PEMP 0317 Pneumothorax In Pediatric Patients.pdf


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Ground Transport


If the pneumothorax is secondary to trauma,
external signs of blunt or penetrating trauma may
be seen on the thorax, abdomen, or back. A seat belt
sign in a patient involved in a motor vehicle crash
is suggestive of significant force over the torso or
abdomen, and internal injury should be considered.

For a secondary pneumothorax that is a result of
an underlying pathological condition such as cystic
fibrosis, the same symptoms and physical examination
findings are seen as in a simple pneumothorax; however, the clinical picture may be complicated by the fact
that the patient has underlying pulmonary disease.

Interfacility ground transport for patients with a
known pneumothorax with a chest tube in place requires that the team ensures that all necessary equipment is available and functioning. Clinicians need to
pay attention to changes in the clinical status of the
patient that may correlate with equipment malfunction, obstruction, or displacement.


Positive-Pressure Ventilation

Patients requiring positive-pressure ventilation in
the setting of pneumothorax with either a bag-valve
mask or endotracheal tube present another set of
challenges to EMS providers and clinicians. Positivepressure ventilation can acutely worsen a pneumothorax, and may lead to the development of tension
physiology. This phenomenon must be recognized
quickly and immediate needle decompression
should be performed.

Early Intervention
The approach to a patient with a suspected pneumothorax is dependent on the etiology. All patients with
traumatic pneumothorax should be managed according to the Advanced Trauma Life Support (ATLS)
guidelines recommended by the American College of
Surgeons Committee on Trauma. If the pneumothorax is secondary to an underlying pulmonary disease,
the management of those patients needs to be addressed on a case-by-case basis.

Early interventions must include appropriate
airway management, administration of supplemental oxygen, and, if necessary, intravenous access.
Evaluation of the initial vital signs and a thorough
examination will help identify patients with symptomatic pneumothoraces who will require more
prompt interventions.

Emergency Department Evaluation
History
The presentation of a pneumothorax is highly variable
and depends primarily on the mechanism and the rate
and extent of air accumulation in the pleural space.
(See Table 3.) Small pneumothoraces may be asymptomatic or may present with only a cough.56 The most
common complaints are chest pain (100% of cases)
and dyspnea (41% of cases).57 Agitation, syncope, and
acute distress may also be presenting symptoms. For
children who are able to give a history, the chest pain
is typically described as sharp or stabbing, and worse
with respirations. Often, PSP occurs at rest or with
minimal exertion. A family history of recurrent pneumothoraces, poor wound healing, or aortic dissection
may be suggestive of underlying collagen vascular
disorders. Additionally, recognition of a marfanoid
habitus in the patient and possibly family members
may suggest Marfan syndrome, which predisposes the
patient to pneumothorax.

Table 3. Signs And Symptoms Of
Pneumothorax
Type of
Pneumothorax

Historical Features

Clinical Findings

Spontaneous

• Chest pain that is
typically sharp or
stabbing
• Shortness of
breath
• Ipsilateral
shoulder pain
• Breathlessness
• Cough

• Diminished unilateral
breath sounds
• Vital signs and
respiratory effort
ranging from normal
to severely abnormal
• Tachypnea
• Tympany

Tension

Same features as
spontaneous, plus:
• Higher suspicion
in the setting
of penetrating
thoracic or
abdominal trauma
• Also seen in blunt
thoracic and
abdominal trauma

• Tracheal deviation to
the contralateral side
• Absent or diminished
aeration on the
ipsilateral side
• Jugular venous
distension
• Shift of the apical
pulses to the
contralateral side
may be present56
• Hypotension

Physical Examination
Classic physical examination findings may include
ipsilateral decreased breath sounds; increased work
of breathing; and tympany, or hyperresonance on
percussion, if there is a large pneumothorax. Vital
signs may be normal, but can also demonstrate
tachypnea, hypoxia, tachycardia, and hypotension,
especially in tension physiology. Other findings of
tension pneumothorax include tracheal deviation,
jugular venous distension, decreased chest excursion, diminished heart sounds, and a shift of the
apical pulse to the contralateral side. In patients with
tension physiology, the degree of tachypnea and
tachycardia can be significant. Hypotension or cardiovascular collapse and, ultimately, cardiac arrest
can also result from a tension pneumothorax.
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