Now, what if the patient becomes
hypotensive with distended
jugular veins while you’re
assessing the airway?
What’s going on in your mind?
What’s your next
I’ll give you a second
to think about this.
You’re thinking the patient may
have a tension pneumothorax.
Can you see what the tension
pneumothorax is on this image?
I’ll give you a second to look at it
and then I’ll point it out to you.
You clearly see the
pneumothorax in the left side,
but what defines it as
tension is the fact that the
mediastinum has now shifted to
the right side of the screen.
However, remember, tension pneumothorax
should never be a radiographic diagnosis.
Remember, tension pneumothorax is a
clinical diagnosis not a radiographic one
and patients with tension pneumothorax
or a pneumothorax associated
with hemodynamic instability is at
high risk for rapid deterioration.
Your quick action can
save the patient’s life.
This is high-yield information.
Now, it’s important to understand
pathophysiology behind tension pneumothorax.
As you know, none of our organ
systems worked in a vacuum.
The interaction between the lung and
the heart is very, very important.
Let’s quickly review.
In a tension pneumothorax, the
pneumothorax shifts the mediastinum.
Subsequently, the pneumothorax is
increasing the intrathoracic pressure.
While it’s not a very high pressure relative
to baseline, it’s a positive pressure.
As a result, there’s
decreased venous return.
The high intrathoracic pressure
decreases the venous return.
And subsequently, there’s less filling
of the heart and hypotension ensues.
This is a series of
pathophysiology behind why
the patients become
If you have a patient
with absent breath sounds
and presented with
the next step in management
is absolutely to
put a chest tube in, not
to get a chest x-ray.
As a reminder,
the decreased venous return is due
to intrathoracic hypertension
which leads to decreased
cardiac output and hypotension
and the treatment is
with a chest tube or
Now let’s move on to
a different topic.
Multiple rib fractures.
If you have a high velocity
mechanism that causes rib fractures
like it’s demonstrated on
this 3D reconstruction,
what’s going on in your mind?
What would you like to
do for the patient?
And what are you
Historically, patients with
multiple rib fractures
particularly those with flail
segments were rendered
immobilize to the chest
wall thinking that the
chest wall immobilization
would help the patient.
And the rationale behind
that was patients experience
significant amount of pain with
the multiple rib fractures
and they splinted and did not take
deep breaths as a result of the pain.
Clinicians back then thought, “Well if
they’re splinting because of the pain,
let’s immobilize the chest wall so there’s
not so much motion and decrease pain.”
by weights did not help.
In fact, it made things worse.
It caused atelectasis
and led to pneumonia.
So, what’s the
Well, largely we want to
maintain pain control.
Pain control is incredibly
important and there
are multifaceted ways
that we can control pain.
The reason we want to make sure the patient
has adequate control of the pain is because
we don’t want them to splint and we want
them to have adequate inspiratory effort.
You can give the patient schedule narcotic
pain medications as well as non-steroidals.
And sometimes, it’s helpful to place
an epidural or a paravertebral block
particularly in patients with multiple
rib fractures or flail segments.
And so simple but very, very important
and effective is pulmonary toilet.
Here, you see an
Every hospital has it.
In fact, all your patients
who will get admitted
should be offered an
Patients take nice deep inspiratory
effort to float the balloon.
This is a similar mechanism.
Just as a reminder to you, flail
segments are multiple rib fractures in
multiple segments and can lead to
paradoxical motion of the chest wall.
Now, what’s the big deal
behind rib fractures?
Well, we used to think the rib fractures
in and of themselves were the problem.
In fact, the rib fractures
did cause pain,
but it’s actually the pulmonary
contusion or bruising of the
lung underneath the rib fracture
that cause more problems.
Here, you see on the right
side a haziness to the
lung as opposed to the
normal aeration on the left.
With the appropriate
for example multiple rib
fractures on the right side,
this is likely pulmonary contusion
or bruising of the lung.
Pulmonary contusion on cross-sectional
imaging is very difficult to
differentiate from, for example, atelectasis
or consolidation like pneumonia.
So again, clinical
context is important.
Remember, what happens
if you bang your knee?
Swelling happens or
This is exactly what
happens in the lung.