Downloaded from http://emj.bmj.com/ on May 24, 2015 - Published by group.bmj.com
Commentary
IMAGES IN EMERGENCY MEDICINE
Traumatic massive tension pneumothorax due to a break in the middle lobe bronchus A patient presented respiratory failure and haemodynamic instability after falling from a height of 6 m. After a high suspicion of tension pneumothorax based on clinical status and pulmonary auscultation, the emergency physician inserted a Pneumocath (8 Fr; 2.7 mm) while in the ambulance. Once in hospital, CT scan (figure 1) showed a tension pneumothorax that caused an important left displacement of the heart, right diaphragm and hepatic silhouette. These findings led to replacing the chest tube by a thicker one (Argyle Thoracic Catheter 28 Fr; 9.3 mm). Due to the presence of massive and persistent air leak, a bronchoscopy was performed. It confirmed a break in the middle lobe bronchus. Finally, the patient underwent a right posterolateral thoracotomy. Bronchial reconstruction was not possible and hence, right middle and lower lobectomy was performed (figure 2). Bronchial rupture is an unusual and potentially lethal condition after blunt chest trauma.1 The right bronchus is most
Figure 2 Macroscopic image: middle and lower lobes after surgery. We can observe a transverse rupture in the insertion point of the middle lobe bronchus. frequently impaired due to its larger diameter and because the left bronchus is more shielded by the surrounding tissue. Airway injuries are mainly located within 2 cm from the carina.2 The distal ruptures in segmental bronchi are exceptional.3 4 The CT scan with multiplanar reconstruction is increasingly used for diagnosing tracheobronchial rupture.5 However, bronchoscopy remains the gold standard. This entity is an emergency and requires prompt and definite treatment. A therapeutic delay can be dangerous. Surgery is usually required to repair the airway. Gerardo Andres Obeso Carillo, Eva Maria Garcia Fontan Department of Thoracic Surgery, Vigo University Clinical Hospital, Vigo, Spain Correspondence to Dr Gerardo Andres Obeso Carillo, Department of Thoracic Surgery, Vigo University Clinical Hospital, Pizarro 22, Vigo 36204, Spain; [email protected] Contributors GAOC is the author of the manuscript. EMGF oversaw and edited this case report. Competing interests None. Provenance and peer review Not commissioned; internally peer reviewed.
To cite Obeso Carillo GA, Garcia Fontan EM. Emerg Med J 2014;31:871. Accepted 16 December 2013 Published Online First 7 January 2014 Emerg Med J 2014;31:871. doi:10.1136/emermed-2013-203392
REFERENCES 1 2 3 4 5
Figure 1 CT scanogram. Kline JA. Emerg Med J November 2014 Vol 31 No 11
Bertelsen S, Howitz P. Injuries of the trachea and bronchi. Thorax 1972;27:188. Stewart BT, Meridew CG, Krishnan M. Post traumatic rupture of the right main bronchus: a rare clinical entity? J R Coll Surg Edinb 1999;44:132–3. Jodra Sanchez S, Garcia Lujan R, De Miguel Poch E. Distal bronchial rupture secondary to an accidental fall. Arch Bronconeumol 2011;47:264–8. Hardin KA, Louie S. Occult tracheobronchial injury: a subsegmental location. J Bronch 2002;9:290–3. Le Guen M, Beigelman C, Bouhemad B, et al. Chest computed tomography with multiplanar reformatted images for diagnosing traumatic bronchial rupture: a case report. Crit Care 2007;11:R94.
871
Downloaded from http://emj.bmj.com/ on May 24, 2015 - Published by group.bmj.com
Traumatic massive tension pneumothorax due to a break in the middle lobe bronchus Gerardo Andres Obeso Carillo and Eva Maria Garcia Fontan Emerg Med J 2014 31: 871 originally published online January 7, 2014
doi: 10.1136/emermed-2013-203392 Updated information and services can be found at: http://emj.bmj.com/content/31/11/871
These include:
References Email alerting service
Topic Collections
This article cites 5 articles, 1 of which you can access for free at: http://emj.bmj.com/content/31/11/871#BIBL Receive free email alerts when new articles cite this article. Sign up in the box at the top right corner of the online article.
Articles on similar topics can be found in the following collections Surgical diagnostic tests (125) Clinical diagnostic tests (990) Radiology (940) Radiology (diagnostics) (847) Ethics (371) Trauma (991)
Notes
To request permissions go to: http://group.bmj.com/group/rights-licensing/permissions To order reprints go to: http://journals.bmj.com/cgi/reprintform To subscribe to BMJ go to: http://group.bmj.com/subscribe/
Commentary
IMAGES IN EMERGENCY MEDICINE
Traumatic massive tension pneumothorax due to a break in the middle lobe bronchus A patient presented respiratory failure and haemodynamic instability after falling from a height of 6 m. After a high suspicion of tension pneumothorax based on clinical status and pulmonary auscultation, the emergency physician inserted a Pneumocath (8 Fr; 2.7 mm) while in the ambulance. Once in hospital, CT scan (figure 1) showed a tension pneumothorax that caused an important left displacement of the heart, right diaphragm and hepatic silhouette. These findings led to replacing the chest tube by a thicker one (Argyle Thoracic Catheter 28 Fr; 9.3 mm). Due to the presence of massive and persistent air leak, a bronchoscopy was performed. It confirmed a break in the middle lobe bronchus. Finally, the patient underwent a right posterolateral thoracotomy. Bronchial reconstruction was not possible and hence, right middle and lower lobectomy was performed (figure 2). Bronchial rupture is an unusual and potentially lethal condition after blunt chest trauma.1 The right bronchus is most
Figure 2 Macroscopic image: middle and lower lobes after surgery. We can observe a transverse rupture in the insertion point of the middle lobe bronchus. frequently impaired due to its larger diameter and because the left bronchus is more shielded by the surrounding tissue. Airway injuries are mainly located within 2 cm from the carina.2 The distal ruptures in segmental bronchi are exceptional.3 4 The CT scan with multiplanar reconstruction is increasingly used for diagnosing tracheobronchial rupture.5 However, bronchoscopy remains the gold standard. This entity is an emergency and requires prompt and definite treatment. A therapeutic delay can be dangerous. Surgery is usually required to repair the airway. Gerardo Andres Obeso Carillo, Eva Maria Garcia Fontan Department of Thoracic Surgery, Vigo University Clinical Hospital, Vigo, Spain Correspondence to Dr Gerardo Andres Obeso Carillo, Department of Thoracic Surgery, Vigo University Clinical Hospital, Pizarro 22, Vigo 36204, Spain; [email protected] Contributors GAOC is the author of the manuscript. EMGF oversaw and edited this case report. Competing interests None. Provenance and peer review Not commissioned; internally peer reviewed.
To cite Obeso Carillo GA, Garcia Fontan EM. Emerg Med J 2014;31:871. Accepted 16 December 2013 Published Online First 7 January 2014 Emerg Med J 2014;31:871. doi:10.1136/emermed-2013-203392
REFERENCES 1 2 3 4 5
Figure 1 CT scanogram. Kline JA. Emerg Med J November 2014 Vol 31 No 11
Bertelsen S, Howitz P. Injuries of the trachea and bronchi. Thorax 1972;27:188. Stewart BT, Meridew CG, Krishnan M. Post traumatic rupture of the right main bronchus: a rare clinical entity? J R Coll Surg Edinb 1999;44:132–3. Jodra Sanchez S, Garcia Lujan R, De Miguel Poch E. Distal bronchial rupture secondary to an accidental fall. Arch Bronconeumol 2011;47:264–8. Hardin KA, Louie S. Occult tracheobronchial injury: a subsegmental location. J Bronch 2002;9:290–3. Le Guen M, Beigelman C, Bouhemad B, et al. Chest computed tomography with multiplanar reformatted images for diagnosing traumatic bronchial rupture: a case report. Crit Care 2007;11:R94.
871
Downloaded from http://emj.bmj.com/ on May 24, 2015 - Published by group.bmj.com
Traumatic massive tension pneumothorax due to a break in the middle lobe bronchus Gerardo Andres Obeso Carillo and Eva Maria Garcia Fontan Emerg Med J 2014 31: 871 originally published online January 7, 2014
doi: 10.1136/emermed-2013-203392 Updated information and services can be found at: http://emj.bmj.com/content/31/11/871
These include:
References Email alerting service
Topic Collections
This article cites 5 articles, 1 of which you can access for free at: http://emj.bmj.com/content/31/11/871#BIBL Receive free email alerts when new articles cite this article. Sign up in the box at the top right corner of the online article.
Articles on similar topics can be found in the following collections Surgical diagnostic tests (125) Clinical diagnostic tests (990) Radiology (940) Radiology (diagnostics) (847) Ethics (371) Trauma (991)
Notes
To request permissions go to: http://group.bmj.com/group/rights-licensing/permissions To order reprints go to: http://journals.bmj.com/cgi/reprintform To subscribe to BMJ go to: http://group.bmj.com/subscribe/
