Rabu, 11 Mei 2011

Open Pneumothorax

Management of Open Pneumothorax Caused by Penetrating Trauma Using Water Sealed Drainage (WSD)

Dana SatriaKusnadi, Liberty TuaPanahatan, Rian Fabian Sofyan, RylisMaryanaTamba, YusakKristianto,
Translator: Adrian Salim, Andrio Wishnu Prabowo, Arnetta Naomi L. Lalisang, Julistian, Muliyadi, Sony Sanjaya, Stefanny, Zamzania Anggia Shalih.
General Surgery, Department of Surgery, Faculty of Medicine Universitas Indonesia – CiptoMangunkusumo Hospital, Jakarta, Indonesia, April 2011

Case Illustration
A 29 year-old man came to the ER with chief complaint open wounds on his chest and neck since 1 hour prior hospital visit. Pasien was severely battered by several people using baton to the head and had also several slash injuries caused by sickle to the left side of his chest, neck and arm. The patient had difficulty breathing and was agitated in the ER.
On physical examination, we found:
Primary Survey
-        Airway           : clear
-        Breathing       : spontaneous with RR 42x/mnts (tachypnea). There was bruises on the left chest, vulnusscissumon anterolateral aspect of the left sixth intercostal space (15x3 cm). Thoracic cavity, diafraghm and lung were intact, no bleeding, but left chest movement was delayed with sucking chest wound (+). This suggested the presence of left open pneumothorax. The patient was given 100% oxygen 10L/mnts via NRM, then underwent emergency chest tube insertion 10 minutes after arrival to the ER. 

-        Circulation      : face and extremities were pale, clammy and cold, pulse rate 110x/mnts, regular but faint,  blood pressure 90/60 mmHg, and oxygen saturation 95,6%. We placed 2 IV lines to give fast RL infusion and placed a central venous line on left jugular vein
-        Disability         : GCS = E3M5V4, total 15
Post-resuscitation and chest tube insertion, blood pressure remained 90/60 mmHg, pulse rate 108x/mnts, RR 38x/mnts, and O2 saturation 99%; breath sounds was vesicular bilateral, no rales and wheezing. We then performed AP and Supine Chest X-ray. 

Secondary Survey
There was pale conjunctiva showing sign of anemia, vulnusscissumon left aspect of the neck with no bleeding. Limbs examination showed clammy extremities with prolongation of CRT (>2 secs) and traumatic amputation of digiti II manussinistraat the level of PIP.
Laboratory values showed the Complete Blood Count and Arterial Blood Gas were within normal values. Other therapies given in inpatient care were chest physiotherapy, routine inhalation therapy, analgesia, antibiotics and liquid diets given per NGT; with close monitoring of vital signs and chest tube drain production. Chest tube drains 375cc per 10 hours (0,6cc/kgs/hour, body weight 60 kgs)

Chest Tube Insertion Report (in the ER)
Sepsis and asepsis of the surgical field were performed.
Vulnusscissum on the anterolateral aspect of left hemithorax, sixth intercostal space was identified, size 15x3 cm. Thoracic cavity and diafraghm were intact, no active bleeding.
A no 32 chest tube was inserted on the left midaxilaris line of sixth intercostal space. Initial fluide production was 30 cc, serohemorrhagic with fluctuation (+), initial bubble (+) and respiratory bubble (-). Chest tube was then fixated using 1.0 silk suture. Open wounds were sutured using vicryl x.0, and closed layer by layer.
Operation is finished.

Literature Review
Thoracic trauma accounts for one-forth of all chest-related mortality; two-thirds of these mortalities happen after hospital admission.1,2Trauma to the chest may cause pneumothorax.2,3Based on the patophysiology, there are two types of pneumothorax: tension pneumothorax and traumatic pneumothorax.
In tension pneumothorax, there is disruption in either visceral pleura, parietal pleura of tracheobronkial tree that create abnormal connection between intrapulmonary and intrapleural air.1Traumatic pneumothorax may be caused by blunt or penetrating trauma.1,3 Penetrating trauma, potentially those that creates big open wound on chest wall, will cause open pneumothorax. When the wound size exceeds two-thirds of tracheal diameter, air will fill the intrapleural space causing the loss of pressure gradient.4The ongoing air collection in the pleural space may shift the mediastinum, a life-threatening emergency condition.2
As with other trauma cases, pneumothorax management consists of the management of Airway, Breathing, and Circulation. Sucking chest wound requires emergent wound closing using occlusive or pressure dressing that is taped to the chest wall on 3 sides. This type of closure may create Flutter Type Valve that allows air to flow outside during expiration but not inside during inspiration.4

Tube Thoracostomy using Water Sealed Drainage (WSD)is still the first management option in pneumothorax. Beside therapeutic, WSD may also be beneficial in establishing diagnosis.5,6WSD is useful to evacuate air, to evacuate and measure bleeding, to detect massive air leak and to see if the patient is indicated to undergo thoracotomy. Indications for thoracotomy includes chest tube drainage of 3-5cc/kgBW/hr for 3 consecutive hours or 5cc/kgBW/hr, the presence  of continuous bubble in large bronchopleuralfistule or the persistence of expiration bubble for more than 2 days in medium-sized bronchopleural fistula.7

The diagnosis of open pneumothoraxwas established based on clinical examination: chest pain, dyspnea with tachypnea, tachycardia, hyperresonant on percussionwith diminished breath sounds and vulnusscissumon the anterolateral aspect of sixth intercostal space of the left hemithorax, size 15x3cm. Chest X-ray done after chest tube insertion showed free air in the pleural space.
In the late stages, pneumothorax patients may experience loss of consciousness, contralateral tracheal deviation, sianosis and hypotension with distented neck veins. Additional examinations that may be suggested are chest x-ray, CT-scan, ultrasonography, arterial blood gas and electrocardiography; but it should be bear in mind that pneumothorax is a clinical diagnosis, laboratory and radiological examination should not delay the emergency management.1

The respiratory distress that this patient experienced is cause by open pneumothorax that created abnormal connection between intrapleural space and atmospheric air. This condition should be managed emergently by inserting a WSD chest tube. While can be done in the ER, care should be taken to make sure a- and antiseptic measures are done correctly.5,6
Chest tube connected to the WSD may be placed anywhere in the chest, as long as it can return the negative intrapleural pressure. The ideal place for tube insertion is fifth or sixth intercostal space between the medial and posterior axillaris line for the right chest, and sixth or seventh intercostal space between the medial and posterior axillaris line for the left chest.5

Chest tube can be removed when the physiological function has returned completely: (1) full expansion of the lungs, as evidenced by clinical and radiographic examination, (2) drain production is less than 100cc per 24 hrs, (3) no air bubble, (4) no fluctuation in the tube, provided there were no tube blockage or kinking. Chest tube may be removed during inspiration or expiration. At the end of inspiration or expiration, the patient should do Valsalvamanuever and hold it until chest tube is removed completely from chest wall.7

1. Open Pneumothorax: Pneumothorax with opening of the pleural space and have abnormal connection with the atmosphere through the defect of the chest wall.

2. CVC: Central Venous Catheter.  Is a catheter that placed into a large vein (Internal Jugular Vein, Vena JugularExternal Jugular Vein,Subclavian Vein,FemoralVein that used to administer medications and fluids, to measure venous oxygen saturation,  and toobtain cardiovascular measurements such as the Central Venous Pressure.

3. VulnusScissum :wound that caused by sharp objects (ex : Knife)

4. CRT: capillary refill time isa quick examination by pressing the soft pad of a finger or toe nails and taking note of the time needed for the color for the color to return, used to evaluate the dehydration status and peripheral perfusion.

5. Undulation: movement of fluids in the WSD tube which follow the respiratory pattern of the patients
1. Sharma A, Jindal P. Principles of diagnosis and management of traumatic pneumothorax. J Emerg Trauma Shock [serial online] 200 [cited 2011 Apr 8];1;34-41. Available from: http://www.onlinejets.org/text.asp?2008/1/1/34/41789

2. Khan MLZ, Haider J, Alam SN, Jawaid M, Maliks KA. Chest Trauma Management: Good Outcomes possible in a general surgical unit. Pak J Med Sci April - June 2009 Vol. 25 No. 2 217-221.

3. M.R. Khammash& F. El Rabee: Penetrating Chest Trauma in North of Jordan: A Prospective Study. The Internet Journal of Thoracic and Cardiovascular Surgery.2006 vol 8(1)

4.American College of Surgeons Committee on Trauma.Thorax Injury. In: Advanced Trauma Life Support for Doctors: Student Course Manual 7th ed. 2004. Jakarta: Trauma Committee “IKABI”. page 111-42.

5. Dural K, Gulbahar G, Kocer B, Sakinci U. A novel and safe technique in closed tube thoracostomy. Journal of Cardiothoracic Surgery 2010, 5:21. Available from: http://www.cardiothoracicsurgery.org/content/5/1/21

6. Muslim M, Bilal A, Salim M, Khan MA, Baseer A, Ahmed M. Tube Thoracostomy: Management and outcome in patients with penetrating chest trauma. J Ayub Med Coll Abbottabad 2008;20(4)

7. Wuryantoro.Water Sealed Drainage (WSD). Presented in The Department of Surgery, Faculty of  Medicine University of Indonesia, CiptoMangunkusumoNational Hospital, May 15, 2009