Core EM - Emergency Medicine Podcast

Episode 213: Pneumothorax

Listen Later

We break down pneumothorax: risks, diagnosis, and management pearls.

Hosts:

Christopher Pham, MD
Brian Gilberti, MD

https://media.blubrry.com/coreem/content.blubrry.com/coreem/Pneumothorax.mp3
Download
Leave a Comment
Tags: Chest Trauma, Pulmonary, Trauma
Show Notes
Risk Factors for Pneumothorax
  • Secondary pneumothorax
    • Trauma: rib fractures, blunt chest trauma (as in the case).
    • Iatrogenic: central line placement, thoracentesis, pleural procedures.
    • Primary spontaneous pneumothorax
      • Young, tall, thin males (10–30 years).
      • Connective tissue disorders: Marfan, Ehlers-Danlos.
      • Underlying lung disease: COPD with bullae, interstitial lung disease, CF, TB, malignancy.
      • Technically, anyone is at risk.
        • Symptoms & Differential Diagnosis
        • Typical PTX presentation: Dyspnea, chest pain, pleuritic discomfort.
        • Exam clues: unilateral decreased breath sounds, focal tenderness/crepitus.
        • Red flags (suggest tension PTX):
          • JVD
          • Tracheal deviation
          • Hypotension, shock physiology
          • Severe tachycardia, hypoxia
          • Differential diagnoses:
            • Pulmonary: asthma, COPD, pneumonia, pulmonary edema (SCAPE), ILD, infections.
            • Cardiac: ACS, CHF, pericarditis.
            • PE and other acute causes of dyspnea.
              • Diagnostics
              • Bloodwork: limited role, except type & screen if intervention likely.
              • EKG: reasonable given chest pain/shortness of breath.
              • Imaging:
                • POCUS (bedside ultrasound)
                  • High sensitivity (86–96%) & specificity (97–100%).
                  • Signs:
                    • Seashore sign: normal lung sliding.
                    • Barcode sign: absent lung sliding.
                    • Lung point: most specific for PTX.
                    • CXR
                      • Sensitivity ~70–90% for small PTX.
                      • May show pleural line, hyperlucency.
                      • CT chest (gold standard)
                        • Defines size/severity.
                        • Rules out mimics (bullae, pleural effusion, hemothorax).
                        • Guides intervention choice.
                          • Management
                          • First step for all: Oxygen supplementation (non-rebreather if possible).
                            • Accelerates resorption of pleural air.
                            • Stable vs. unstable decision point:
                              • Unstable/tension PTX
                                • Immediate needle thoracostomy (14-g angiocath, 2nd ICS midclavicular).
                                • Temporizing until chest tube/pigtail placed.
                                • Stable, small PTX (<2 cm on O₂)
                                  • Observation, supplemental O₂, conservative management.
                                  • Stable, larger PTX or symptomatic
                                    • Chest tube or pigtail catheter insertion.
                                    • Pigtail catheters: less invasive, more comfortable, similar efficacy for simple PTX.
                                    • Large bore tubes: indicated if associated with blood, pus, large collections.
                                      • Disposition
                                      • Admit all patients with chest tubes; cannot be discharged with tube in place.
                                      • Service responsible varies by hospital: trauma, CT surgery, MICU, etc.
                                      • Level of care (ICU vs. floor) depends on stability:
                                        • ICU if unstable course, intubated, shock physiology.
                                        • Stepdown/floor if stable and straightforward.
                                          • Take Home Points
                                          • Always broaden differential in dyspnea/chest pain → don’t anchor on asthma/COPD.
                                          • Exam findings + history (trauma, risk factors) crucial to raising suspicion.
                                          • Ultrasound is more sensitive than CXR and highly specific when lung point found.
                                          • Oxygen is first-line; intervention determined by size + stability.
                                          • Pigtail catheters increasingly favored for simple, stable PTX.
                                          • All patients with intervention require admission; service varies by institution.

                                            • Read More
                                            ...more
                                            View all episodesView all episodes
                                            Download on the App Store
                                            Core EM - Emergency Medicine PodcastBy Core EM
                                            • 4.5
                                            • 4.5
                                            • 4.5
                                            • 4.5
                                            • 4.5

                                            4.5

                                            244 ratings

                                            More shows like Core EM - Emergency Medicine Podcast

                                            View all
                                            EMCrit FOAM Feed by Scott D. Weingart, MD FCCM

                                            EMCrit FOAM Feed

                                            1,867 Listeners

                                            Emergency Medicine Cases by Dr. Anton Helman

                                            Emergency Medicine Cases

                                            557 Listeners

                                            The Resus Room by Simon Laing, Rob Fenwick & James Yates

                                            The Resus Room

                                            105 Listeners

                                            EM Clerkship by Zack Olson, MD ; Mike Estephan, MD ; Maddie Watts, MD

                                            EM Clerkship

                                            813 Listeners

                                            The Curbsiders Internal Medicine Podcast by The Curbsiders Internal Medicine Podcast

                                            The Curbsiders Internal Medicine Podcast

                                            3,370 Listeners

                                            Emergency Medical Minute by Emergency Medical Minute

                                            Emergency Medical Minute

                                            259 Listeners

                                            Core IM | Internal Medicine Podcast by Core IM Team

                                            Core IM | Internal Medicine Podcast

                                            1,149 Listeners

                                            Emergency Medicine Board Bombs by EM Board Bombs

                                            Emergency Medicine Board Bombs

                                            330 Listeners

                                            The Internet Book of Critical Care Podcast by Adam Thomas & Josh Farkas

                                            The Internet Book of Critical Care Podcast

                                            701 Listeners

                                            The Clinical Problem Solvers by The Clinical Problem Solvers

                                            The Clinical Problem Solvers

                                            514 Listeners

                                            Harrison's PodClass: Internal Medicine Cases and Board Prep by AccessMedicine

                                            Harrison's PodClass: Internal Medicine Cases and Board Prep

                                            369 Listeners

                                            Run the List by Walker Redd, Emily Gutowski, Navin Kumar, Joyce Zhou, Blake Smith

                                            Run the List

                                            248 Listeners

                                            Critical Care Scenarios by Brandon Oto, PA-C, FCCM and Bryan Boling, DNP, ACNP, FCCM

                                            Critical Care Scenarios

                                            251 Listeners

                                            Ninja Nerd by Ninja Nerd

                                            Ninja Nerd

                                            317 Listeners

                                            Critical Care Time by Critical Care Time Podcast

                                            Critical Care Time

                                            270 Listeners