Professional Documents
Culture Documents
com
Introduction
Background
A pneumothorax refers to a collection of gas in the pleural space resulting in collapse of the lung
on the affected side. A tension pneumothorax is a life-threatening condition caused by air within
the pleural space that is under pressure; displacing mediastinal structures and compromising
cardiopulmonary function. A traumatic pneumothorax results from blunt or penetrating injury that
disrupts the parietal or visceral pleura. Mechanisms include injuries secondary to medical or
surgical procedures.
Pathophysiology
A tension pneumothorax results from any lung parenchymal or bronchial injury that acts as a
one-way valve and allows free air to move into an intact pleural space but prevents the free exit
of that air. In addition to this mechanism, the positive pressure used with mechanical ventilation
therapy can cause air trapping.
As pressure within the intrapleural space increases, the heart and mediastinal structures are
pushed to the contralateral side. The mediastinum impinges on and compresses the
contralateral lung.
Hypoxia results as the collapsed lung on the affected side and the compressed lung on the
contralateral side compromise effective gas exchange. This hypoxia and decreased venous
return caused by compression of the relatively thin walls of the atria impair cardiac function. The
decrease in cardiac output results in hypotension and, ultimately, in hemodynamic collapse and
death to the patient, if untreated.
Frequency
United States
International
Mortality/Morbidity
The clinician should assume that a tension pneumothorax results in hemodynamic instability
and death, unless immediately treated.
Sex
The male-to-female ratio is about 6:1 for primary spontaneous pneumothorax development.
In men, the risk of spontaneous pneumothorax is 102 times higher in heavy smokers
than in nonsmokers. Spontaneous pneumothorax most frequently occurs in tall, thin men
aged 20-40 years.
Catamenial pneumothorax is a rare phenomenon that generally occurs in women aged
30-50 years. It frequently begins 1-3 days after menses onset. Its etiology may be
primarily related to associated diaphragmatic defects.
Men undergoing treatment for tension pneumothorax are more likely to have a larger body
habitus with wider chest wall. Tension pneumothorax patients with wider chest walls undergoing
needle thoracostomy may need a catheter longer than 5 cm to reliably penetrate into the pleural
space.
Harcke et al using CT scan analysis of deployed male military personnel determined that, at the
second right intercostal space in the midclavicular line, the mean horizontal thickness was 5.36
cm, and that an 8-cm angiocatheter would reach the pleural space in 99% of the male soldiers
in this series.[2 ]
Age
Pneumothorax occurs in 1-2% of all neonates. The incidence of pneumothorax in infants with
neonatal respiratory distress syndrome is higher. In one study, 19% of such patients developed
a pneumothorax.
Clinical
History
The signs and symptoms produced by tension pneumothorax are usually more impressive than
those seen with a simple pneumothorax. Unlike the obvious patient presentations oftentimes
used in medical training courses to describe a tension pneumothorax, actual case reports
include descriptions of the diagnosis of the condition being missed or delayed because of subtle
presentations that do not always present with the classically described clinical findings of this
condition.
Physical
Findings at physical examination may include the following:
Causes
A wide variety of disease states and circumstances increase the patient's risk of a
pneumothorax. If a pneumothorax is complicated by a one-way valve effect, tension
pneumothorax may result.
Infants requiring ventilatory assistance and those with meconium aspiration have a
particularly high risk for tension pneumothorax. Aspirated meconium may serve as a
one-way valve and produce a tension pneumothorax.
Trauma may cause a pneumothorax.
o Tension pneumothorax may be the result of blunt trauma with or without
associated rib fractures.
o Incidents that may cause tension pneumothoraces include unrestrained head-on
motor vehicle accidents, falls, and altercations involving laterally directed blows.
o Any penetrating wound that produces an abnormal passageway for gas
exchange into the pleural spaces and that results in air trapping may produce a
tension pneumothorax.
o Significant chest injuries carry an estimated 10-50% risk of associated
pneumothorax. In about half of these cases, the pneumothorax may be occult;
therefore, chest CT should always be performed.
o In one study, 12% of patients with asymptomatic chest stab wounds had a
delayed pneumothorax or hemothorax.
o McPherson et al, analyzing data from the Vietnam Wound Data and Munitions
Effectiveness Team study, determined that tension pneumothorax was the cause
of death in 3-4% of fatally wounded combat casualties.[3 ]
Many procedures performed in an intensive care or emergency setting can result in an
iatrogenic pneumothorax and tension pneumothorax. Examples of these procedures
include incorrect chest tube insertion, mechanical ventilation therapy, central venous
cannulation; cardiopulmonary resuscitation; hyperbaric oxygen therapy; needle,
transbronchial, or transthoracic lung biopsy; liver biopsy or surgery; and neck surgery.
Secondary or spontaneous tension pneumothorax is possible in many medical
conditions.
o Pneumothorax is associated with asthma, chronic obstructive pulmonary
disease, pneumonia (especially with Staphylococcus, Klebsiella,
Pseudomonas, and Pneumocystis species), pertussis, tuberculosis, lung
abscess, and cystic fibrosis.
o In pulmonary disorders such as asthma and emphysema, hyperexpansion
disrupts the alveoli.
o Increased pulmonary pressure due to coughing with a bronchial plug of mucus or
phlegm bronchial plug may play a role.
o Marfan syndrome is associated with an increased risk of pneumothorax.
o Individuals may inherit a predisposition for primary spontaneous pneumothorax.
o Although rare, spontaneous pneumothorax occurring bilaterally and progressing
to tension pneumothorax has been documented.
Differential Diagnoses
Acute Coronary Syndrome Pediatrics, Pneumonia
Acute Respiratory Distress Pericarditis and Cardiac Tamponade
Syndrome
Anxiety Pneumonia, Aspiration
Asthma Pneumonia, Bacterial
Congestive Heart Failure and Pneumonia, Empyema and Abscess
Pulmonary Edema
Diaphragmatic Injuries Pneumonia, Immunocompromised
Dissection, Aortic Pneumonia, Mycoplasma
Esophageal Perforation, Rupture Pneumonia, Viral
and Tears
Foreign Bodies, Trachea Pneumothorax, Iatrogenic, Spontaneous and
Pneumomediastinum
Myocardial Infarction Tuberculosis
Pediatrics, Pertussis
Other Problems to Be Considered
Airway obstruction
Hemothorax
Workup
Laboratory Studies
ABG analysis does not replace physical diagnosis nor should treatment be delayed while
awaiting results if symptomatic pneumothorax is suspected. However, ABG analysis may be
useful in evaluating hypoxia and hypercarbia and respiratory acidosis.
Imaging Studies
Procedures
Needle thoracostomy is performed as follows:
o Locate puncture site. The second intercostal space in the midclavicular line on
the affected side immediately superior to the rib is most commonly recommended
site.
o Prepare the puncture site with povidone-iodine (Betadine), alcohol scrubs, or
both.
o Insert a large-bore Angiocath (14-gauge in an adult, 18- or 20-gauge in an infant)
into the desired intercostal space over the top of the rib and perpendicular to the
chest wall. Listen for a rush of air.
o Remove the needle.
o Secure the Angiocath in place, and establish a water seal or flutter valve.
o Immediately prepare to insert a chest tube.
o Listen for a rush of air on insertion to confirm the diagnosis of tension
pneumothorax. Note this finding on the patient's chart. In an area with high
ambient noise, the escape of air may not be detected.
o Needle thoracostomy requires follow-up placement of a chest tube.
o Potential morbidity associated with needle thoracostomy includes pneumothorax
(with potential to tension later), cardiac tamponade, hemorrhage (which can be
life-threatening), loculated intrapleural hematoma, atelectasis, pneumonia,
arterial air embolism (when needle thoracostomy is performed and no tension
pneumothorax is present), and pain to the patient.
Tube thoracostomy is performed as follows:
o If the patient is hemodynamically stable, consider conscious sedation with careful
titration of a short-acting narcotic and benzodiazepine. However, use of a local
anesthetic often is adequate.
o Place the patient in a 30-60° reverse Trendelenburg position, scrub the site with
povidone-iodine (Betadine), alcohol, or both, and anesthetize the site with
lidocaine.
o Make a 3- to 4-cm incision over the fifth or sixth rib in the midaxillary line.
o Use a curved hemostat to puncture the intercostal muscles and parietal pleura
immediately superior to the rib border, avoiding damage to the underlying lung.
Then, slide a finger over the clamp to maintain the formed tract.
o Perform a digital examination to assess the location and to evaluate pulmonary
adhesions. Sweep the finger in all directions, and feel for the diaphragm and
possible intra-abdominal structures. To avoid losing the desired tract, keep the
finger in place until the tube is inserted.
o Insert the chest tube along side of the finger, using a clamp on the tube, if
desired.
o Direct the chest tube posteriorly and inferiorly, and insert it until it is at least 5 cm
beyond the last hole of the tube.
o Attach the tube to a water seal and vacuum device (eg, Pleur-Evac). Look for
respiratory variation and bubbling of air through the water seal. Document the
amount of blood or other fluids that may drain.
o Suture the site, and secure the tube. A variety of anchoring and closure
techniques exist, all of which are probably equivalent. Cover the site with
petroleum jelly–impregnated gauze, and apply a suitable dressing.
o Follow-up chest radiography is required to confirm tube placement and lung
reexpansion.
o Complications of tube thoracostomy include death, injury to lung or mediastinum,
hemorrhage (usually from intercostal artery injury), neurovascular bundle injury,
infection, bronchopleural fistula, and subcutaneous or intraperitoneal tube
placement.
Treatment
Prehospital Care
Attention to the ABCs is mandatory for all patients with thoracic trauma. Evaluate the patency of
the airway and the adequacy of the ventilatory effort. Assess the circulatory status and the
integrity of the chest wall.
Failure of the emergency medical service personnel and medical control physician to
make a correct diagnosis of tension pneumothorax and to promptly perform needle
decompression in the prehospital setting can result in rapid clinical deterioration and
cardiac arrest.
However, if an incorrect diagnosis of tension pneumothorax is made in the prehospital
setting, the patient's life is endangered by unnecessary invasive procedures. Close
cooperation and accurate communication between the emergency department and the
emergency medical service personnel is of paramount importance.
To prevent reentry of air into the pleural cavity after needle thoracostomy and
decompression in the prehospital setting, a one-way valve should be attached to the
distal end of the Angiocath. If available, a Heimlich valve may be used. If a commercially
prepared valve is not available, attach a finger condom or the finger of a rubber glove
with its tip removed to serve as a makeshift one-way valve device.
Clothing covering a wound that communicates with the chest cavity can play a role in
producing a one-way valve effect, allowing air to enter the pleural cavity but hindering its
exit. Removing such clothing items from the wound may facilitate decompression of a
tension pneumothorax.
A tension pneumothorax is a contraindication to the use of military antishock trousers.
In a preliminary 2006 study from Norway, Busch evaluated the feasibility of using portable
ultrasound in an air rescue setting.[7 ]Concluding that prehospital ultrasonography could provide
diagnostic and therapeutic benefit when conducted by a proficient examiner who used goal-
directed and time-sensitive protocols. Further study in this area may help to determine the
indications and role of prehospital sonography.
Hernandez et al noted that ultrasonography is the only radiographic modality allowing patients
with nonarrhythmogenic cardiac arrest to continue undergoing resuscitation while searching for
easily reversible causes of asystole or PEA.[8 ]Their proposal is for further investigation into a
protocol (using the acronym C.A.U.S.E. for cardiac arrest ultrasound exam) in which cardiac
arrest patients, concurrent with resuscitation, receive bedside ultrasonography to look for
cardiac tamponade, massive pulmonary embolus, severe hypovolemia, and tension
pneumothorax. Their hope is that the eventual adoption of ultrasonography in this setting may
allow increased "real-time" diagnostic acumen, decreasing the time required to receive
appropriate condition-related therapy.
Consultations
Medication
Follow-up
If the patient has had repeated episodes of pneumothorax or if the lung remains
unexpanded after 5 days with a chest tube in place, surgery may be necessary. The
surgeon may use treatment options such as thoracoscopy, electrocautery, laser
treatment, resection of blebs or pleura, or open thoracotomy.
In patients with repeated pneumothoraces who are not good candidates for surgery,
sclerotherapy with talc or doxycycline may be necessary.
In a preliminary study by Dente et al, ultrasonographic evaluation for pneumothorax was
found to be very accurate for the first 24 hours after insertion of a thoracostomy tube.
However, its accuracy is not sustained over time. Twenty-four hours after thoracostomy,
diagnostic sensitivity of ultrasonography for pneumothorax fell to 55%, and its positive
predictive value to 43%. This may be related to intrapleural adhesion formation.[9 ]
Deterrence/Prevention
Advise patients to wear safety belts and passive restraint devices while driving.
Encourage smoking cessation.
The incidence of iatrogenic tension pneumothorax may be decreased with prophylactic
insertion of a chest tube in patients with a simple pneumothorax that requires positive
pressure ventilation.
When subclavian vein cannulation is required, use the supraclavicular approach rather
than the infraclavicular approach when possible to help decrease the likelihood of
pneumothorax formation.
Prompt recognition and treatment of bronchopulmonary infections decreases the risk of
progression to a pneumothorax.
Complications
Complications of tension or traumatic pneumothorax may include the following:
Prognosis
The prognosis is generally good with appropriate therapy, but it varies depending on the
etiology.
Miscellaneous
Medicolegal Pitfalls
The diagnosis of a tension pneumothorax should largely be made based on the history
and physical examination findings. Ultrasonography in the emergency setting is being
increasingly used as an adjunct to the physical examination when there is doubt
regarding the diagnosis. Chest radiography or CT scanning should be used only in those
instances when the clinician is in doubt regarding the diagnosis and when the patient's
clinical condition is sufficiently stable. Obtaining such imaging studies when the
diagnosis of tension pneumothorax is not in question causes an unnecessary and
potentially lethal delay in treatment.
A tension pneumothorax is a life-threatening condition and requires immediate action
(eg, needle thoracostomy or chest tube insertion). However, the clinician should be wary
of prematurely diagnosing a tension pneumothorax in a patient without respiratory
distress, hypoxia, hypotension, or cardiopulmonary compromise. If the patient's clinical
presentation is questionable and if the patient appears stable, the clinician should
reexamine the patient and use bedside ultrasonography or request immediate portable
chest radiography (or reexamine the chest radiographs if they have already been
obtained) to confirm the diagnosis.
Consider the diagnosis of a pneumothorax and/or tension pneumothorax with blunt and
penetrating trauma. In the patient with blunt trauma and mental status changes, hypoxia,
and acidosis, symptoms may be attributed to a suspected intracerebral injury rather than
a tension pneumothorax. Portable chest radiography should always be included in the
initial radiographic evaluation of major trauma. Chest CT scanning should always be
performed for significant chest injuries since they carry an estimated risk of associated
pneumothorax as high as 50% and about half of these pneumothoraces may be occult.
When assessing the trauma patient, be aware that clinical presentations of tension
pneumothorax and myocardial rupture with tamponade may be similar.
The rare event of spontaneous pneumothorax leading to tension pneumothorax may be
misdiagnosed as an asthma crisis or COPD exacerbation in the patient presenting with
tachycardia, subcutaneous emphysema, dyspnea, and shock.
A significant number of patients have a larger chest wall than can be penetrated by a
catheter length of 5 cm. Although thinner patients requiring thoracostomy can be treated
using shorter catheter lengths, patients with a body habitus suggestive of a wider chest
wall may need a catheter longer than 5 cm to reliably penetrate into the pleural space. In
one study, a catheter length of patients at an American level 1 trauma center showed
that a catheter length of 5 cm would reliably penetrate the pleural space in only 75% of
patients.[10 ]A 2008 study analyzing average chest wall thickness at the second
intercostal space in the midclavicular line concluded that a 4.5-cm catheter length may
not penetrate the chest wall in approximately 10-35% of trauma patients, depending on
age and gender.[11 ]
Maintain a high index of suspicion for a tension pneumothorax in patients using
ventilators who have a rapid onset of hemodynamic instability or cardiac arrest,
particularly if they require increasing peak inspiratory pressures. Patients at greatest risk
of a pneumothorax and/or tension pneumothorax include those with COPD who are
using ventilators; those with acute respiratory distress syndrome; and those requiring a
tidal volume greater than 12 mL/kg, a peak airway pressure greater than 60 cm H2 O, or
a positive end-expiratory pressure greater than 15 cm H2 O.
Avoid assuming that a patient with a chest tube does not have a tension pneumothorax if
he or she has respiratory or hemodynamic instability. Chest tubes can become plugged
or malpositioned and cease to function. In addition, improper attachment of a one-way
valve to the chest tube may produce tension pneumothorax.
A 2005 study of emergency physicians used a sampling of 25 emergency physicians, 21
of which had completed ATLS training. When attempting to correctly locate the needle
thoracostomy site on a human volunteer, only 60% were able to correctly identify the
second intercostal space, and all placed the thoracentesis needle medial to the
midclavicular line. In this same study, 8% of participants inappropriately identified the
site used for needle pericardiocentesis and 4% inappropriately identified the fifth
intercostal space in the anterior axillary line.[12 ]
Related to the development of apparent life-threatening hemorrhage after
decompression in the second intercostal space at the anterior, midclavicular line in
patients with no initial evidence of hemothorax on presentation, it has been suggested
that a potentially safer option is to decompress a pneumothorax in the fifth intercostal
space at the anterior axillary line, similar to recommendations for chest drain insertion.
Multimedia
Media file 1: Pneumothorax, Tension and Traumatic.
Media file 2: Pneumothorax, Tension and Traumatic.
Media file 3: Pneumothorax, Tension and Traumatic.
Media file 4: Pneumothorax, Tension and Traumatic.
Media file 5: Pneumothorax, Tension and Traumatic.
Media file 6: Pneumothorax, Tension and Traumatic.
Media file 7: Subcutaneous emphysema and pneumothorax.
References
2. Harcke HT, Pearse LA, Levy AD, Getz JM, Robinson SR. Chest wall thickness in military
personnel: implications for needle thoracentesis in tension pneumothorax. Mil
Med. Dec 2007;172(12):1260-3. [Medline].
3. McPherson JJ, Feigin DS, Bellamy RF. Prevalence of tension pneumothorax in fatally
wounded combat casualties. J Trauma. Mar 2006;60(3):573-8. [Medline].
4. Knudtson JL, Dort JM, Helmer SD, Smith RS. Surgeon-performed ultrasound for
pneumothorax in the trauma suite. J Trauma. Mar 2004;56(3):527-30. [Medline].
5. Zhang M, Liu ZH, Yang JX, Gan JX, Xu SW, You XD. Rapid detection of pneumothorax
by ultrasonography in patients with multiple trauma. Crit
Care. 2006;10(4):R112. [Medline].
9. Dente CJ, Ustin J, Feliciano DV, Rozycki GS, Wyrzykowski AD, Nicholas JM, et al. The
accuracy of thoracic ultrasound for detection of pneumothorax is not sustained over
time: a preliminary study. J Trauma. Jun 2007;62(6):1384-9. [Medline].
12. Ferrie EP, Collum N, McGovern S. The right place in the right space? Awareness of site
for needle thoracocentesis. Emerg Med J. Nov 2005;22(11):788-9. [Medline].
13. Bense L, Eklund G, Wiman LG. Smoking and the increased risk of contracting
spontaneous pneumothorax. Chest. Dec 1987;92(6):1009-12. [Medline].
15. Bridges KG, Welch G, Silver M, Schinco MA, Esposito B. CT detection of occult
pneumothorax in multiple trauma patients. J Emerg Med. Mar-Apr 1993;11(2):179-
86. [Medline].
16. Chan SS. Emergency bedside ultrasound to detect pneumothorax. Acad Emerg
Med. Jan 2003;10(1):91-4. [Medline].
17. Chung MJ, Goo JM, Im JG, Cho JM, Cho SB, Kim SJ. Value of high-resolution
ultrasound in detecting a pneumothorax. Eur Radiol. May 2005;15(5):930-5. [Medline].
18. Dulchavsky SA, Schwarz KL, Kirkpatrick AW, et al. Prospective evaluation of thoracic
ultrasound in the detection of pneumothorax. J Trauma. Feb 2001;50(2):201-
5. [Medline].
19. Gordon R. The deep sulcus sign. Radiology. Jul 1980;136(1):25-7. [Medline].
20. Greene R, McLoud TC, Stark P. Pneumothorax. Semin Roentgenol. Oct 1977;12(4):313-
25. [Medline].
21. Holloway VJ, Harris JK. Spontaneous pneumothorax: is it under tension?. J Accid Emerg
Med. May 2000;17(3):222-3. [Medline].
22. Leigh-Smith S, Davies G. Tension pneumothorax: eyes may be more diagnostic than
ears. Emerg Med J. Sep 2003;20(5):495-6. [Medline].
23. Leigh-Smith S, Harris T. Tension pneumothorax--time for a re-think?. Emerg Med
J. Jan 2005;22(1):8-16. [Medline].
24. Lichtenstein D, Meziere G, Biderman P, Gepner A. The "lung point": an ultrasound sign
specific to pneumothorax. Intensive Care Med. Oct 2000;26(10):1434-40. [Medline].
26. Melton LJ, Hepper NG, Offord KP. Incidence of spontaneous pneumothorax in Olmsted
County, Minnesota: 1950 to 1974. Am Rev Respir Dis. Dec 1979;120(6):1379-
82. [Medline].
28. Ogata ES, Gregory GA, Kitterman JA. Pneumothorax in the respiratory distress
syndrome: incidence and effect on vital signs, blood gases, and
pH. Pediatrics. Aug 1976;58(2):177-83. [Medline].
29. Rawlins R, Brown KM, Carr CS, Cameron CR. Life threatening haemorrhage after
anterior needle aspiration of pneumothoraces. A role for lateral needle aspiration in
emergency decompression of spontaneous pneumothorax. Emerg Med
J. Jul 2003;20(4):383-4. [Medline].
30. Sargsyan AE, Hamilton DR, Nicolaou S, Kirkpatrick AW, Campbell MR, Billica
RD. Ultrasound evaluation of the magnitude of pneumothorax: a new concept. Am
Surg. Mar 2001;67(3):232-5; discussion 235-6. [Medline].
31. Soldati G, Iacconi P. The validity of the use of ultrasonography in the diagnosis of
spontaneous and traumatic pneumothorax. J Trauma. Aug 2001;51(2):423. [Medline].
32. Soldati G, Testa A, Sher S, Pignataro G, La Sala M, Silveri NG. Occult traumatic
pneumothorax: diagnostic accuracy of lung ultrasonography in the emergency
department. Chest. Jan 2008;133(1):204-11. [Medline].
36. Waydhas C, Sauerland S. Pre-hospital pleural decompression and chest tube placement
after blunt trauma: A systematic review. Resuscitation. Jan 2007;72(1):11-25. [Medline].
37. Wilder RJ, Beacham EG, Ravitch MM. Spontaneous pneumothorax complicating
pulmonary tuberculosis. J Thorac Cardiovasc Surg. 1962;46:331.
Keywords
Author
Jeffrey Glenn Bowman, MD, MS, Consulting Staff, Highfield MRI, Columbus, Ohio
Disclosure: Nothing to disclose.
Medical Editor
Joseph A Salomone III, MD, Associate Professor and Attending Staff, Truman Medical
Centers, University of Missouri-Kansas City School of Medicine; EMS Medical Director, Kansas
City, Missouri
Joseph A Salomone III, MD is a member of the following medical societies: American Academy
of Emergency Medicine, National Association of EMS Physicians, and Society for Academic
Emergency Medicine
Disclosure: Nothing to disclose.
Pharmacy Editor
Managing Editor
Eric L Legome, MD, Chief, Department of Emergency Medicine, Kings County Hospital Center;
Associate Professor, Department of Emergency Medicine, New York Medical College
Eric L Legome, MD is a member of the following medical societies: Alpha Omega Alpha,
American Academy of Emergency Medicine, American College of Emergency Physicians,
Council of Emergency Medicine Residency Directors, and Society for Academic Emergency
Medicine
Disclosure: Nothing to disclose.
CME Editor
John D Halamka, MD, MS, Associate Professor of Medicine, Harvard Medical School, Beth
Israel Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and
Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel
Deaconess Medical Center
John D Halamka, MD, MS is a member of the following medical societies: American College of
Emergency Physicians, American Medical Informatics Association, Phi Beta Kappa, and Society
for Academic Emergency Medicine
Disclosure: Nothing to disclose.
Chief Editor
Rick Kulkarni, MD, Assistant Professor of Surgery, Section of Emergency Medicine, Yale-New
Haven Hospital
Rick Kulkarni, MD is a member of the following medical societies: Alpha Omega Alpha,
American Academy of Emergency Medicine, American College of Emergency Physicians,
American Medical Association, American Medical Informatics Association, Phi Beta Kappa, and
Society for Academic Emergency Medicine
Disclosure: WebMD Salary Employment
Further Reading
© 1994-2010 by Medscape.
All Rights Reserved
(http://www.medscape.com/public/copyright)