7/29/2019 tension(p47-p48).pdf

1/2

Hong Kong Journal of Emergency Medicine

Can tension haemopneumothorax have stable haemodynamics?

AYC Siu and CH Chung

Tension pneumothorax or haemopneumothorax is a clinical diagnosis. Plain radiography is not advised to

confirm the diagnosis and may delay definitive treatment. Unstable haemodynamics is one of the pre-

requisites for the diagnosis. We report a case in which the patient suffered from haemopneumothorax with

all the typical radiological features of tension, but without any clinical sign of unstable haemodynamics.

Close monitoring of patients suspected to have pneumothorax is recommended, especially in the radiology

suite. (Hong Kong j.emerg.med. 2003;10:47-48)

Keywords: Diagnosis, haemopneumothorax, pneumothorax, tension

Correspondence to:Siu Yuet Chung, Axel,FRCS(Edin), FHKCEM, FHKAM(Emergency Medicine)North District Hospital, Accident and Emergency Department,9 Po Kin Road, Sheung Shui, N.T., Hong KongEmail: ycasiu@rcsed.ac.uk

Chung Chin Hung, FRCS(Glasg), FHKAM(Surgery), FHKAM(EmergencyMedicine)

Introduction

Tension pneumothorax and haemopneumothorax are life-

threatening emergencies. Delayed resuscitation will result

in morbidity and even mortality. The differentiation

between simple and tension pneumothorax is purely

clinical. The presence of hypotension or instability will

suggest the presence of tension. Radiological investigation

is not recommended as a tool to detect tensionpneumothorax though there are well-documented

changes. In the absence of hypotension, one may have

difficulty in diagnosing tension pneumothorax. This may

create a dilemma against the traditional teaching on the

role of radiological diagnosis.

Case history

A 27-year-old lady with good past health returned from

Mainland China after a collision accident involving mini-

racing car. She was restrained in the mini-racing car and

suffered contusion to her right upper back. She complaint

of severe pain over the back but there was no shortness of

breath. On arrival, she was conscious and alert. Her blood

pressure was 100/62 mmH g, pulse rate was 96/min,

respiratory rate was 20/min and oxygen saturation was

96% in room air.

Ini tial assessment showed decreased breath sound over

right lung and the trachea was central. The heart sound

was normal. H owever, the chest radiograph showedmassive right haemopneumothorax. The trachea was

central but the mediastinum was shifted to the left.

(Figure 1)

Figure 1.

7/29/2019 tension(p47-p48).pdf

2/2

Hong Kong j. emerg. med.Vol. 10(1)Jan 200348

A diagnosis of tension haemopneumothorax was made.

She was immediately resuscitated with intravenous fluid

replacement and tube thoracostomy was performed

immediately. The drain yielded 500 mL of fresh blood

initially and the right lung re-expanded after theprocedure. She was admitted to surgical ward for further

management. Due to the continuous output from the

chest drain, emergent thoracoscopy and thoracotomy

were performed which confirmed a tear at the anterior

branch of the right subclavian artery. Haemostasis was

successful and the post-operative course was uneventful.

She was discharged after six days of hospitalisation.

Discussion

The definition of tension pneumothorax was different in

different settings. In experimental models, "tension" was

defined as a continuous positive intrapleural pressure in

a spontaneously breathing patient. However, in daily

clinical setting, tension pneumothorax was basically a

clinical diagnosis and hypotension with respiratory1

compromise in the presence of pneumothorax was the

hallmark of the condition. The tradit ional teaching stated

that radiological confirmation was not required as it might

delay the treatment. It was also highlighted in the manualof Advanced Trauma Life Support (ATLS) provider course

that a prompt clinical diagnosis and immediate needle

decompression were of utmost importance in salvaging

the patient's life.2

Without the presence of compromised haemodynamic

state, one may have difficulty deciding clinically

whether the pneumothorax is in tension or not. We

have illustrated a case of haemopneumothroax with

radiological evidence of tension but stable

haemodynamics. The time course from the eventfurther perplexed the physician in making the

diagnosis as there was about 10 hours delay in

presentation. Plewa et al. reported a case of tension

pneumothorax which developed several days after

central venous catheterisation and positive pressure

ventilation.3

There are a lot of theories postulating the patho-

physiology of tension pneumothorax. It is believed that

the tension change is the result of progressive

accumulation of air in the pleural cavity. This collapses

the ipsilateral lung and shifts the mediastinum to the

contralateral side, resulting in compression on the vena

cava and the right ventricle. The loss of ventricular fill ing

causes vascular collapse.4 For a normal person, the bodywill attempt to overcome the insult by compensatory

mechanisms. However, once the critical point has been

reached, haemodynamic compromise will occur. The time

lag between the onset of tension change and the clinical

manifestation of cardiopulmonary failure depends on the

rate of development of tension and the physiological

reserve of the patient.

Holloway and Harris also described four cases of tension

pneumothorax without hypotension.5 They pointed out

that the good physiological reserve might mask out the

potentially lethal condition. They were still at risk of

sudden deterioration and cardiac arrest. Our patient was

also relatively young and fit and her physiological reserve

might provide adequate compensation against the

pathophysiological impact of the tension changes. But

once the compensatory mechanism was overwhelmed,

cardiopulmonary failure could result.

Patients presenting with typical features of tension

pneumothorax without hypotension or hypoxaemiashould not be dealt with lightly. There may still be a

chance of deterioration at anytime when the

compensatory mechanism fails. For uncertain diagnosis,

plain radiography may still have a role to play. However,

it is only recommended in a setting with close monitoring

and immediately available resuscitation facilities.

References

1. Rutherford RB, Hurt HH Jr, Brickman RD, Tubb JM.The pathophysiology of progressive tensionpneumothorax. J Trauma 1968;8(2):212-27.

2. American College of Surgeons. Advanced trauma lifesupport manual. Chicago:ACS; 1997:Chapter 4.

3. Plewa MC, Ledri ck D, Sferra JJ. Delayed tensionpneumothorax complicating central venouscatheterisation and positive pressure ventilation. Am JEmerg Med 1995;13(5):532-5.

4. Barton ED. Tension pneumothorax. Curr Opin PulmMed 1999;5(4):269-74.

5. Holloway VJ, Harri s JK. Spontaneous pneumothorax:is it under tension? J Accid Emerg Med 2000;17(3):222-3.