Treatment of Occult Pneumothoraces from Blunt Trauma

Brasel, Karen J.; Stafford, Renae E.; Weigelt, John A.; Tenquist, J. E.; Borgstrom, David C.

doi:10.1097/00005373-199906000-00001

Cited by 126 publications

(51 citation statements)

References 8 publications

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“…Consequently, a prophylactic chest tube placement is considered [18] in small asymptomatic pneumothoraces (<20%), although controversies exist about this practice in the literature [21]. However, there is growing evidence that occult pneumothorax can be safely treated without thoracostomy in non-ventilated patients [19].…”

Section: Pleuramentioning

confidence: 99%

CT imaging of blunt chest trauma

2011

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BackgroundThoracic injury overall is the third most common cause of trauma following injury to the head and extremities. Thoracic trauma has a high morbidity and mortality, accounting for approximately 25% of trauma-related deaths, second only to head trauma. More than 70% of cases of blunt thoracic trauma are due to motor vehicle collisions, with the remainder caused by falls or blows from blunt objects.MethodsThe mechanisms of injury, spectrum of abnormalities and radiological findings encountered in blunt thoracic trauma are categorised into injuries of the pleural space (pneumothorax, hemothorax), the lungs (pulmonary contusion, laceration and herniation), the airways (tracheobronchial lacerations, Macklin effect), the oesophagus, the heart, the aorta, the diaphragm and the chest wall (rib, scapular, sternal fractures and sternoclavicular dislocations). The possible coexistence of multiple types of injury in a single patient is stressed, and therefore systematic exclusion after thorough investigation of all types of injury is warranted.ResultsThe superiority of CT over chest radiography in diagnosing chest trauma is well documented. Moreover, with the advent of MDCT the imaging time for trauma patients has been significantly reduced to several seconds, allowing more time for appropriate post-diagnosis care.ConclusionHigh-quality multiplanar and volumetric reformatted CT images greatly improve the detection of injuries and enhance the understanding of mechanisms of trauma-related abnormalities.

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Section: Pleuramentioning

confidence: 99%

CT imaging of blunt chest trauma

2011

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“…In some patients, expert opinions support that close observation is safe, provided that the patient is not mechanically ventilated and that the pneumothorax is not increasing in size [3,4,35,36]. The importance of therapy is more relevant in the intubated patient on positive-pressure ventilation, as they are at increased risk of complications.…”

Section: Managementmentioning

confidence: 99%

Occult pneumothorax, revisited

Omar

Abdelmalak

Mangar

et al. 2010

J Trauma Manage Outcomes

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Pneumothorax is a recognized cause of preventable death following chest wall trauma where a simple intervention can be life saving. In cases of trauma patients where cervical spine immobilization is mandatory, supine AP chest radiograph is the most practical initial study. It is however not as sensitive as CT chest for early detection of a pneumothorax. "Occult" pneumothorax is an accepted definition of an existing but usually a clinically and radiologically silent disturbance that in most patients can be tolerated while other more urgent trauma needs are attended to. However, in certain patients, especially those on mechanical ventilation (with subsequent increase of intrapleural air with positive pressure ventilation), missing the diagnosis of pneumothorax can be deleterious with fatal consequences. This review will discuss the occult pneumothorax in the context of 3 radiological examples, which will further emphasize the entity. Because a negative AP chest radiograph can dangerously delay its recognition, we recommend that any trauma victim presenting to the emergency department with symptoms of respiratory distress should be screened with either thoracic ultrasonography or chest CT scan to avoid missing a pneumothorax.

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“…8,10 Most importantly, there is criticism regarding the excessive use of CT because of their minimal impact in changing the management of patients with OPTX; some argue for the refinement of CT use to identify critical lesions instead of trivial findings. 11 Although CT will continue to be the gold standard for diagnosing PTX, there is scant evidence in the literature accurately characterizing the ability of AP SCR to detect PTX in trauma patients.…”

Section: Introductionmentioning

confidence: 99%

Occult Pneumothoraces in Acute Trauma Patients

Ernst¹,

McIntyre²,

Weiss³

et al. 2011

WestJEM

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IntroductionMany traumatic pneumothoraces (PTX) are not seen on initial chest radiograph (CR) (occult PTX) but are detected only on computed tomography (CT). Although CR remains the first tool for detecting PTX, most trauma patients with significant thoracoabdominal injuries will receive both CT and CR. The primary objective of this study was to retrospectively determine the effectiveness of CR for detecting PTX in trauma patients. Our hypotheses were that CR is a sensitive indicator of PTX on CT, that chest pain and shortness of breath are good predictors of PTX on CR, and that we could determine other predictors of PTX on CR.MethodsAll trauma patients presenting to our Level I trauma center with a CT-diagnosed PTX over a 2-year period who had both a CR and a chest CT were included. The CT reading was considered the gold standard for PTX diagnosis. Electronic medical records were searched using key words for diagnoses, symptoms, demographics, and radiologic results. We recorded the official radiologist readings for both CR and CT (positive or negative) and the size of the PTX on CT (large, moderate, small, or tiny). The outcome variable was dichotomized based on presence or absence of PTX detected on CR. Descriptive statistics and χ2 tests were used for univariate analysis. A regression analysis was performed to determine characteristics predictive of a PTX on CR, and 1 variable was added to the model for every 10 positive CRs. With equal-size groups, this study has the power of 80% to detect a 10% absolute difference in single predictors of PTX on CR with 45 subjects in each group.ResultsThere were 134 CT-documented PTXs included in the study. Mean age was 42, and 74% were men. For 66 (49%) patients, PTX was detected on CR (sensitivity = 50%). The CR detected 30% of small PTX, 35% of moderate PTX, and 33% of large PTX. Comparing patients with and without PTX on CR, there were no significant differences in shortness of breath or chest pain. There no relationships between PTX detected on CR and age, gender, penetrating versus blunt injury, bilaterality of the PTX, or presence of lung contusion or hemothorax on CT. After adjusting for all significant variables, predictor of a PTX detected on CR was air in the tissue on CR (adjusted odds ratio [OR] = 3.8) and PTX size (compared to a tiny PTX, adjusted OR = 2.0 for a small PTX, 7.5 for a moderate PTX, and 51 for a large PTX). Chest tubes were used in 89% of patients with PTX on CR and 44% of patients with PTX only on CT (difference 45%; 95% confidence interval 30, 58).Conclusion Factors associated with PTX on CR included air in the soft tissue on CR and size of the PTX. Even when PTX is not apparent on CR, 44% of these PTXs received placement of a chest tube.

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Treatment of Occult Pneumothoraces from Blunt Trauma

Abstract: Observation of OPTX is not associated with an increased incidence of pneumothorax progression or respiratory distress. These pneumothoraces can be safely observed in patients with blunt trauma injury regardless of the need for positive pressure ventilation.

Cited by 126 publications

References 8 publications

CT imaging of blunt chest trauma

CT imaging of blunt chest trauma

Occult pneumothorax, revisited

Occult Pneumothoraces in Acute Trauma Patients

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