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
Conflict of interest • No COI
Road Traffic injuries - 2016 • Lethal : 351 • BIBA: 1476 • Minor: 35 826 • Population: 8.2 millions
Quebec City - Level 1 trauma center QuickTime™ et un QuickTime™ et un décompresseur sont requis pour visionner cette image. décompresseur sont requis pour visionner cette image.
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.
Plan • Diagnostic phase • Treatment plan
Injury Mechanisms Demographics • N= 16,773 • Mean age (SD): 47.8 (19.9) Car • Male : 76.2% Motorbike Bicycle • Mean ISS (SD) : 20.7 (7.5) Pedestrian • Mortality : 4.8 % High-fall Low-fall
Plan • Diagnostic phase • Treatment plan
Diagnostic phase • Plain x-rays • Ultrasound • Delayed hemothorax
Oblique Chest x-rays!
95% CI 95 % CI PPV = 95.6 (0.86 to 0.99 ) PPV = 93.6 ( 0.84 to 0.98) (0.87 to 0.91) (0.89 to 0.91) NPV = 90.1 NPV = 90.4 Sensitivity = 61.4 (0.56 to 0.64) Sensitivity = 62.9 (0.57 to 0.66) Specificity = 99.2 (90.98 to 1.00) Specificity = 98.8 (0.97 to 1.00)
Ultrasound
Ultrasound
Ultrasound
Ultrasound – Hemothorax Systematic Review
Prehospital ultrasound
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
Delayed hemothorax
Delayed hemothorax
Delayed hemothorax
Plan • Diagnostic phase • Treatment plan
Treatment modalities • Wait and see! • Drain it!
Occult pneumotorax: please do not touch?
Occult pneumotorax: please do not touch?
Occult pneumotorax: please do not touch?
Occult pneumotorax: please do not touch?
Occult pneumotorax: please do not touch?
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!
Occult pneumotorax: please do not touch?
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%
Needle decompression – size and location matter?!
Needle decompression – size and location matter?! 5 cm catheter at ICS 5 - AAL 8 cm catheter at ICS 2 – MCL
Needle decompression – size and location matter?!
What size/type of tube for hemothorax?
What size/type of tube for hemothorax?
What size/type of tube for hemothorax?
What size/type of tube for hemothorax?
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?
Thank you! • www.cetie.info • E-mail: marcel.emond@fmed.ulaval.ca • Twitter: @marcel_mond
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