A 39-year-old African American female (AAF) went to

the emergency department (ED) with a chief

complaint (CC) of chest pain and shortness of breath
(SOB). These complaints were of sudden onset and
started while she was typing on her computer. She
complained of (c/o) squeezing, pressure-like sensation
in her midsternal area and over her left side. She rated
her pain as a 10 on a scale of 1/10. She had similar
complaints recently when she had a left-sided
pneumothorax. However, this time she felt worse.
 Past medical history (PMH)
Systemic lupus erythematosus (SLE) and pulmonary fibrosis with a recent left
pneumothorax.
Past surgical history (PSH)
Cholecystectomy, recent thoracotomy with bleb resection for spontaneous
pneumothorax.
Medications
Prednisone, esomeprazole (Nexium), doxepin, hydroxyzine (Atarax).
Allergy
Penicillin, amoxicillin, reaction unknown
Family history (FH)
breast CA in her sister, lupus in her other sister, hypertension (HTN), diabetes
type 2 (DM2).
Social history (SH)
Stopped smoking 8 years ago.
Physical examination
VS :
T 36.5
BP 78/61
HR 140
RR 20.
Chest: Decrease in chest rise and diminished breath
sounds on the left side.
CVS: Tachycardic but regular.
Abdomen: Soft, normal
What is the most likely diagnosis?

Why the blood pressure (BP) is low?

Pneumothorax?
Pneumonia?
Effusion?
Atelectasis?
Rontgen thorax (CXR)?
EKG?
Cardiac enzymes (sometimes called chest pain panel,
CPP)
The 12-lead EKG showed a sinus tachycardia rhythm
with a rate of 139 bpm, no ischemia.

The CXR showed a complete left pneumothorax with a

mediastinum shift - a tension pneumothorax, and a
large bulla.
CXR report: 2 views show
a large left
pneumothorax with near
total collapse of the left
lung and mediastinal
shift to the right with
decreased right lung
volume and small air
fluid level at the left base.
Heart is normal size.
Conclusion: Severe left
tension pneumothorax.
 Tension pneumothorax is true life-threatening emergency.
Immediately place the patient on 100% oxygen. Do
emergency needle decompression without delay. After
needle decompression, insert a thoracostomy tube.

The surgical house officer was called and a chest tube was
inserted. The repeated CXR several minutes later showed a
resolving pneumothorax and a mediastinum in normal
position.
Final diagnosis

Spontanous left tension pneumothorax.

What did we learn from this case?

Tension pneumothorax is a true life-threatening

emergency. Immediately place the patient on 100%
oxygen and do emergency needle decompression
without delay.
 A 16-year-old male patient came to the emergency department
with complaints of shortness of breath and chest pain which
started one day ago. The shortness of breath was mild in severity,
made worse by exertion and relieved with rest, associated with
pleuritic chest pain, left sided, 5-6/10, sharp in nature. He denied
any similar symptoms in the past.
Past medical, social, surgical and family history
He also denied any use of illicit drug like cocaine or and any
history of trauma. He did not have any past medical history or
past surgical history. He had no family history of premature CAD
or asthma. He did not smoke or drink alcohol. He was on no
prescription medications and he participated in sports without
any difficulty.
 Physical examination

Blood pressure was 112/70 mm/Hg, HR 90 bpm, temp. 98.7

F and RR was 23/min, SpO2 90 % on room air. His height
was 510 with BMI of 19.9. He was in mild respiratory
distress. HENT exam was unremarkable. No crepitus was
felt. Trachea was in the midline. On auscultation, there
were no breath sounds on the left side with hyperresonance
on percussion. S1 and S2 were normal with no
murmurs/rubs or gallops. The abdomen was unremarkable.
No pedal edema was appreciated. No clinical stigmata of
Marfans syndrome like high arched palate or increased arm
span were observed.
What is the next
step in the
management of
this patient?

A chest X-ray was

done which
showed a large left
pneumothorax
with tracheal
deviation to the
right
An emergency
chest tube was
placed and the
lung re-
expanded
CBC and BMP were normal.
Urine toxic screen was negative.
A CT scan of the chest was done which did not show
any blebs/bulla or lung parenchymal abnormalities.
 The chest was clamped after 48 hours but the
pneumothorax expanded.
Subsequently, he was given two more trials of clamping
which were unsuccessful.
Finally, after a week he was taken to surgery for a possible
bronchopleural fistula leak.
During surgery, he was found to have a bulla at the apex of
the lung which was ligated.
He tolerated the procedure well and the pneumothorax did
not recur.
Diagnosis

Spontaneous Primary Pneumothorax.

A 61-year-old man fell down from a stepladder about
1meter in height and suffered a heavy blow to the left
abdomen during performance of carpenters work.
Next day, he went to a clinic because of continued left
chest pain.
In a chest X-ray, fluid effusion in his left thoracic space
without pneumothorax was noted and he was
transported to the emergency center of our hospital
based on diagnosis of hemorrhagic shock with
hemothorax.
 In chest x-rays (figure 1A), the left tension hemothorax was
apparent when he arrived at our institution.
He underwent left chest drainage and about 1,500 ml blood
was drained.
After releasing tension hemothorax, we performed
enhanced chest computed tomography (CT) scanning and
found only bleeding into the thoracic space from a branch
of the left inferior phrenic artery without involvement of
the abdomen in the delay phase (Figure 1B).
Additionally, obvious lung injury, rib fracture or diaphragm
rupture were not found.
Figure 1
(A)Chest X-ray film showing
left tension hemothorax;
(B) Enhanced chest
computed tomography (CT)
shows left hemothorax and
bleeding into the thoracic
space from a branch of the
left inferior phrenic artery
without involvement of the
abdomen in the delay phase;
(C)Note the leak of contrast
medium into the thoracic
space on angiography of the
selected left phrenic artery;
(D)Bleeding was markedly
reduced after coil
embolization.
We performed interventional radiology (IVR) for
continuous bleeding control before thoracotomy.
Since we confirmed bleeding from the left phrenic
artery by IVR (Figure 1C), coil embolization was
performed and the bleeding gradually reduced (Figure
1D).
Emergency thoracotomy was planned due to further
bleeding of about 800 ml, serious anemia (hemoglobin
decrease from 11.3 g/dl to 7.1 g/dl), hypotension
through hemorrhagic shock and respiratory disorder
due to a huge hematoma in the thoracic space.
As the finding of left thoracotomy (Figure 2), we
located the blood vessel thought to be a branch of the
inferior phrenic artery of the diaphragm surface
without obvious lung damage, rib fracture or
diaphragm rupture, in line with the preoperative
images.
When oozing was confirmed from the site, it was
sutured with three 10 silk stitches, and on
confirmation of no further bleeding, thoracotomy was
completed with MAP 6 U infusion to improve serious
anemia.
Final diagnosis
Traumatic hemathorax
A 24 year old male was admitted in a gasping state to
the emergency surgical ward with a history of vehicular
accident. Examination showed the patient to be
markedly tachypnoeic and cyanosed with a pulse rate
of 140 per minute and respiratory rate of 48 per
minute. Local examination revealed multiple fractures
of ribs (2nd to 9th) with a significant flail and
paradoxical movement of the left chest
Plain radiograph of the chest showed multiple
fractures of ribs on the left side with a
hemopneumothorax.[
The patient also had a compound fracture of the left
humerus and left tibia-fibula.
Arterial blood gas analysis showed p02-54 mm. Hg.,
pCO2 30 mm. Hg., pH-7.43 and SaO2,-88%.
 Immediate endotracheal intubation was followed by
tracheostomy, intercostal drainage of hemo and
pneumothorax by a Malecot's catheter connected to under
water bottle, and IPPR on a Bird's respirator with oxygen
under a pressure of 15-20 lbs/sq. inch.
On respirator, blood gas analysis after 24 hours showed
p02-110, mm. Hg. pC02 34, mm. Hg. pH-7.38 and Sa02 98%.
The patient was kept on IPPR for a period of 3 weeks.
Any attempt at weaning off the respirator produced a fall in
p02, (59 mm. 11g.) within 4 hours.
The patient was also given antibiotics, humidification in a
nebuliser, chest physiotherapy and the orthopedic
problems were dealt with.
flail chest