Pneumo or Hemothorax: An EBM Primer for Diagnostic and Treatment - - PowerPoint PPT Presentation

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Pneumo or Hemothorax: An EBM Primer for Diagnostic and Treatment - - PowerPoint PPT Presentation

Feb 11, 2023 161 likes •650 views

Pneumo or Hemothorax: An EBM Primer for Diagnostic and Treatment Dr Marcel mond MSc CCFP(EM) FRCP(C) CHU de Qubec Enfant-Jsus Associate professor, Universit Laval Research director, CETIe Conflict of interest No COI Road

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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

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Conflict of interest

  • No COI
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Road Traffic injuries - 2016

  • Lethal : 351
  • BIBA: 1476
  • Minor: 35 826
  • Population: 8.2

millions

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Quebec City - Level 1 trauma center

QuickTime™ et un décompresseur sont requis pour visionner cette image.

QuickTime™ et un décompresseur sont requis pour visionner cette image.
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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.

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Plan

  • Diagnostic phase
  • Treatment plan
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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

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Plan

  • Diagnostic phase
  • Treatment plan
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Diagnostic phase

  • Plain x-rays
  • Ultrasound
  • Delayed hemothorax
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Oblique Chest x-rays!

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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)

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Ultrasound

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Ultrasound

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Ultrasound

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Ultrasound – Hemothorax Systematic Review

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Prehospital ultrasound

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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

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Delayed hemothorax

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Delayed hemothorax

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Delayed hemothorax

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Plan

  • Diagnostic phase
  • Treatment plan
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Treatment modalities

  • Wait and see!
  • Drain it!
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Occult pneumotorax: please do not touch?

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Occult pneumotorax: please do not touch?

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Occult pneumotorax: please do not touch?

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Occult pneumotorax: please do not touch?

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Occult pneumotorax: please do not touch?

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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!
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Occult pneumotorax: please do not touch?

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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%
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Needle decompression – size and location matter?!

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Needle decompression – size and location matter?!

5 cm catheter at ICS 5 - AAL 8 cm catheter at ICS 2 – MCL

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Needle decompression – size and location matter?!

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What size/type of tube for hemothorax?

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What size/type of tube for hemothorax?

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What size/type of tube for hemothorax?

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What size/type of tube for hemothorax?

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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?

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Thank you!

  • www.cetie.info
  • E-mail: marcel.emond@fmed.ulaval.ca
  • Twitter: @marcel_mond