Pearls and Pitfalls

Fig 3: Tracheo-bronchial injury

Pearls

• If you do perform needle thoracocentesis, have some saline in the syringe to demonstrate bubbling when the tension is ‘hit’
• Gross surgical emphysema in combination with pneumomediastinum (as per chest X-ray (CXR)) and a chest drain that continues to bubble, suggests tracheo-bronchial injury (image, right)
• If there is good clinical and radiological evidence of significant lateral chest wall injury, consider the second intercostal space anteriorly for the chest drain insertion — it’s safer for the operator and less painful for the awake patient

Pitfalls

• One third of initial CXRs in trauma will not detect pneumothorax –anaesthetic colleagues need to be aware of this if your patient leaves for theatre
• Cardiac tamponade may give similar signs clinically –shock, with distended neck veins.  A combination of your eFAST skills and consideration of the mechanism of injury should help you distinguish the two.
• Beware other pathology masquerading as large (possibly tensioning?) pneumothorax on the CXR – see Question in next section for more on this.