Hong Kong Journal of Emergency Medicine

Can tension haemopneumothorax have stable haemodynamics?

AYC Siu and CH Chung

Tension pneumothorax or haemopneumothorax is a clinical diagnosis. Plain radiography is not advised to confirm the diagnosis and may delay definitive treatment. Unstable haemodynamics is one of the prerequisites for the diagnosis. We report a case in which the patient suffered from haemopneumothorax with all the typical radiological features of tension, but without any clinical sign of unstable haemodynamics. Close monitoring of patients suspected to have pneumothorax is recommended, especially in the radiology suite. (Hong Kong j.emerg.med. 2003;10:47-48) Keywords: Diagnosis, haemopneumothorax, pneumothorax, tension

Introduction
Tension pneumothorax and haemopneumothorax are lifethreatening emergencies. Delayed resuscitation will result in morbidity and even mortality. The differentiation between simple and tension pneumothorax is purely clinical. The presence of hypotension or instability will suggest the presence of tension. Radiological investigation is not recommended as a tool to detect tension pneumothorax though there are well-documented changes. In the absence of hypotension, one may have difficulty in diagnosing tension pneumothorax. This may create a dilemma against the traditional teaching on the role of radiological diagnosis.

of severe pain over the back but there was no shortness of breath. On arrival, she was conscious and alert. Her blood pressure was 100/62 mmHg, pulse rate was 96/min, respiratory rate was 20/min and oxygen saturation was 96% in room air. Initial assessment showed decreased breath sound over right lung and the trachea was central. The heart sound was normal. However, the chest radiograph showed massive right haemopneumothorax. The trachea was central but the mediastinum was shifted to the left. (Figure 1)

Case history
A 27-year-old lady with good past health returned from Mainland China after a collision accident involving miniracing car. She was restrained in the mini-racing car and suffered contusion to her right upper back. She complaint
Correspondence to: Siu Yuet Chung, Axel, FRCS(Edin), FHKCEM, FHKAM(Emergency Medicine) North District Hospital, Accident and Emergency Department, 9 Po Kin Road, Sheung Shui, N.T., Hong Kong Email: ycasiu@rcsed.ac.uk Chung Chin Hung, FRCS(Glasg), FHKAM(Surgery), FHKAM(Emergency
Medicine)

Figure 1.

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Hong Kong j. emerg. med.

Vol. 10(1) Jan 2003

A diagnosis of tension haemopneumothorax was made. She was immediately resuscitated with intravenous fluid replacement and tube thoracostomy was performed immediately. The drain yielded 500 mL of fresh blood initially and the right lung re-expanded after the procedure. She was admitted to surgical ward for further management. Due to the continuous output from the chest drain, emergent thoracoscopy and thoracotomy were performed which confirmed a tear at the anterior branch of the right subclavian artery. Haemostasis was successful and the post-operative course was uneventful. She was discharged after six days of hospitalisation.

accumulation of air in the pleural cavity. This collapses the ipsilateral lung and shifts the mediastinum to the contralateral side, resulting in compression on the vena cava and the right ventricle. The loss of ventricular filling causes vascular collapse.4 For a normal person, the body will attempt to overcome the insult by compensatory mechanisms. However, once the critical point has been reached, haemodynamic compromise will occur. The time lag between the onset of tension change and the clinical manifestation of cardiopulmonary failure depends on the rate of development of tension and the physiological reserve of the patient. Holloway and Harris also described four cases of tension pneumothorax without hypotension.5 They pointed out that the good physiological reserve might mask out the potentially lethal condition. They were still at risk of sudden deterioration and cardiac arrest. Our patient was also relatively young and fit and her physiological reserve might provide adequate compensation against the pathophysiological impact of the tension changes. But once the compensatory mechanism was overwhelmed, cardiopulmonary failure could result. Patients presenting with typical features of tension pneumothorax without hypotension or hypoxaemia should not be dealt with lightly. There may still be a chance of deterioration at anytime when the compensatory mechanism fails. For uncertain diagnosis, plain radiography may still have a role to play. However, it is only recommended in a setting with close monitoring and immediately available resuscitation facilities.

Discussion
The definition of tension pneumothorax was different in different settings. In experimental models, "tension" was defined as a continuous positive intrapleural pressure in a spontaneously breathing patient. However, in daily clinical setting, tension pneumothorax was basically a clinical diagnosis and hypotension with respiratory 1 compromise in the presence of pneumothorax was the hallmark of the condition. The traditional teaching stated that radiological confirmation was not required as it might delay the treatment. It was also highlighted in the manual of Advanced Trauma Life Support (ATLS) provider course that a prompt clinical diagnosis and immediate needle decompression were of utmost importance in salvaging the patient's life.2 Without the presence of compromised haemodynamic state, one may have difficulty deciding clinically whether the pneumothorax is in tension or not. We have illustrated a case of haemopneumothroax with radiological evidence of tension but stable haemodynamics. The time course from the event further perplexed the physician in making the diagnosis as there was about 10 hours delay in presentation. Plewa et al. reported a case of tension pneumothorax which developed several days after central venous catheterisation and positive pressure ventilation.3 There are a lot of theories postulating the pathophysiology of tension pneumothorax. It is believed that the tension change is the result of progressive

References
1. 2. 3. Rutherford RB, Hurt HH Jr, Brickman RD, Tubb JM. The pathophysiology of progressive tension pneumothorax. J Trauma 1968;8(2):212-27. American College of Surgeons. Advanced trauma life support manual. Chicago:ACS; 1997:Chapter 4. Plewa MC, Ledrick D, Sferra JJ. Delayed tension pneumothorax complicating central venous catheterisation and positive pressure ventilation. Am J Emerg Med 1995;13(5):532-5. Barton ED. Tension pneumothorax. Curr Opin Pulm Med 1999;5(4):269-74. Holloway VJ, Harris JK. Spontaneous pneumothorax: is it under tension? J Accid Emerg Med 2000;17(3): 222-3.

4. 5.