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Pneumo or Hemothorax: An EBM
Primer for Diagnostic and
Treatment
Dr Marcel Émond MSc CCFP(EM) FRCP(C)
CHU de Québec – Enfant-Jésus
Associate professor, Université Laval
Research director, CETIe
Conflict of interest
• No COI
Road Traffic injuries - 2016
• Lethal : 351
• BIBA: 1476
• Minor: 35 826
• Population: 8.2
millions
Quebec City - Level 1 trauma center
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Objectives
• To examine recent evidence on the detec-
tion and treatment of pneumothorax,
hemothorax, delayed hemothorax in the
emergency department.
• To compare the diagnostic modalities
available and evaluate the need to drain a
small, occult, or large pneumothorax or
hemothorax.
Plan
• Diagnostic phase
• Treatment plan
Demographics
• N= 16,773
• Mean age (SD): 47.8 (19.9)
• Male : 76.2%
• Mean ISS (SD) : 20.7 (7.5)
• Mortality : 4.8 %
Injury Mechanisms
Car
Motorbike
Bicycle
Pedestrian
High-fall
Low-fall
Plan
• Diagnostic phase
• Treatment plan
Diagnostic phase
• Plain x-rays
• Ultrasound
• Delayed hemothorax
Oblique Chest x-rays!
95% CI PPV = 95.6 (0.86 to 0.99) NPV = 90.1 (0.87 to 0.91) Sensitivity = 61.4 (0.56 to 0.64) Specificity = 99.2 (90.98 to 1.00)
95% CI PPV = 93.6 ( 0.84 to 0.98) NPV = 90.4 (0.89 to 0.91) Sensitivity = 62.9 (0.57 to 0.66) Specificity = 98.8 (0.97 to 1.00)
Ultrasound
Ultrasound
Ultrasound
Ultrasound – Hemothorax
Systematic Review
Prehospital ultrasound
Delayed Hemothorax
• Misthos (2004) : incidence of
7.4 % in the 14 days after a
thoracic injury
• Longest delayed hemothorax
was at nearly 45 days.
• Possible mortality and
morbidity
Delayed hemothorax
Delayed hemothorax
Delayed hemothorax
Plan
• Diagnostic phase
• Treatment plan
Treatment modalities
• Wait and see!
• Drain it!
Occult pneumotorax: please do not
touch?
Occult pneumotorax: please do not
touch?
Occult pneumotorax: please do not
touch?
Occult pneumotorax: please do not
touch?
Occult pneumotorax: please do not
touch?
Occult pneumotorax: please do not
touch?
• 277/602 (46%) of patients managed
conservatively
• 252/277 (90%) did not require subsequent
thoracic intervention
• Positive pressure ventilation = no
influence
• Less than 2 cm!
Occult pneumotorax: please do not
touch?
Needle decompression –
size and location matter?!
• ATLS: decompression using a 5-cm
angiocatheter at the second
intercostal space (ICS2) on the
midclavicular line (MCL)
• Failure rate – 13-40%
Needle decompression –
size and location matter?!
Needle decompression –
size and location matter?!
5 cm catheter at ICS 5 - AAL 8 cm catheter at ICS 2 – MCL
Needle decompression –
size and location matter?!
What size/type of tube for
hemothorax?
What size/type of tube for
hemothorax?
What size/type of tube for
hemothorax?
What size/type of tube for
hemothorax?
Take home messages!
• Diagnostic phase – Oblique Chest-Xray could be useful
– Ultrasound at the bedside
– Delayed hemothorax can be predicted
• Treatment plan – Small pneunothorax : conservative?
– Needle decompression: use a bigger or change location
– Hemothorax : smaller drain?
