PNEUMOTHORAX Forensic Medicine

1. PNEUMOTHORAX
Dr.MAHIMALAL

2. What is PNEUMOTHORAX?
◦ It is the presence of air in the pleural space which can either occur
spontaneously or result from iatrogenic injury or trauma to the lungs or
chest wall.

3. Incidence
◦ This condition occurs in 7.4 to 18 per 100,000 men each year and 1.2 to 6
per 100,000 women each year.

4. Types of PNEUMOTHORAX
◦ Spontaneous
1. primary
2. secondary
◦ Traumatic

5. Spontaneous
◦ Primary
. Occurs in patients with no history of lung disease.
. Smoking,tall stature and presence of apical subpleural blebs –risk factors
◦ Secondary
.affects patients with pre-existing lung disease and is associated with higher
mortality rates.
.COPD,TB,asthma,lung abscess,lung cancer

6. Traumatic
Open: Chest wall is damaged by any wound- -outside air enters pleural space and
causes lungs to collapse.
Closed: here chest wall is punctured or air leaks from a ruptured bronchus
latrogenic: Ex. Postoperative Mechanical ventilation, Thoracocentesis & Central venous
cannulation.
Tension pneumothorax

8. Case scenario
◦ An intoxicated 25-year-old man was brought to the emergency department (ED) by
paramedics after he was involved in an altercation and sustained several stab wounds
to the torso and upper extremities. His initial vital signs in the ED showed pulse rate of
100 beats per minute, blood pressure of 112/80 mm Hg, respiratory rate of 20 breaths
per minute, and Glasgow coma scale of 13.

9. ◦ A 2-cm stab wound is noted over the left anterior chest just below the left nipple.
Additionally, there is a 2-cm wound adjacent to the umbilicus, and several 1- to 2-cm
stab wounds are noted in right arm and forearm, near the antecubital fossa. The
abdominal and chest wounds are not actively bleeding and there is no apparent
hematoma associated with these wounds. However, one of the wounds in the right arm
is associated with a 10-cm hematoma that is actively oozing.

10. Tension pneumothorax
◦ Tension pneumothorax develops when a lung or chest wall injury is such that it allows
air into the pleural space but not out of it (a one-way valve).
◦ As a result, air accumulates and compresses the lung, eventually shifting the
mediastinum, compressing the contralateral lung, and increasing intrathoracic pressure
enough to decrease venous return to the heart, causing shock.d55

11. ◦ Tension pneumothorax diagnosed clinically, before the chest x-ray is obtained.
◦ ALTHOUGH THE CLASSIC PRESENTATION INCLUDES,
1. Distended neck veins
2. Hypotension or evidence of hypoperfusion
3. Diminished or absent breath sounds on the affected side
4. Tracheal deviation to the contralateral side
◦ PERFORM IMMEDIATE NEEDLE DECOMPRESSION

13. Clinical presentation
◦ Sudden/Gradual
◦ Chest trauma
◦ Chest pain (sharp & stabbing) commonest, may be absent in chronic cases
◦ Dyspnea, frequently present, associated cyanosis, sweatiness & fainting

14. Differential diagnosis
◦ Tension Pneumothorax.
◦ Spontaneous pneumothorax
◦ Pericardial tamponade
◦ Rib fractures
◦ Pulmonary Embolism
◦ Acute Coronary Syndrome

15. Chest X ray

16. ◦ In critically ill patients, when they cannot be moved to an erect position, look for the
deep sulcus sign, a deep lateral costo-phrenic angle, on the affected side.

17. Management
◦ Treatment options are oxygen, observation, needle or catheter aspiration, and tube
thoracostomy
◦ Immediate needle decompression followed by moderate or large-size chest tube
insertion, water seal drainage, and admission; immediate chest tube placement ideal

18. Needle compression
◦ The most common approach to needle
decompression is to introduce a 14-gauge IV
needle and catheter into the pleural space in
the mid- clavicular line just above the rib at
the second intercostal space

19. ◦ An anterior midclavicular approach is important because this is the shortest distance from the
skin to the pleura, avoids the internal mammary vessels that are located approximately 3 cm
lateral to the sternal border, and avoids mediastinal vessels.

20. ◦ A rush of air exiting the pleural space may be audible and is diagnostic of a
pneumothorax.
◦ Needle depression converts the tension pneumothorax into an open
pneumothorax; needle decompression is a temporizing measure and should be
followed promptly with tube thoracostomy.

21. Cause of death in tension pneumothorax
◦ A tension pneumothorax can cause severe hypotension (obstructive shock) and even
death. Increased central venous pressure can result in distended neck veins and
hypotension. Patients may have tachypnea, dyspnea, tachycardia, and hypoxia.

22. Autopsy findings