OPEN PNEUMOTHORAX

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OPEN PNEUMOTHORAX MANAGEMENT

      The incidence of chest injuries is one of the trauma that often in the some case, if not handled properly, will lead to death. Chest trauma incident occurred about a quarter of the number of deaths due to trauma that occurred, as well as about a third of the deaths that occurred in some hospitals. (1,2) Some chest injuries that can occur, they are tension pneumothorax, open pneumothorax, flail chest, hematothoraks, cardiac tamponade. Pneumothorax is a common chest injuries found on the incidence of trauma outside of the hospital, as well as an emergency medical service that should be given as soon as possible to avoid the handling of death. Lack of knowledge to know the signs and symptoms of pneumothorax pressed causing many patients died of a once or on the way to hospital.(3) Actual handling of urgency pneumothorax can be done with basic life support without the need for surgery, before sending the patient to the nearest medical care center, so that knowledge required here for the early identification of symptoms of pneumothoraks, provide basic life support, and send them to the nearest medical services, to reduce the rate of morbidity and mortality. Pneumothorak can be caused by the following:

1. Tearing pleural visceralis, so when inspiration comes from the alveolar air will enter the pleural cavity. This type is called a closed pneumothorax. If the leak pleural visceralis function as valves, then the incoming air when inspiration will not be able to get out of the pleural cavity at the time of expiration. As a result, the longer the more air that push towards the contralateral mediastinal and cause tension pneumothorax.
2. Tearing of the chest wall and parietal pleura, so that there is a relationship between the pleural cavity and the outside world. If the hole is larger than 2/3 the diameter of the trachea, the air tends to be passed through the hole than the respiratory tract. At the moment of inspiration, pressure in the chest cavity to decrease, so that outside air into the pleural cavity through the hole and cause the collapse of the ipsilateral lung. On expiration, chest cavity pressure increases, as a result of air from the pleural cavity out through the hole. This condition is referred to as an open pneumothorax.

Open pneumotorak due to penetrating trauma. Injury can be incomplete (limited to the parietal pleura) or complete (parietal pleura and visceralis). If there is an open pneumotorak incomplete at the time of inspiration outside air will enter into the pleural cavity. As a result, the lungs can not inflate because of the pressure intrapleura not negative. The effect will occur hyperexpansion pressing mediastinal pleural cavity to the healthy lungs.

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When open pneumotorak complete the moment of inspiration can occur hyperexpansion urged mediastinal pleural cavity to the side of healthy lungs and expiratory air trapped in the pleural cavity and the lung due to injury valve is closed. Furthermore, there was an emphasis vena cava, shuntingudara to healthy lungs, and airway obstruction. Consequently can make symptoms of pre-shock or shock due to the emphasis vena cava. This incident is known as tension pneumotorak.

In the open pneumothorax, looks like the symptoms pneumothoraks coupled with the sucking wound in the chest cavity. Also not obtained insistence mediastinum, but because there are people with severe ventilation disorder seemed very crowded, rapid breathing, cyanosis and possibly shock. If this is allowed, ended with the death of patient

How is the management?(4)

Principle

•         Primary survey-secondary survey

•         Standard diagnostic examinations (which can only be done when the patient is stable), are: portable x-ray, portable blood examination, portable bronchoscope. Not justified to examination by moving patients from the emergency room.

•         Handling patients not to diagnose but to find a life-threatening problems and perform life-saving actions.

•         Taking anamnesis (history) and physical examination performed after handling procedures trauma.

Primary Survey

Airway

Pay attention to airway patency, listen to the sound of his breathing

Management:

•         Do chin-lift and jaw thrust, remove objects blocking the airway

•         Re-positioning of the head, we suspect a cervical fracture, post-neck collar

•     Do cricothyroidotomy or traheostomi or intubation (oral / nasal) if the airway can not be patente

Breathing

Check the respiratory rate, respiration and movement note, notice the retraction of the respiratory muscles and chest wall movement

Management:

•         Perform assisted ventilation if there is indication

•         Perform emergency surgery if necessary

Circulation

Check the heart rate and pulse, check your blood pressure, pulse check oxymetri, check the neck veins and skin color (cyanosis)

Management:

•         Fluid resuscitation with installing two IV lines

•         Thoracotomy emergency when necessary

•         Exploration of vascular emergency surgery if necessary

Disability

Check the patient's level of consciousness

Specific handling Open pneumothorax

Outside Hospital

In the open pneumothorax with sucking chest wound, to stop air entering the thoracic cavity through the wound, immediately close the wound on three sides. Destination leaves one side of the wound remains open is that when expiratory air can still go out through the open side, whereas when inspiration gauze dressings impede air into the thoracic cavity (a one-way valve or ventiles opposite of tension pneumothorax). (3)

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In the Emergency Room

•         The wound should not be closed tightly (to create a mechanism ventiles)

•         Install WSD (Water Sealed Drainage) first and cover the wound

•         Get rid of the injury / laceration of the lungs or other organs of intra thoracic.

Seal Water Drainage (WSD) is a drainage system that uses a water seal to drain air or fluid from the pleural cavity (pleural cavity)

Purpose:

•         Drain / drainage of air or fluid from the pleural cavity to maintain the negative pressure cavity

•         Under normal circumstances the pleural cavity has a negative pressure and only slightly filled pleural fluid / lubrican.

Sources

1. American Colege Of Surgeons Commite On Trauma, Student Course Manual 7^th Editon : advanced Trauma Life Suport for Doctors : Bab 5 Trauma Thoraks: 11- 127.
2. De jong W., Sjamsuhidajat R., Karnadihardja W. Prasetyono T.O, Rudiman R. : Buku Ajar Ilmu Bedah; Bab 28: 498-513
3. Sharma A, Jindal P : Priciples of diagnosis and management of traumatic pneumothorax. 208 ;34 – 40
4. Idres M.M, Ingleby A.M, Wali S.O : Evalution and Managemet of Pneumothorax. Saudi Med J 203; vol.24(5):47