© Springer International Publishing Switzerland 2016
Abe Fingerhut, Ari Leppäniemi, Raul Coimbra, Andrew B. Peitzman, Thomas M. Scalea and Eric J. Voiglio (eds.)Emergency Surgery Course (ESC®) Manual10.1007/978-3-319-21338-5_2626. Thoracic Emergencies
(1)
Department of General and Thoracic Surgery, French Military Health Service Academy Ecole du Val de Grace, Paris, France
(2)
Department of General and Thoracic Surgery, Percy Military Hospital, Clamart, France
26.1 Pneumothorax
26.1.1 Tension Pneumothorax
26.2.1 Types of Effusion and Causes
26.2.2 Diagnosis
26.2.3 Indications
26.3.1 Causes
26.3.2 Diagnosis
26.4 Summary
Objectives
Recognize patients requiring a needle thoracocentesis or an emergency chest tube insertion
Perform safe thora(co)centesis or chest tube insertion
Recognize when a patient needs an emergency pericardiocentesis
Perform a subxiphoid pericardial window
Every general surgeon should be able to manage the following non-trauma chest emergencies:
Tension pneumothorax
Pleural effusions (compressive or empyema)
Cardiac tamponade
26.1 Pneumothorax
26.1.1 Tension Pneumothorax
26.1.1.1 Causes
Pneumothorax may occur spontaneously in non-trauma patient without apparent chronic lung disease (primary). This is usually subsequent to ruptures of small pulmonary blebs.
Pneumothorax may also occur in patients with chronic lung disease (“secondary”); e.g., emphysema, tumors. In that case, the rupture involves bullae or diseased pulmonary parenchyma.
26.1.1.2 Diagnosis
Main symptoms:
Chest pain and shortness of breath
High-pitched sounds on percussion
Chest X-ray: confirmation of pneumothorax and determination of volume
Tension pneumothorax (one-way air leak)
Rare
May lead to respiratory distress, oxygen deprivation, tachycardia, hypotension, tracheal deviation, and cardiac arrest
Specifically when there is preexisting impaired lung function
26.1.1.3 Indications
When symptoms are severe, urgent insertion of chest tube is needed.
Initial management by needle decompression is easy and allows to gain time.
26.2 Liquid Pleural Effusions
26.2.1 Types of Effusion and Causes
Blood: primary spontaneous hemothorax (can occur in patients under anticoagulant treatment).
Pus: thoracic empyema (or pyothorax) can be responsible for poor clinical status and respiratory failure.
Serous liquid: secondary to pulmonary infection, pulmonary embolism, cancers, etc.
26.2.2 Diagnosis
Relies on symptoms (dyspnea, chest pain), chest percussion, chest X-ray, and CT scan.
Symptomatology depends on the volume of the collection.
Pleurocentesis can identify the nature of the aspirate (blood, pus, serous liquid, transudate, exudate, etc.)
26.2.3 Indications
Most pleural effusions can be managed initially by medical physician’s referral to thoracic or cardiovascular surgeon and may be necessary according to the type and nature of the pathology.
Two circumstances require urgent treatment:
1.
Respiratory failure (dyspnea, cyanosis, hypoxemia, etc.); insert a chest tube promptly
Pleurocentesis can improve the clinical status of the patient before the chest tube is inserted.
2.
Purulent collections found on pleurocentesis or empyema
(a)
Definitions:
i.
Empyema means pus in a natural cavity.
ii.
Thoracic empyema means pus in the pleural cavity.
(b)
Diagnosis can be
i.
Frank pus is found
ii.
Or demonstration of organisms by direct examination or culture
iii.
And/or biochemical criteria such as pH <7.2, WBC >15,000, LDH >1,000 IU/ML, and glucose <400 mg/l
Chest tube thoracotomy with IV antibiotics
Thoracocentesis constitutes the first step of the treatment.
May be sufficient (success rate is 70 %)
Should be followed by drainage thoracostomy
To allow complete evacuation of accumulated pus
In case of failure (multiloculated effusion) and according to the stage of the empyema, surgery is necessary.
To clean the pleural cavity
To perform decortication as needed (Fowler-Delorme procedure)
Can be performed via VATS or thoracotomy
Referral to specialized centers and/or surgeon preferable
26.2.4 Thoracentesis (Also Called Thoracocentesis or Pleurocentesis) and Chest Tube Insertion
26.2.4.1 Thoracocentesis or Pleurocentesis (Pleural Tap)
Equipment:
20 cc syringe
Intramuscular (IM) needle
Xylocaine
20 gauge catheter or better, a Veress needle
Longer and reaches the pleural collection easily when the chest wall is thick.
Retractable tip limits the risk of lung puncture.
Puncture site
Pneumothorax best exsufflated in second costal interspace, just anterior to the midclavicular line.
In obese patients with thick chest wall, lateral approach in the fourth costal interspace anterior to the midaxillary line is preferred.
Fluid collection best treated by a posterior approach, just in the middle of area of matted percussion with patient sitting upright on the bedside and leaning forward on a table and arms over a pillow.Related posts:
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