Stable vital signs allow time for chest radiographs, confirming the diagnosis. Pneumothorax with hypotension

equates to a tension pneumothorax requiring needle tho ­

racostomy followed immediately by tube thoracostomy

(Figure 24-2).

TREATMENT

Oxygen is a mainstay of treatment. Reabsorption, normally

occurring at a rate of 1-2% per day, is hastened with 02

(3-4 L/min increases the rate 4-fold). Tube thoracostomy

is indicated in patients with secondary spontaneous pneumothoraces; those greater than 20% in size or expanding

pneumothoraces; bilateral or tension pneumothoraces;

those associated with significant symptoms; or in patients

requiring positive pressure ventilation or air transport.

Small ( <20%) pneumothoraces can be observed and

the patient can be discharged if there is no progression

seen on a CXR repeated after 6 hours. Failure rates, defined

by the eventual need for tube thoracostomy, with observation alone are as high as 40%.

Catheter aspiration reduces a moderate to large pneumothorax to a small one that will resolve on its own. A

CXR is needed immediately after aspiration and again

6 hours later to verify successful aspiration and to ensure

that there is no reaccumulation of air. Catheter aspiration

decreases length of stay without affecting mortality or

complications.

PNEUMOTHORAX

I nspiratory and

expiratory CXR Tension pneumothorax

Perform needle thoracostomy

Administer 02;

observe, aspirate, or

insert chest tube

Tube thoracostomy

.A. Figure 24-2. Pneumothorax diag nostic algorithm. CXR, chest x-ray.

A trend toward discharging patients after insertion

of a small-bore catheter with a small 1 -way valve

attached (ie, Heimlich valve) has emerged. After consultation with a specialist (cardiothoracic surgeon or pillmonologist) , discharge is either completed after an

observation period or immediately with a next-day

follow-up appointment.

DISPOSITION

� Admission

If a chest tube is inserted, patients are admitted to the hospital. The chest tube must be attached to a water seal and

vacuum device (Pleur-Evac). Patient with small (<20%)

traumatic pneumothoraces that are managed conservatively are usually admitted for observation.

� Discharge

If the pneumothorax is small ( <20%) and patients are

healthy, reliable, and minimally symptomatic, they may

be observed. A second CXR 6 hours later should be

performed to ensure that there has been no change in the

size of the pneumothorax before discharge. Close followup with a specialist should be arranged. Patients must

avoid air travel until the pneumothorax shows complete

resolution.

SUGGESTED READING

Humphries RL, Young WF. Spontaneous and iatrogenic pneumothorax. In: Tintinalli JE, Stapczynski JS, Ma OJ, Cline DM,

Cydulka RK, Meckler GD. Tintinalli's Emergency Medicine: A

Comprehensive Study Guide. 7th ed. New York, NY: McGrawHill, 20 1 1, pp. 500-504.

Henry M, Arnold T, Harvey J. BTS guidelines for the management

of spontaneous pneumothorax. Thorax. 2003;58:ii39-ii52.

Kulvatunyou N, Vigayasekaran A, et al. Two-year experience of using

pigtail catheters to treat traumatic pneumothorax: A changing

trend. J Trauma Injury Infect Grit Care. 2011;71:1104-1 107.

Sahn SA, Heffner JE. Spontaneous pneumothorax. N Eng! f Med.

2000;342:868-874.

Wakai A, O'Sullivan R, McCabe G. Simple aspiration versus inter ­

costals tube drainage for primary spontaneous pneumothorax

in adults. Cochrane Database Syst Rev. 201 1;1:CD004479.

Pu l monary Embolism

Harsh Sule, MD

Key Points

• Consider pulmonary embolism (PE) in patients with

complaints of dyspnea, chest pain, hemoptysis, or

syncope.

• Dyspnea, pleuritic chest pain, or tachypnea is present in

92% of patients with PE.

INTRODUCTION

Pulmonary embolism (PE) is a potentially life-threatening

condition associated with a partial or complete obstruction of the pulmonary artery caused by a thrombus that

b

.

reaks off from a peripheral vein, migrates via the right

s1de of the heart, and lodges in the pulmonary artery

circulation. About 90% of emboli originate from venous

thrombi in the lower extremities and pelvis. The presence

of emboli in the pulmonary vasculature blocks normal

blood flow to the lung and increases pulmonary resistance. This, in turn, increases pulmonary artery pressure

and right ventricular pressure. When greater than 50% of

the vasculature is occluded, the patient experiences significant pulmonary hypertension and acute cor pulmonale. Undetected, this leads to long-term morbidity and

death.

PE is the third most common cause of death from

cardiovascular disease, with approximately 650,000

cases of PE occurring per year in the United States. The

diagnosis is frequently missed, with 30% of cases diagnosed antemortem. Massive PE occurs in only 5% of

cases, but has an associated mortality rate of 40%.

Overall, mortality is 3-10% if treated and 1 5-30% if

untreated.

• If PE is considered in the differential, use clinical decision rules (PERC, Wells, Geneva) to help guide decisions

regarding the patient work-up.

• Consider thrombolytics in hemodynamically unstable

patients with confirmed PE.