P016: PRESSURE'S ON: DIAGNOSIS & MANAGEMENT OF TENSION PNEUMOTHORAX AFTER COMPLEX GASTRIC CANCER RESECTION
Gregory J Mickus, MD; Mayo Clinic Florida
Tension pneumothorax (TPT) is a life-threatening condition encountered in the ICU. Diagnosis is made by clinical and radiographic signs, allowing for swift therapeutic decompression to maintain oxygenation and hemodynamic stability. The incidence is thought to occur in 5% of pre-hospital major trauma patients and 1-3% of adult ICU patients.(1) Our case illustrates the need for vigilance in a patient with evolving tension pneumothorax and impending cardiac arrest.
34-y/o WF with diffuse gastric cancer currently POD#6 from ex lap with total gastrectomy, splenectomy, distal pancreatectomy and esophagectomy, seen by critical care for altered level of consciousness. Initially she was dyspneic and agitated, placed on BiPap and given lorazepam and hydromorphone, then became altered with lethargy. Flumazenil and naloxone were given without improvement, SpO2 mid-80s. She was intubated for hypoxic respiratory failure, with bilateral distant breath sounds, had ETT placement confirmed with EtCO2 colorimetry, and was transferred to the SICU. Upon SICU arrival, SpO2 remained low-80s despite 100% FiO2, with PAP in the 30s. Portable post-ETT chest x-ray was reviewed bedside, showing moderate bilateral pneumothoraces with >50% right lung collapse, and leftward mediastinal shift consistent with TPT. An arterial line was placed during skin prep for right chest tube (CT) thoracostomy. Systolics dropped to low-70s, and improved after CT drainage of >1L purulent fluid along with 5% albumin resuscitation and vasopressin 0.04 units/minute. SpO2 increased to mid-90s. EGD revealed >50% dehiscence of the esophageal-jejunal anastomosis, repaired with an esophageal wall clip and covered metal stent. Pleural fluid cx NGTD. She was discharged on POD#23 with a right CT and Pleur-evac, removed 1-month later.
The case illustrates the need to maintain a broad differential during emergent situations. As clinicians, it is imperative to recognize key clinical signs indicative of TPT so that timely diagnosis can be made and rapid action taken to minimize the possibility of cardiovascular collapse.