Tracheal Shift and Spontaneous Pneumothorax

[Roostmonkey]

So far, one of my guest instructors has told me that spontaneous pnuemothrorax will NOT result in a tracheal shift, EVER. She pretty much told us that there is no way to tell a pneumothorax in the field, and it only comes up under xray.

The other guest paramedic instructor today told us the EXACT opposite, which I am much more inclined to believe. I am pretty sure I would hear much different lung sounds in each case, and if the left lung was collapsed, wouldn't the trachea want to shift towards the right lung?

I have taken interest in this particular condition considering that I am a very tall, thin, white, male smoker

Thoughts?

[flight-lp]

Tracheal deviation is a late ominous sign. In my experience most spontaneous pneumo's will not develop enough to cause a shift or are treated prior to that point. The only time I have seen deviation is in a patient that is dead or one that soon dies. All patients that I have ever placed a chest tube into that have exhibited a tracheal shift have died, despite the correctable treatment being in place. (And yes the tube was placed properly!)

[nsmedic393]

First, you guest instructor is full of crap.

Flight LP is absolutly correct, a deviated trachea is one of the latest signs of a pneumothorax and a good indicator that your patient is about to check out.

As far as not being able to tell if someone has a pneumo in the field, that is just flat out wrong. There may be times that you will not figure it out but in my experience it may be in the early stages when the symptoms are not very severe. As it progresses it usually becomes more evident what the problem is. Most of the time a good detailed physical assesment with with a focused history will reveal a pneumo.

Plus (and maybe its just me) I find that most of the patients that I have seen with a pneumo/hemothorax look and breath and act a certain way. Hard to be more specific about that though.

[ERDoc]

A pt with a tension pneumo will have tracheal deviation (amongst many other bed signs). You MUST recognise this in the field or your pt will die. Obviously this depends on how rapidly the pressure in the cavity builds up, but if it has gotten to this point they need a needle in their chest. A spontaneous pneumo does not have to become a tension pneumo, but depending on how large the pneumo is you may or may not be able to pick it up. You would be surprised how many trauma pts come in with a small ptx. Most times there is nothing that needs to be done except give oxygen and recheck the xray a few hours later. Most spontaneous ptx are large enough to require a chest tube or pig tail, but do not produce a tension ptx. Pts with spontaneous ptx are tall, thin, white smokers with a sudden onset of sob and/or chest pain. They will generally be tachypneic. Their sats will usually not be abnormal. Their LS will be decreased on the affected side and if you percuss the chest it will be tympanic.

[Ridryder 911]

Please have your instructor join this site ! I would love to hear their explanation of why one can not determine pnuemothorax in the field.. oh, they are F.O.S. .. ask what that medical abbreviation is. :wink: They are right about tracheal deviation it is a late sign as others has posts.. remember it takes a lot of movement to shift the lung, heart, mediastianum to cause tracheal deviation...

Here is a pic that a Flight nurse has that shows a major pnuemo..please not the shift on the film at the trachea level...

guess what gang the patient denied of any complaints ....

[Dustdevil]

I dunno about the trachea, but his heart is in his right armpit! :shock:

Most significant spontaneous pneumo I recall was, sure enough, an 18 year old, stereotypically tall, slender white male on a church bus trip. He started feeling bad out on a lonely highway in the middle of nowhere. By the time they made it to the next town to call for help (pre-cellphone/pre-911 days), he was on death's door with a tension pneumo. Luckily, the gas station they stopped at was less than a mile from the hospital I was stationed at, and we had a surgical team in the house at the time.

So yeah... that instructor needs to get off the transfer trucks for awhile and experience some EMS. :?

SPELL CHECKED: No errors found. 8)

[Roostmonkey]

Thanks alot guys. The xray was particularly helpful. I'll ask about FOS, never heard of that before!

[Nate]

Dang, that guys is skinny.

[Roostmonkey]

Looks like me, heh

[medik8]

Wow...I'm glad I'm not a tall, skinny white man with a pack of Camels in my pocket that lives anywhere NEAR your guest instructor...holy crap! :shock: