X-ray Rounds Jay Green Emergency Medicine Resident, PGY-2 November 15, 2007

Case 1 19M MVC, high speed police chase Struck pole, unrestrained Chase on foot x 20min, caught c/o back pain O/E 86bpm, RR=16, 134/76, 98% NRB Diaphoretic, agitated, pale AE=AE, gen. abdo tenderness What now?

?Occult pneumothorax

Deep sulcus sign

Case 2 26M MBC ~80km/h Ejected, ~5min LOC, helmet cracked O/E 105bpm, 134/82, RR=20, 99%NRB Drousy, withdrawing to pain, non-verbal AE=AE, abdo soft, pelvis stable # femur L, # tib/fib R What now?

Case 2 continued Pt intubated Sent for CT panscan CT chest…

Occult pneumothorax

Case 2 Occult pneumothorax Intubated What now? What if the patient wasn’t intubated?

Pneumothorax

Traumatic Pneumothorax - Fast Facts 15-50% of severe chest trauma Rib # driven inward Significant pulmonary injury Tend not to heal spontaneously +/- hemothorax

Types of Pneumothorax Simple small ( 60%) May be occult

Simple Pneumothorax

Types of Pneumothorax Simple small ( 60%) May be occult Open Lung collapse on inspiration Severely impaired ventilation and oxygenation

Open Pneumothorax

Types of Pneumothorax Simple small ( 60%) May be occult Open Lung collapse on inspiration Severely impaired ventilation and oxygenation Tension one-way valve  intrapleural air accumulates  mediastinal shift  structures compressed  rapid onset hypotension, hypoxia, shock, acidosis

Tension Pneumothorax

Signs/Symptoms Chest pain, SOB Signs of chest trauma, respiratory distress, hypoxemia ↓ breath sounds, hyperresonance, SC emphysema Exam may be NORMAL Tension pneumothorax Agitated, cyanotic, tachycardic, ↓ cognition, severe respiratory distress, ↓ breath sounds, shift Late findings Distended neck veins, tracheal deviation, hypotension

Chest X-Ray Upright inspiratory film preferred Not seen  expiratory film 1/3 are missed in initial trauma CXR

CXR Signs of Pneumothorax Pleural margin Deep sulcus Crisp cardiac silhouette Hyperlucent hemithorax Double diaphragm Depressed diaphragm Apical pericardial fat RARELY USED! Am J Surg. 2005;189:541-6

Other Imaging CT Sensitive in any patient position Occult pneumothorax Bedside U/S Not studied enough

Treatment Chest tube Underwater seal ± suction Re-expand slowly if pneumo present > 3 days Continuous air leak  tracheobronchial injury Simple pneumothorax May observe if small (<20%), healthy pt, symptom-free, size not increasing, no PPV (1/3 progress)

Treatment Open pneumothorax Occlusive dressing + chest tube Watch for tension pneumo Intubate if defect is too large to adequately seal Tension pneumothorax Treat if suspected clinically Needle thoracostomy  open pneumothorax

Some films…

Deep sulcus

Crisp cardiac silouhette

Deep sulcus

Double diaphragm sign

Deep sulcus sign

Depressed diaphragm Pleural line

Deep sulcus sign

Normal

Occult pneumothorax

Occult Pneumothorax Absent on initial CXR Seen on subsequent CXR/CT Between 29-72% of all traumatic PTX NOT smaller in size J Trauma 2006;60(2):294-9.

Can J Surg 2003;46(5):373-9

Observe vs. Chest Tube Current opinion Close observation if no PPV, static size, asymptomatic pt Some authors advocate observation for PPV UNCLEAR J Trauma 2005;59(4): Am Surg 1992 Dec;58(12):743-6

Occult Pneumothorax Studies Background Table 2 from J Can Chir Observation (J Trauma 1999;46:987-91) 2/9 observed patients had progression Chest tube (J Trauma 1993;35:726-30) 8/15 observed patients had progression with 3 tension PTX Can J Surg 2003;46(5):373-9

Occult Pneumothorax Study Background Local data (J Trauma 2005;59(4):917-25) 0/4 observed pts had complications, 22% chest tube complications

Complications of Chest Tube Infection/Empyema Hemothorax Re-expansion pulmonary edema Bronchopleural fistula Pleural leaks SC emphysema Contralateral pneumothorax

Occult Pneumothorax Study Pilot Study - ongoing Andrew W Kirkpatrick, Kevin B Laupland, David Zygun, Rosaleen Chun, Chad Ball, John Kortbeek, Rohan Lall Issue Can we safely observe ventilated patients with a small- moderate sized occult pneumothorax? OPTICC Occult PneumoThorax In Critical Care Trial

Occult Pneumothorax Study Inclusion Small/moderate PTX No respiratory distress No HTX Admitted to ICU and being ventilated

Occult Pneumothorax Study Exclusion Chest tube thought to be needed by treating MD Obvious PTX on CXR Large OPTX Not being ventilated HTX that requires drainage Chest tube or other drain in situ

So far… 16 patients enrolled Of those observed: No progression of PTX No tension PTX None needing chest tube for PTX treatment One chest tube for hypotension (did not resolve)

Take home points 1/3 of PTX missed on initial trauma CXR Look for other signs of PTX Deep sulcus, crisp cardiac silhouette, hyperlucent hemithorax, double diaphragm, depressed diaphragm, apical pericardial fat Occult ≠ small Can we observe intubated occult PTX pts?

References Ball CG, Hameed SM, Evans D, Kortbeek J, Kirkpatrick AW. Occult pneumothorax in the mechanically ventilated trauma patient. Can J Surg 2003;46: Ball CG, Kirkpatrick AW, Laupland KB, Fox DL, Litvinchuk S, Dyer DM, et al. Factors related to the failure of radiographic recognition of occult posttraumatic pneumothoraces. Am J Surg 2005;189: Ball CG, Kirkpatrick AW, Laupland KB, Fox DI, Nicolau S, Hameed SM, et al. Incidence, risk factors, and outcomes for occult pneumothoraces in victims of major trauma. J Trauma 2005;59(4): Brasel KJ, Stafford RE, Weigelt JA, Tenquist JE, Borgstrom DC. Treatment of occult pneumothoraces from blunt trauma. J Trauma 1999;46: Enderson BL, Abdalla R, Frame SB, Casey MT, Gould MT, Gould H, et al. Tube thoracostomy for occult pneumothorax: a prospective randomized study of its use. J Trauma 1993;35: Ball CG, Kirkpatrick AW, Fox DL, Laupland KB, Louis LJ, Andrews GD, Dunlop MP, Kortbeek JB, Nicolaou S. Are occult pneumothoraces truly occult or simply missed? J Trauma 2006;60(2): Collins JC, Levine G, Waxman K. Occult traumatic pneumothorax: immediate tube thoracostomy versus expectant management. Am Surg 1992;58(12):743-6.