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Old 09-21-2011
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Default Spontanous pneumothorax management, Q

I found this Q in the web, I would like to share it with you:
27-year-old tall, thin man presented to the ER for shortness of breath. In the ED, he is not distressed. BP is 110/75 mm Hg, HR is 81, RR is 16, and oxygen saturation is 97% on room air & in sinus rhythem. Cardiac, lung, and abdominal examinations are normal. A chest radiograph shows a small -sided (less than 10% of the hemithorax). The diagnosis spontaneous pneumothorax.

A repeat chest x-ray 6 hours later reveals a decreased pneumothorax. Which of the following is the most appropriate next step in management?
a. Nothing to be done, discharge the patient with follow-up in 24 hours
b. Perform needle decompression in the second intercostal space, midclavicular
line
c. Insert a chest tube into right hemithorax
d. Needs observation for another 6 hours
e. Admit for pleurodesis
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Old 09-21-2011
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Quote:
Originally Posted by ag2011n View Post
I found this Q in the web, I would like to share it with you:
27-year-old tall, thin man presented to the ER for shortness of breath. In the ED, he is not distressed. BP is 110/75 mm Hg, HR is 81, RR is 16, and oxygen saturation is 97% on room air & in sinus rhythem. Cardiac, lung, and abdominal examinations are normal. A chest radiograph shows a small -sided (less than 10% of the hemithorax). The diagnosis spontaneous pneumothorax.

A repeat chest x-ray 6 hours later reveals a decreased pneumothorax. Which of the following is the most appropriate next step in management?
a. Nothing to be done, discharge the patient with follow-up in 24 hours
b. Perform needle decompression in the second intercostal space, midclavicular
line
c. Insert a chest tube into right hemithorax
d. Needs observation for another 6 hours
e. Admit for pleurodesis
With decrease you mean it's now less than before I assume. If so, and if less than 10% anyway, the Rx would be observation at home.
I don't think you mean that it has increased in size as there's no percentage mentioned, If above 30% (I think) then it would be chest tube.
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Old 09-21-2011
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a. Nothing to be done, discharge the patient with follow-up in 24 hours
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Old 09-21-2011
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Originally Posted by step1an View Post
a. Nothing to be done, discharge the patient with follow-up in 24 hours
ok, u mean to say in case of resolving spontaneous pneumothorax ,pateint hemodynamically stable, pt can be discharged without doing anything.
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Old 09-22-2011
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Originally Posted by iron View Post
OK, u mean to say in case of resolving spontaneous pneumothorax ,patient hemodynamically stable, pt can be discharged without doing anything.
I think so.

The indication for chest intubation in a pt of spontaneous pneumothorax is symptomatic pt & pneumothorax involving more than 20%.
Small pneumothorax can get reabsorbed on itself. So no need to intubate if its resolving on its own & pt is stable.

I hope i am right...
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d. Needs observation for another 6 hours
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Old 09-22-2011
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The correct answer is a: Nothing to be done, discharge the patient with follow-up in 24 hours.
Pneumothorax: Two major categories,
  • spontaneous : A. simple: healthy individual, no underline lung disease, due to rupture of subpleural blebs, high recurrence, tall, lean, young men. Management: small asymptomatic: nothing to be done, just observation. If symptomatic: small chest tube (one –way valve) B. secondary: COPD, asthma & others. Management: O2 supplementation & chest tube.
  • traumatic. Often iatrogenic. Remember always do CXR afer the following procedures: Transthoracic needle aspiration, Thoracentesis & central line placement.
Management of tension Pneumothorax: Medical emergency, do not do CXR, insert large –bore needle in 2nd or 3rd intercostal space midclavicular line, followed by chest tube placement.
Management of open Pneumothorax: close the defect, use gauze & tape it on 3 sides only (otherwise you get tension Pneumothorax).
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