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