OSCE – Tension Pneumothorax

1. Introduction : identity & informed consent

2. Primary Survey
a. Airway Maintenance with Cervical Spine Protection
i. Look for Cause of Airway Compromise : maxilla fracture, laryngeal
fracture, burns/inhalation, neck haematoma, GCS ≤8, neuromuscular
paralysis, vomiting, stridor
ii. Management :
1. Airway maneuvers : jaw trhust, head-tilt-chin-lift
2. Remove foreign bodies
3. Suction
4. Artificial airway : naso-/oropharyngeal, intubation, surgical
cricothyroidotomy
5. Triple immobilization : hard collar, blocks/sandbags, tape over
chin & forehead
b. Breathing and Ventilation
i. Inspection : statis & dinamis (lihat dari kaki pasien)
1. Respiratory Rate ( ) & Saturations
2. Pergerakan dada ( ) (uni-/bilateral)
3. Patah tulang iga : lebam, deformitas
4. Flail chest : paradoxical chest wall movement

5. Look : cyanosis, respiratory effort, neck vein distention (★),

bruises
ii. Palpation : deformitas, krepitasi, nyeri tekan
1. Surgical emphysema, tenderness over ribs
2. Chest expansion : simetris ( ), expansion ( )
iii. Percussion : seluruh lapang paru (depan & belakang)
1. Pneumothorax : hyperresonant
2. Hemothorax : dull/pekak
3. Pneumohemothorax
iv. Auscultation : seluruh lapang paru (depan & belakang)
1. Bunyi nafas : /
 v. Management : chest decompression (needle thoracostomy) + high flow
O2
1. Pastikan posisi tension pneumothorax (kanan/kiri)
2. Alat : 14/16 G IV cannula/abocath + spuit 10 cc
3. Persiapan : handschoen steril -> a- & antiseptic (chlorhexidine)
4. Insertion : 2nd ICS mid-clavicular line 90o (tepat di atas costa-3)
5. Aspirasi saat menusuk sampai udara dapat diaspirasi
6. Jarum/spuit ditahan – canulla didorong sampai kulit
7. Lepaskan jarum & spuit
8. Fiksasi dengan plester

9. (★) tension pneumothorax -> simple pneumothorax

c. Circulation with Hemorrhage Control

i. Heart rate, blood pressure, periphera pulse, heart sounds
ii. Bleeding : chest, abdomen, pelvis, long bones, active external bleeding
1. Examine now –resuscitation-> FAST scan, X-ray, CT-scan
iii. Management : 2 wide-bore IV cannulae + take blood
1. Hemostasis & Immobilization of fracture site
d. Disability (Neurologic Evaluation)
i. Glasgow Coma Scale : Eye(4) Motoric(6) Verbal(5)
ii. Limb Movement : paresis, plegia/paralysis
iii. Pupils Reactivity : refleks cahaya langsung & tidak langsung
e. Exposure / Environmental Control
i. Expose (look) : perdarahan, deformitas, luka
ii. Avoid heat loss : don’t expose unless absolutely necessary
f. Resuscitation : O2 & Ventilation, Shock & Bleeding, Life Threatening Injuries
3. Secondary Survey : after Primary Survey & Resuscitation -> Vital Functions (N)
a. History Taking : Allergies, Medication, Past medical history/Pregnancy, Last
meal, Events/Environment related to injury
i. Mechanism of Injury : kecelakaan, riwayat trauma (tajam/tumpul)
b. Physical Examination : head-to-toe examination
i. Plot all injuries on a drawing
4. Terapi Definitif : chest tube + Water Sealed Drainage
a. Clean area
b. Lidocaine freezing
 c. Incision above 6th rib in 5th IC (or 4th IC) space along anterior axillary line
d. Bluntly dissect down with Kelly’s
e. May use more freezing once intercostals are visible (block intercostals nerves)
f. Pop through pleura and spread with Kelly’s and feel with finger
g. Place a 32 french CT using Kelly’s directed superiorly and posteriorly
h. Attach to under water seal suction at 20 mmH2O
i. Check patient’s tetanus status –> treat if appropriate

Reference :
1. http://www.oscenotes.com/table-of-contents/surgery/pneumothorax/
2. http://www.oscestop.com/ATLS.pdf
3. http://www.oscestop.com/ABCDE_management.pdf
4. http://www.oscestop.com/Needle_thoracostomy.pdf