Image of the Day 25: Open Chest Wall with Open Pneumothorax

28 year old gentleman was brought to casualty after alleged assaulted by a known person with “parang”. Upon arrival, he was fully conscious but drowsy, pallor, with clothes and bandage soaked in blood. Blood pressure was not recordable but radial pulse was palpable with very low volume and tachycardia. Heart rate at that time was 124. Patient still having spontaneous breathing with oxygen saturation on air was 90% but improved to 100% with high flow mask 15L/min.

A primary survey revealed intact airway and breathing, a large incised wound measuring 30 cm at the right posterior medial aspect of the back with traumatic incision of the right posterior inferior lobe of the lung, and multiple laceration wound over the back, and defensive wound at right palmar of hand, left hand first web space.

Patient was resuscitated with 2 pints of normal saline, 1 packed cell, 1 whole blood and four unit of fresh frozen plasma. Haemostatic suturing of the open chest wound was done and chest tube was inserted at safety triangle. Other wound was irrigated and haemostatic suture was applied. Blood pressure picking up to 120/73 and remain stable. IV Fentanyl was given as analgesia and patient was covered with IV Cefuroxime and sent to operation theater for definitive management. 

30 cm deep incised wound at the right posterior medial aspect.

incised wound of the posterior inferior lung lobe

Discussion

Before we proceed, let us recall the algorithm in trauma life support. “ABCDE”, A is for airway and cervical protection, B is for breathing and ventilation, C is for circulation and bleeding control, D is for disability and E is for exposure and environmental factor.

In primary survey, we should play an attention to the condition that will kill the patient immediately if no intervention done. The mnemonic as being taught by all the emergency physician is ATOM FC which describe 1) Airway obstruction, 2) Tension pneumothorax, 3) Open chest wound / Open Pneumothorax, 4) Massive hemothorax, 5) Flail chest and 6) Cardiac temponade.

Patient should also be look for the Hidden 6 usually in secondary survey. Hidden six which being describe by mnemonic PATMET will resulting in patient death if being discharge home or improper disposal. It includes 1)Pulmonary contusion, 2) Aortic disruption, 3) Tracheobronchial disruption, 4)Myocardial contusion, 5)Esophageal trauma, and 6)Traumatic diaphragmatic rupture.

This case explain about open pneumothorax. A quick diagnosis should be made during the primary survey and fast intervention should be provided.

In normal physiology, air will enter the lung  during inspiration due to negative intra thoracic pressure. When there is a chest wall defect especially if the size of the hole is more than 0.75 times the size of trachea. The reason is that, the chest wall defect is shorter than trachea, providing less resistance to flow.

As the air enter the pleural space, a tension may develop especially if the flap is created, allowing the air to come in but not out. This will resulting in inadequate oxygentation and ventilation.

Oxygen delivery should be started with 100% oxygen via the non rebreather mask. Any failure to oxygenation or ventilation require intubation. An open wound must be closed with a seal and a chest tube must be inserted urgently.

if there is no chest tube and proper seal especially during the field assessment, a  cover with three sided tape can be applied which act as a valve, allowing the air to escape from the pneumothorax during inspiration but not to enter during the inspiration.

After stabilization, complete secondary survey must be done and patient should be sent for definitive management in operation theater.

Reference:

1) http://www.trauma.org/archive/thoracic/CHESTopen.html

2) Shirley Ooi