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Foundations Case Presentation

Foundations I Course:

Case 90

Presentation Author: Dr. Marshall Howell

Presentation Editor: Dr. E. Liang Liu

Last Revised: Fall 2024

Creative Commons ©Foundations of Medical Education, Inc.

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Case Home Base

ECG

Labs

X-Ray

CT

US

Critical Actions

Initial Vitals

Repeat A

Repeat B

Teaching

29 y/o M presents with shortness of breath and stab wound to chest

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Initial Presentation

HR: 118 BP: 75/38 RR: 30 T: 37 °C

Sat: 89% on RA Wt: 100 kg

29 yo M presents with shortness of breath and stab wound to chest

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Reevaluation A

HR: 95 BP: 115/78 RR: 28

Sat: 95% on NRB

29 yo M presents with shortness of breath and stab wound to chest

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Reevaluation B

HR: 136 BP: 60/palp RR: 40

Sat: 82% on RA

29 yo M presents with shortness of breath and stab wound to chest

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Lab Results

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ECG

Sinus tachycardia, no evidence of ischemia

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US - B Mode

Courtesy of E. Liang Liu, MD

Courtesy of E. Liang Liu, MD

Courtesy of E. Liang Liu, MD

Right Thorax

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US

M Mode

Right Thorax

Left Thorax

Courtesy of E. Liang Liu, MD

Courtesy of E. Liang Liu, MD

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US

Courtesy of E. Liang Liu, MD

Courtesy of E. Liang Liu, MD

Courtesy of E. Liang Liu, MD

Courtesy of E. Liang Liu, MD

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CXR�(fig 90.4)

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CT

Radiology: “Is this patient stable enough for CT?”

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Case Diagnosis:

Primary: Tension Pneumothorax

Secondary: Penetrating Chest Trauma, Hemothorax

Critical Actions

  • Recognition of tension pneumothorax prior to CXR
  • Emergent decompression of tension pneumothorax via tube thoracostomy, or needle decompression followed by tube thoracostomy
  • POCUS eFAST exam
  • Confirmation of tube thoracostomy with CXR
  • Trauma surgery consult and admission

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Tension Pneumothorax

  • One-way valve physiology
  • Mediastinal shift → IVC Compression�**Obstructive Shock**
  • Hypoxia, Shock, Arrest
  • Exam Triad:
    • Hypotension
    • Distended Neck Veins
    • Diminished Breath Sounds

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Clinical Diagnosis

  • Clinical diagnosis, NOT imaging
  • If diagnosis is uncertain, lung US is more sensitive than XR
    • Lung point (right) - most specific
    • Absence of lung sliding
    • Barcode sign

Courtesy of E. Liang Liu, MD

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Chest Tube Placement

Follow for instructional videos and more FOAMed Content

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Management

  • Immediate chest tube or �needle decompression
    • Locations for each?
    • Pigtail vs Surgical Chest Tube
  • Drainage system to suction
  • Confirm placement with CXR

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References

Foundations Case #90

Case Author(s): Dr. Dana Loke

Ultrasound Content: Dr. Rachel Haney, Dr. Sierra Beck

Case Editors: Dr. Kristen Grabow Moore

Additional References:

  • Chest Tube Placement.; 2016. Accessed November 13, 2024. https://www.youtube.com/watch?v=IdmMR8JxmFo
  • How to Setup a Single Collection Chest Drain.; 2016. Accessed November 13, 2024. https://www.youtube.com/watch?v=JBg_1xT3WVA
  • Hill J. Tube Thoracostomy.; 2018. Accessed November 13, 2024. https://www.tamingthesru.com/chest-tube
  • DeVivo A. Unlocking Common ED Procedures - Cutting Through the Triangle: A Review of Tube Thoracostomy in the ED. emDOCs.net - Emergency Medicine Education. June 20, 2019. Accessed November 13, 2024. https://www.emdocs.net/unlocking-common-ed-procedures-cutting-through-the-triangle-a-review-of-tube-thoracostomy-in-the-ed/
  • Image References
    • Baedr-9439, CC0, via Wikimedia Commons. https://commons.wikimedia.org/wiki/File:Tension-pneumothorax.png
    • Cpl. Alicia R. Giron, Public domain, via Wikimedia Commons. https://commons.wikimedia.org/wiki/File:USMC-100924-M-9206G-071.jpg
    • U.S. Air Force photo by Senior Airman John Wright, Public domain, via Wikimedia Commons. https://commons.wikimedia.org/wiki/File:Ground_Surgical_Teams_sharpen_skills_(6516975).jpg
    • Procedural Microskills: Chest Tubes courtesy of Dr. Marshall Howell