All posts by TheTraumaPro

What Percent Pneumothorax Is It?

What percent pneumothorax?

Frequently, radiologists and trauma professionals are coerced into describing the size of a pneumothorax seen on chest xray in percentage terms. They may say something like “the patient has a 30% pneumothorax.”

The truth is that one cannot estimate a 3D volume based on a 2D study like a conventional chest xray. Everyone has seen the patient who has no or a minimal pneumothorax on a supine chest xray, only to discover one of significant size with CT scan.

Very few centers have or use the software that can determine the percentage of chest volume taken up with air. There are only two percentages that can be determined by viewing a regular chest xray: 0% and 100%. Obviously, 0% means no visible pneumothorax, and 100% means complete collapse. Even 100% doesn’t really look like 100% because the completely collapsed lung takes up some space. See the xray at the top for a 100% pneumothorax.

If you line up 10 trauma professionals and show them a chest xray with a pneumothorax, you will get 10 different estimates of their size. And there aren’t any guidelines as to what size demands chest tube insertion and what size can be watched.

Bottom line: The solution is to be as quantitative as possible. Describe the pneumothorax in terms of the maximum distance the edge of the lung is from the inside of the chest wall, and which intercostal space the pneumothorax extends to. So instead of saying “the patient has a 25% pneumo,” say “the pneumothorax is 1 cm wide and extends from the apex to the fifth intercostal space on an upright film.”

Mystery Diagnosis: The Answer

A young male suffered blunt torso trauma when struck by a car. Many of you sent your guesses for what is shown in the image below:

This patient sustained a traumatic pneumatocele. It is an uncommon injury in blunt trauma, and can also be caused by penetrating injury. It’s essentially a complicated laceration that fills with air leaking from torn airways (alveoli or bronchi of various sizes). 

There is usually some focal hemorrhage around the injury, which looks (and is) a pulmonary contusion. The hallmark is the bubble (or bubbles) of air that form in the area of the injury. Frequently, these can be seen on chest xray as well, although CT is much more sensitive. They are more commonly located near the pleural surface of the lung in blunt trauma, because this is the area of maximum impact. When present, they are often situated very close to a rib fracture.

Generally, these injuries do not require any specific management. They slowly heal over time, but it may take months for them to completely resolve.

Related posts:

Mystery Diagnosis

Here’s a not so common trauma problem. See if you can figure it out.

A 30 year old male was crossing the street after leaving a bar(!). He failed to notice a speeding SUV, which promptly struck him and sent him flying. He was evaluated as a trauma activation at your hospital, and you scanned his torso. You find this in his chest:

What is it, and what do you need to do about it?

Reply, Tweet, or email your ideas. Answers tomorrow!

Nurses: Stop The Insanity! When The Doc Won’t Listen

“Insanity: doing the same thing over and over again and expecting different results.”

– Albert Einstein

This post applies specifically to nurses. I know it’s happened to you. Your patient is having a problem. You do a little troubleshooting, but you feel that a doctor needs to know and possibly take some action. So you page them and duly note it in the medical record. No response. You do it again, and document it. No response. And a third time, with the same result.

And now what? Call someone else? Give up and hope the patient improves? 

What if the doctor on call is a known asshole? Are you even reluctant to call in the first place? Do you delay as long as you possibly can?

Believe it or not, I’ve seen many chart review cases over the years where this situation does arise. And every once in a while, the patient actually dies. Sometimes this is directly related to the lack of intervention, but sometimes it just sets the ball rolling that eventually leads to patient demise days or weeks later.

What’s the answer? We all want to provide the best care possible for our patients. But sometimes social factors (or pager malfunctions) just get in the way. Here’s how to deal with it.

Every hospital / nursing unit needs to have a procedure for escalating patient care calls to more advanced providers. When one of your patients develops a problem, you usually have a pretty good idea of what the possible solutions are. So call/page the proper person (PA/NP/MD) who can provide that solution. If they don’t give you the “right answer”, then question it. They are not all-knowing. 

If they give you a good explanation, go with it, but keep your eye on your patient’s progress. If they can’t explain why they are giving you the wrong answer, suggest they check with someone more senior. And if they don’t want to, let them know that you will have to. Consider no answer the same as a wrong answer.

Don’t stop going up the chain of command until you get that right answer, or an explanation that satisfies you. The hard part here is going up the chain. You may not be comfortable with this. But you do have resources that can help you that have more authority (nurse manager, supervisor, etc). If they, too, are uncomfortable, then your hospital has much bigger problems (unhealthy workplace). 

Example: trauma unit nurses at my hospital will call the first year resident first, then escalate to the junior and/or chief residents. If they don’t do the right thing, the in-house trauma attending gets the call. If they don’t handle it, then the trauma medical director (me) gets called. And, of course, I always do the right thing (chuckle). And our nurses know that the surgeons support them completely, since this facilitates the best patient care. The residents and PAs are educated about this chain of command when they first start on the trauma service, and it makes them more likely to choose the “right answer” since they know the buck may not stop with them.