Presentation
Stabbed to the left chest with kitchen knife. Chest pain and shortness of breath. Sats and blood pressure normal.
Patient Data
Minor rotation and underinspired film.
No ECG leads, ET tube or chest drain.
Large left-sided pneumothorax with contralateral mediastinal shift indicating a tension pneumothorax. No pleural effusion.
This is a clinical emergency and the pneumothorax should be decompressed urgently (usually with a cannula in the 2nd intercostal space anteriorly).
Large left-sided pneumothorax with associated collapsed lung.
The midline is clear from the spinous processes (dashed line).
The trachea (yellow) is displaced from the midline, away from the side of the pneumothorax - it is under tension.
A cannula was inserted into the 2nd intercostal space with apparent symptomatic improvement.
A large bore chest drain was inserted into the lateral chest wall to facilitate decompression. However, 1 hour later, symptoms of breathlessness have returned and heart rate has increased.
The chest drain is no longer swinging and the chest is hyper-resonant to percussion.
A smaller bore anterior chest drain is inserted and the patient is transferred to radiology for a CT.
Persistent left-sided tension pneumothorax.
The large drain that has been inserted into the lateral chest wall has its tip within (or adjacent to) lung parenchyma which is likely limiting its efficacy.
Case Discussion
This case demonstrates the common findings in tension pneumothorax:
- increased lucency on the side of the pneumothorax
- lung edge
- absence of lung markings peripherally
- mediastinal shift away from the pneumothorax (indicating tension)
Prompt decompression and chest drain insertion is required, but an assessment of the patient is key to ensure that when the chest drain is in place, it is working appropriately.
If there is clinical concern, reassessment of the patient and the drain must happen and further imaging may be required.
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