based provision of hyperbaric oxygen therapy. Attempts to avoid thoracotomy by combination of high oxygen partial pressure breathing (the concept of inherent unsaturation) and greatly slowed rates of chamber decompression proved successful on several occasions. When this delicate balance designed to prevent the intrapleural gas volume from expanding faster than it contracts proved futile, chest drains were inserted. The presence of pneumothorax was misdiagnosed or missed altogether with disturbing frequency, resulting in wide-ranging clinical consequences. One patient succumbed before the chamber had been fully decompressed. Another was able to ambulate unaided from the chamber before being diagnosed and managed conventionally. In between these two extremes, patients experienced varying degrees of clinical compromise, from respiratory distress to cardiopulmonary arrest, with successful resuscitation. Pneumothorax associated with manned chamber operations is commonly considered to develop while the patient is under pressure and manifests during ascent. However, published reports suggest that many were pre-existing prior to chamber entry. Risk factors included pulmonary barotrauma-induced cerebral arterial gas embolism, cardiopulmonary resuscitation, and medical or surgical procedures usually involving the lung. This latter category is of heightened importance to hyperbaric operations as an iatrogenically induced pneumothorax may take as long as 24 hours to be detected, perhaps long after a patient has been cleared for chamber exposure.

Congenital diaphragmatic hernia in patient with 1p36 deletion.

Key Clinical Message: This case underscores the atypical presentation of late-onset congenital diaphragmatic hernia in a 9-old with 1p36 deletion syndrome. Recognition of respiratory distress and abdominal symptoms is crucial for intervention. Abstract: Congenital Diaphragmatic Hernia (CDH) is a condition characterized by the protrusion of abdominal contents into the thoracic cavity due to a defect in the diaphragm. While typically observed in the neonatal period, CDH can present in later life. This case report describes the presentation, diagnosis, and management of a nine-year-old boy with 1p36 deletion syndrome who presented with respiratory distress, abdominal pain, vomiting, and anorexia. The initial diagnosis was tension pneumothorax, and thus the patient underwent chest tube placement. However, a high-resolution CT scan revealed a left hemidiaphragmatic hernia, and the patient eventually underwent an emergency laparotomy due to acute-onset respiratory distress. Intraoperatively, a diagnosis of Bochdalek hernia with gastric perforation was made, and the CDH and gastric perforations were resolved successfully. This case highlights the importance of considering late-presenting CDH as a possible diagnosis in pediatric patients with similar symptoms and the radiological findings suggestive of tension pneumothorax. Early recognition and prompt surgical intervention can lead to successful management of such cases.

Recurrent Spontaneous Pneumothorax Secondary to Marijuana and Tobacco Abuse.

Primary spontaneous pneumothorax occurs in patients without apparent clinical lung disease, with a higher incidence in tall, thin males between the ages of 10 and 30. Tension pneumothorax is a life-threatening condition that can develop within minutes due to progressive air accumulation in the pleural space; mechanical pressure can lead to significant cardiorespiratory compromise. Tobacco association with a higher incidence of spontaneous pneumothorax has been well documented, but marijuana and spontaneous pneumothorax connection has not been well studied. However, it has been observed that patients who use marijuana and tobacco simultaneously have a higher incidence of spontaneous tension and larger pneumothoraces, as well as longer postoperative stay and higher recurrence than cigarette-only users. We present a case of a 26-year-old young male with a history only significant for excessive tobacco and marijuana smoking who developed multiple recurrent spontaneous pneumothorax and had to undergo right-sided video-assisted thoracoscopic surgery (VATS) with minimally invasive thoracotomy and had a prolonged hospital stay. With our case report, we hope to add to the evidence the effects of combined marijuana and tobacco smoking on bullous lung disease and pneumothorax while emphasizing the importance of conducting a detailed substance use history in patients with spontaneous pneumothorax.

Needle Decompression Causing Pericardial and Pulmonary Artery Injuries in Patients With Blunt Trauma: Two Case Reports and Literature Review.

Tension pneumothorax (TPX) is a severe chest complication of blunt or penetrating trauma. Immediate decompression is the lifesaving action in patients with TPX. Needle decompression (ND) is frequently used for this purpose, particularly in limited resources setting such as the prehospital arena. Despite the safe profile, the blind nature of the procedure can result in a serious range of complications, including injury to the vital intrathoracic structures such as the lungs, great vessels, and heart. Here, we reported 2 cases of blunt chest trauma resulting in TPX demanding immediate ND; however, nonintentional pericardial and pulmonary artery injuries occurred. The first case was a 42-year-old man with a needle-related pulmonary artery injury that required surgery. The second case was a 19-year-old man in whom a needle-related pneumopericardium occurred and was treated conservatively. In both cases, trained personnel performed the ND. Although ND in the field is a lifesaving intervention, it may further complicate the patient condition. Therefore, it should be performed in adherence to the universal guidelines.

MANAGEMENT OF COMPLICATIONS FOLLOWING BUTTON BATTERY INGESTION.

Ingestion of button batteries by children is increasing every year, which is becoming a clinical problem for pediatricians. The number of complications and mortality when using batteries exceeds similar indicators when accidentally swallowing other foreign bodies. This is due to the electrochemical and mechanical effect of the battery on the mucous membrane of the gastrointestinal tract and especially the esophagus. With a late diagnosis, an ordinary battery leads to the development of fatal complications. In modern literature, there are no protocols that would relate to the treatment of similar situations, in particular, in the development of a tracheoesophageal fistula. The article describes a case of successful treatment of a tracheoesophageal fistula due to a long-term stay of a battery in the esophagus. This condition was also complicated by the development of bilateral tension pneumothorax. The dilemma in such cases is always difficult: to choose operative or conservative treatment. Both methods have their advantages and disadvantages. In this clinical case, preference was given to conservative treatment, which ended quite successfully. But the main goal is to prevent such situations. This can be achieved by raising parents' awareness of the risks of battery ingestion. Also, the efforts of a doctor who is faced with a similar situation should be directed to the fastest possible diagnosis and removal of such a foreign body as a battery.

Unexpected Tension Pneumothorax Developed during Anesthetic Induction Aggravated by Positive Pressure Ventilation: A Case Report.

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.

Tension pneumothorax in small odontocetes.

Pneumothorax, the accumulation of air in the pleural cavity, occurs when air enters the pleural space by the pleuro-cutaneous, pleuro-pulmonary, or pleuro-oesophageal-mediastinal route. Tension pneumothorax is an infrequent and severe form of pneumothorax where a positive pressure in the pleural space is built up during at least part of the respiratory cycle, with compression of both lungs and mediastinal vessels, and, if unilateral, with midline deviation towards the unaffected hemithorax. We describe 9 cases of tension pneumothorax in 3 species of small cetaceans (striped dolphin Stenella coeruleoalba, common dolphin Delphinus delphis, and common bottlenose dolphin Tursiops truncatus) from the western Mediterranean coast of Spain, and one case from a dolphinarium. Computed tomography (CT) imaging performed in 2 carcasses before necropsy showed lung compression, midline deviation, and pressure on the diaphragm, which was caudally displaced. Tension pneumothorax was recognized at necropsy by the presence of pressurized air in one of the hemithoraces. Seven of the pneumothorax cases were spontaneous (2 primary and 5 secondary to previous lung pathology). In the other 2 dolphins, the pneumothorax was traumatic, due to oesophageal-pleural perforation or rib fractures. We hypothesize that pneumothorax in dolphins is predominantly tensional because of their specific anatomical and physiological adaptations to marine life and the obligate exposure to extreme pressure changes as diving mammals.

Tension pneumothorax caused by the ruptured hydatid cyst of the lung.

Hydatid cyst disease puts a significant burden on the health of humans every year. The lung is the second most common organ of implantation of Echinococcus larvae. Due to the importance of early diagnosis of tension pneumothorax, this paper provides four cases of hydatid disease that presented with tension pneumothorax.

Misconnected chest tube: An extremely unusual fatal complication of secondary pneumothorax.

A rare and fatal complication of suction drainage of secondary spontaneous pneumothorax is reported. The patient, likely by a mistake, arbitrarily connected the oxygen supply tube to the thoracic drain. The sharp increase of intrapleural pressure combined with the atmospheric intraalveolar environment caused diffuse lung injury and cardiopulmonary collapse without a direct lung injury. The conflicting interests of patient autonomy and patient safety require further consideration.

Unexpected Tension Pneumothorax after Double-Lumen Endotracheal Intubation in Patients with Pulmonary Edema: A Case Report.

Tension pneumothorax is a relatively rare complication after anesthetic induction that requires prompt diagnosis and treatment. Several handling errors related to intubation procedures or equipment and vigorous positive pressure ventilation are potentially important etiologies of tension pneumothorax in patients with underlying lung disease or in mechanically ventilated patients. We describe a case of tension pneumothorax observed after double-lumen tube (DLT) insertion followed by single-lumen tube replacement using an airway exchanger catheter in a mechanically ventilated patient. An 84-year-old female on mechanical ventilation underwent minimally invasive cardiac surgery under general anesthesia. Immediately after left-sided DLT insertion using an airway exchanger catheter, oxygen saturation decreased to 89%, peak airway pressure increased to 35 cm H2O with inadequate tidal volume, and blood pressure gradually dropped to 69/41 mmHg. Breath sounds from the right hemithorax were significantly reduced. Severe collapse of the right lung, a flattened diaphragm, and compressed abdominal organs were identified on chest radiography. Therefore, a tube thoracotomy was performed based on the findings of a tension pneumothorax. Then, oxygen saturation, peak airway pressure with adequate tidal volume, and blood pressure improved, and the distended abdomen normalized. After the pneumothorax resolved, a bronchoscopy was performed. Slight redness was noted in the right bronchus, indicating that the DLT was incorrectly inserted into the right side. In conclusion, the possibility of a tension pneumothorax should be considered during DLT intubation or endotracheal tube replacement with an airway exchange catheter.

Association between three prehospital thoracic decompression techniques by physicians and complications: a retrospective, multicentre study in adults.

INTRODUCTION: We sought to compare the complication rates of prehospital needle decompression, finger thoracostomy and three tube thoracostomy systems (Argyle, Frontline kits and endotracheal tubes) and to determine if finger thoracostomy is associated with shorter prehospital scene times compared with tube thoracostomy. METHODS: In this retrospective cohort study we abstracted data on adult trauma patients transported by three helicopter emergency medical services to five Major Trauma Service hospitals who underwent a prehospital thoracic decompression procedure over a 75-month period. Comparisons of complication rates for needle, finger and tube thoracostomy and between tube techniques were conducted. Multivariate models were constructed to determine the relative risk of complications and length of scene time by decompression technique. RESULTS: Two hundred and fifty-five patients underwent 383 decompression procedures. Fifty eight patients had one complication, and two patients had two complications. There was a weak association between decompression technique (finger vs tube) and adjusted risk of overall complication (RR 0.58, 95% CI: 0.33-1.03, P = 0.061). Recurrent tension physiology was more frequent in finger compared with tube thoracostomy (13.9 vs 3.2%, P < 0.001). Adjusted prolonged (80th percentile) scene time was not significantly shorter in patients undergoing finger vs tube thoracostomy (56 vs 63 min, P = 0.197), nor was the infection rate lower (2.7 vs 2.1%, P = 0.85). CONCLUSIONS: There was no clear evidence for benefit associated with finger thoracostomy in reducing overall complication rates, infection rates or scene times, but the rate of recurrent tension physiology was significantly higher. Therefore, tube placement is recommended as soon as practicable after thoracic decompression.

Bilateral tension pneumothoraxes in buffalo chest several months after Nuss procedure for pectus excavatum.

Primary spontaneous pneumothorax usually occurs in tall and thin young people without an underlying disease or traumatic history. Most patients with pectus excavatum have similar body shapes as patients with pneumothorax. Haller indices of the patients with pneumothorax and pectus excavatum are higher than normal. Pectus excavatum may be a predisposing factor for the development of primary pneumothorax. The Nuss procedure involves inserting a metal bar through the substernal space to correct the pectus excavatum, resulting in a buffalo chest in which both pleural cavities communicate with each other. Therefore, if pneumothorax occurs after the Nuss procedure, it can occur bilaterally. Recently, we encountered a life-threatening case of bilateral tension pneumothoraxes after the Nuss procedure for pectus excavatum, which were not related to surgical complications.

Intraoperative spontaneous tension pneumothorax during robotic-assisted coronary artery bypass grafting.

Patients undergoing robotic-assisted coronary artery bypass grafting are increasing. Several complications have emerged with the increasing use of minimally invasive procedures. We reported a case of spontaneous tension pneumothorax that developed in the ventilated lung during robotic assisted left internal mammary artery harvesting causing severe hemodynamic instability. A sudden rise of airway pressure occurred, and the patient became hypotensive. Immediately, the surgeon was notified to look at the right pleura. Pneumothorax was identified, the right pleura was opened using robotic arms, and the right lung was decompressed. A small emphysematous bulla was identified and stabled. Proper identification of the procedure-associated complications is essential for timely management. Tension pneumothorax is a potentially fatal complication, especially in patients under positive pressure ventilation.