Geekymedics.com-Pneumothorax Acute Management Abcde PDF

Preview

Summary

Download Geekymedics.com-Pneumothorax Acute Management Abcde PDF

Description

Pneumothorax | Acute Management | ABCDE geekymedics.com/pneumothorax-acute-management-abcde-approach/ Dr Celestine Weegenaar

August 21, 2018

All types of pneumothorax have the potential to become a tension pneumothorax, which is lifethreatening and must be recognised and treated in a timely manner. A tension pneumothorax is one of the 4Hs and 4Ts of reversible cardiac arrest. You can read more about the 4Hs and 4Ts here. This guide gives an overview of therecognition and immediate management of pneumothorax using the ABCDE approach. You can check out our overview of the ABCDE approach here. This guide has been created to assist students in preparing foremergency simulation sessions as part of their training. It is not intended to be relied upon for patient care .

Clinical features of a pneumothorax A pneumothorax is a collection of air between the parietal and visceral pleura. There are several different ways to classify and name pneumothoraces. Most simply, a pneumothorax can be either primary or secondary: A primary pneumothorax occurs without any underlying disease. A secondary pneumothorax is due to underlying lung disease such as asthma or COPD. Pneumothoraces can also be described as either spontaneous or traumatic (e.g. occurring secondary to penetrating chest trauma).

Tension pneumothorax All types of pneumothorax can potentially develop into atension pneumothorax. A tension pneumothorax is life-threatening because it results in a sudden rise in intrathoracic pressure which reduces venous return to the heart and ultimately causes cardiac arrest.

1/10

Symptoms Classical symptoms of a pneumothorax include: Sudden onset chest pain Acute shortness of breath A feeling of not being able to take a full breath

Signs Classical clinical signs include: Tachypnoea Tachycardia Hypoxia Reduced breath sounds on the affected side Hyperresonance on the affected side Tracheal deviation (away from the affected side) is a clinical sign of tension pneumothorax and warrants prompt treatment with decompression

Tips before you begin Treat all problems as you find them Reassess regularly and after every intervention to see if your management is effective Make use of the team around you todelegate tasks where appropriate All critically unwell patients should havecontinuous monitoring equipment attached for accurate observations including: Blood pressure 3-lead ECG Oxygen saturations Heart rate Respiratory rate Communicate how often you would like these observations to be relayed to you Call for help early using an appropriate SBARR handover structure (check out the guide here) You need to both request investigations and review results as they become available You don’t have to memorise everything off by heart, ask forguidelines and algorithms that are relevant (i.e. pneumothorax treatment guidelines) If you would like medications or fluids, these will need to be prescribed Don’t forget to document everything you have found and done in the patient notes!

Initial steps You are likely to be called to see this patient as a new presentation to ED with chest pain and/or shortness of breath. 2/10

Inspection Perform a quick general inspection of the patient to get a sense of how unwell they are: If the patient is unconscious, check for a pulse and check that the patient is breathing.

If the patient is unconscious or unresponsive and not breathing start the basic life support (BLS) algorithm as per resuscitation guidelines. Call 2222 for help! (see our BLS guide here) Perform AVPU and assess their consciousness level How do they look? What is their breathing like? Are there any clues from around the bedside? (look for drug charts, medication, IV lines, monitoring equipment etc)

Interaction Introduce yourself to the patient If the patient is able to answer questions, ask how they are feeling

Preparation Ensure you have as much information as possible available to you Patient notes Drug charts including diabetes charts Observations charts Does this patient have an underlying lung condition? (e.g. COPD, cystic fibrosis, pneumonia or lung cancer) Is the patient a smoker?

Airway Assessment Assess the patient’s ability to speak, listen to the patient’s breathing for added sounds and inspect the mouth.

3/10

Intervention If you think your patient has acompromised airway you need help. Put out a crash call immediately as you require urgent anaesthetic input to secure the airway. You can perform some simple airway manoeuvres in the meantime.

Maintaining the airway whilst awaiting senior support 1. Perform a head tilt, chin lift manoeuvre. 2. If noisy breathing persists, try ajaw thrust. 3. If this is still not enough to open up the airway you can consider the use of an airway adjunct: If your patient is still semi-conscious then consider using anasopharyngeal (NP) airway. If your patient is able to tolerate anoropharyngeal (OP, or Guedel) airway then you can use one of these. However, this indicates that your patient is seriously unwell as they no longer have a gag reflex.

Reassess after any intervention If your patient starts to improve throughout your assessment, they may no longer be able to tolerate the OP airway and you should remove it as soon as possible to prevent gagging/aspiration.

Breathing Assessment Oxygen saturation Aim for 94-98% If the patient has COPD with known CO2 retention then you can consider aiming for an oxygen saturation range of 88-92%, however, in an acute setting, it is often acceptable to commence high-flow oxygen and then titrate down once the patient has stabilised

Respiratory rate Tachypnoea is the body’s response to hypoxia Impaired consciousness may lead to a reduced respiratory rate (bradypnoea)

4/10

Examination Auscultate, palpate and percuss both lungs Examination findings during the assessment of the chest in pneumothorax include: Unilaterally reduced chest expansion Unilateral hyper-resonance Unilaterally reduced air entry

A tension pneumothorax is a clinical diagnosis. Treat for a tension pneumothorax immediately (without waiting for a CXR) if you find clinical signs of a pneumothorax in addition to: Tracheal deviation Raised jugular venous pressure (JVP)

Investigations Arterial blood gas An arterial blood gas may be useful to quantify the degree of hypoxia if your patient has low oxygen saturations. ABG results in pneumothorax may show low PaO2 and normal/low PaCO2 due to hyperventilation.

Chest x-ray A CXR will identify most pneumothoraces Typical CXR findings include: Air in the pleural space Decreased lung markings around the outer edge of the lung field Lung collapse Small pneumothoraxes can be difficult to see on the CXR, especially if you aren’t looking for them! There may be an indication to request aCT scan of the chest if you are uncertain of the diagnosis but you should speak to a senior about this

A chest x-ray showing a tension pneumothorax should ideally never be seen, as it should have been identified during clinical examination and treated immediately. If, however, a chest x-ray was performed, you would expect to see visibletracheal deviation and lung collapse.

5/10

Intervention Oxygen Administer oxygen as soon as possible High-flow oxygen (15 litres) through a non-rebreathe mask If the patient is conscious, sit them upright Maintain oxygen saturations between 94-98%

Simple pneumothorax treatment There are very clear guidelines from theBritish Thoracic Society (BTS) on how to treat a pneumothorax. The choice of treatment depends on: History of smoking or underlying lung disease (secondary pneumothoraces) Age Size of pneumothorax Degree of breathlessness Response to treatment

The BTS guidelines for a simple pneumothorax (not tension) can be found in fullhere, but the key management options are summarised below. Consider discharge and review in 2-4 weeks: This is for patients with a small primary pneumothorax and no breathlessness Aspirate with a 16-18G cannula (up to 2.5L): This is for patients with a large primary pneumothorax or those who are symptomatic or for patients with a small secondary pneumothorax Admit and administer high flow oxygen and observe: This is for patients with a very small (...