What is the diagnosis?

Right-sided pneumothorax (PTX) with underlying rib fractures.

What diagnosis cannot be missed with this presentation?

Tension PTX - When a PTX begins to compress venous return, it can lead to cardiac arrest. First signs are hemodynamic instability. Immediate decompression should be performed without confirmatory imaging/testing.

• Pearl: Decompress with 14 gauge angiocath placed in the second intercostal space, mid-clavicular line. You may hear a rush of air once it is placed and the patients’ vital signs should stabilize. 

• Pearl: Additional techniques include  finger thoracostomy in the same location as a chest tube insertion (anterior axillary line, 4-5th intercostal space), OR an angiocath in this location can also be performed[1].

What is the mechanism of injury?

PTX can be spontaneous (primary or secondary), traumatic, or iatrogenic.

• Pearl: Primary spontaneous PTX occurs most commonly in patients between 20-30 years old. Secondary spontaneous PTX is seen more in older age patients (60-65 years), and has a much higher incidence in patients with COPD. The annual incidence of traumatic PTX is estimated to be 81 per 100,000 people, and the condition accounts for 20.6% of major trauma patients (2,3,4).

What physical exam findings are expected?

Diminished or absent breath sounds on the affected side, hyperresonance on percussion, loss of tactile fremitus, and possible crepitus (more common with trauma).

• Pearl: If a patient comes in with chest pain and/or shortness of breath and  has unstable vital signs, you should have high suspicion for tension PTX. In addition to the above exam findings, you may also note tracheal deviation, distended neck veins, and signs of respiratory distress. 

Which imaging modalities can be used?

An upright AP chest XR can allow for quick identification of a PTX and is usually the first imaging obtained. If there is still concern for a PTX and none is seen on x-ray, a CT chest can be performed and is considered the gold standard for diagnosis. This will increase the sensitivity and allow you to visualize small pneumothoracies that may not be seen on xray [7].

• Pearl: Ultrasound (US) has become a great adjunct to evaluate for PTX. It has been noted to be 90% sensitive compared to x-ray which is 52% sensitive [6]. 

What is the management in the ED?

If the patient is unstable, immediate decompression should occur. If the patient is stable, then treatment guidelines are commonly institutionally dependent. In patients with a small PTX who are clinically stable, a repeat x-ray at 4 hours can be performed. If the PTX is stable and not expanding, the patient can likely be discharged with a repeat x-ray to be performed 24-48 hours after discharge. If the PTX is expanding or a large PTX is now present, the patient will likely need a chest tube placed and will require admission to the hospital for observation [8]. 

Does a surgical team need to be consulted?

Not for immediate treatment. General surgery will typically manage the chest tubes as an inpatient however and will likely need to be consulted for ongoing management. Orthopedics definitely do not need to be consulted in this case.