EMS, Pneumothorax IdentificationWithout Ancillary Testing

Pneumothorax is a principal diagnosis for emergency management services (EMS) providers to make because it is a potentially life-threatening condition that is commonly associated with complaints such as chest pain, shortness of breath, and trauma. The condition spans all age groups, and EMS providers should, therefore, maintain a high index of suspicion for pneumothorax for any patient with a sudden onset of acute respiratory distress and ipsilateral chest pain. Pneumothorax is the entry of air into the potential space between the parietal and visceral pleura. Air can enter the chest cavity from a rupture in the lung tissue or trauma to the pleura. Lung tissue can burst spontaneously in patients with risk factors such as tobacco use, Marfan’s syndrome, underwater diving, airplane travel, and male gender. It can also occur secondarily as a part of a chronic lung disease such as chronic obstructive pulmonary disease (COPD), interstitial lung disease, or pneumocystis pneumonia (PCP) due to the destruction of lung tissue. EMS providers may also encounter several different mechanisms of injury that violate the pleura creating a pneumothorax, such as penetrating trauma to the chest or blunt trauma with a rib fracture. EMS providers may be called to the outpatient setting where medical/holistic procedures involving the chest or neck may cause an iatrogenic pneumothorax, such as central venous catheter placement, thoracentesis, and lung biopsies. EMS providers are challenged in making the diagnosis for several reasons. They do not have access to emergency department tools such as chest radiographs and point of care thoracic ultrasound which may clinch the diagnosis. Many patients will have comorbid conditions that may mimic a pneumothorax including COPD/asthma, congestive heart failure (CHF), and pleural effusions, which may have decreased breath sounds during acute exacerbations and acute dyspnea. A hemothorax will have a similar presentation as a hemothorax such as dyspnea, hypoxia, decreased breath sounds, and chest pain. A key clinical finding that separates these two is that a pneumothorax will have hyper-resonance to percussion, but a hemothorax will have a hypo-resonance to percussion. Both of these will need a chest tube, but only a tension pneumothorax will require needle decompression. Ambient noise in the field may drown out differences in lateralized breath sounds. Low light, body fluid, and other environmental factors may make otherwise obvious chest wall openings unapparent in emergencies. In the appropriate clinical setting of acute dyspnea, but equivocal breath sounds, EMS providers may percuss the thorax for unilateral hyper-resonance and asymmetric tactile fremitus in making the diagnosis.