2.

Pneumothorax vs Cardiac Tamponade

Pneumothorax
 Spontaneous pneumothorax: No clinical signs or symptoms in primary spontaneous
pneumothorax until a bleb ruptures and causes pneumothorax; typically, the result is
acute onset of chest pain and shortness of breath, particularly with secondary
spontaneous pneumothoraces
 Iatrogenic pneumothorax: Symptoms similar to those of spontaneous
pneumothorax, depending on patient’s age, presence of underlying lung disease, and
extent of pneumothorax
 Tension pneumothorax: Hypotension, hypoxia, chest pain, dyspnea
 Catamenial pneumothorax: Women aged 30-40 years with onset of symptoms within
48 hours of menstruation, right-sided pneumothorax, and recurrence
 Pneumomediastinum: Must be differentiated from spontaneous pneumothorax;
patients may or may not have symptoms of chest pain, persistent cough, sore throat,
dysphagia, shortness of breath, or nausea/vomiting

X-ray Pneumothorax
Procedure: Upright PA chest x-ray in inspiration is the modality of choice.
Supportive findings of pneumothorax
 Ipsilateral pleural line with reduced/absent lung markings
 Abrupt change in radiolucency
Deep sulcus sign
 Decreased radiodensity and deep costophrenic angle on the ipsilateral side.
 The sign is a result of interpleural air that collects basally and anteriorly in the supine
position.
Hemidiaphragm elevation on the ipsilateral side
If pulmonary disease is present: airway or parenchymal lesions

Supportive findings of tension pneumothorax

 Ipsilateral diaphragmatic flattening/inversion and widened intercostal spaces
 Mediastinal shift toward the contralateral side
 Tracheal deviation toward the contralateral side

Cardiac Tamponade (beck’s triad)

 Hypotension with a narrowed pulse pressure
o The fall in arterial blood pressure results from pericardial fluid accumulation
inside the pericardial sac, which decreases the maximum size of the
ventricles. This limits diastolic expansion (filling) which results in a lower EDV
(End Diastolic Volume) which reduces stroke volume, a major determinant of
 systolic blood pressure. This is in accordance with the Frank-Starling law of
the heart, which explains that as the ventricles fill with larger volumes of
blood, they stretch further, and their contractile force increases, thus causing
a related increase in systolic blood pressure.
 Jugular venous distention (JVD)
o The rising central venous pressure is evidenced by distended jugular veins
while in a non-supine position. It is caused by reduced diastolic filling of the
right ventricle, due to pressure from the adjacent expanding pericardial sac.
This results in a backup of fluid into the veins draining into the heart, most
notably, the jugular veins. In severe hypovolemia, the neck veins may not be
distended.
 Muffled heart sounds
o The suppressed heart sounds occur due to the muffling effects of the fluid
surrounding the heart.
 Echocardiography is the main diagnostic method for detection of pericardial effusion
and tamponade.

X-ray Find :
4. Complication Electrical Burn
Burns can be classified as high or low voltage. High voltages greater than 500-1000 Volts
cause deep burns and extensive deep tissue and organ damage. Low voltage exposures tend
to result in lesser injury. United States households are supplied with voltages in the 110 to
220 range which causes muscle tetany and can lead to prolonged exposure to the electrical
source, as the patient cannot let go.

Complications from electrical injuries are similar to those of other thermal burns, such as
 infection (which can progress to sepsis),
 compartment syndrome,
 and rhabdomyolysis (due to extensive muscle damage from internal burns).
 injuries from being thrown from the electrical source or from falling from a height
(roof, bucket truck, ladder) due to the electrical shock, and these injuries (long bone
fractures, spinal fractures, lacerations, pneumothorax, etc.).

Cardiac complications can occur. One can have

 an arrhythmia.
Anyone who experiences an arrhythmia or any chest pain or other typical cardiac-related
symptoms is also at risk of arrhythmia in the 24 to 48 hours following the injury. Thus these
patients should be kept on a cardiac monitor at all times. Any high voltage injury should
have continuous cardiac monitoring for a minimum of 8 hours.

A special consideration is pediatric electrical injuries that occur as the result of a child
putting a cord in the mouth and biting down, causing burn injury to the corners of the
mouth. These patients can be sent home if there are no other associated injuries, however,
the complication in this case to warn parents about is delayed bleeding from the labial
artery, which can occur about 7 days following the date of injury.
Due to the complicated nature of injury patterns with electrical injuries, anything more than
a minor electrical injury should have a qualified trauma and burn center as a final
disposition.

6. Treatment Tension Pneumothorax, Treatment PneumoHemothorax

Tension Pneumothorax
 Needle decompression followed by tube thoracostomy

Treatment of tension pneumothorax is immediate needle decompression by inserting a large-

bore (eg, 14- or 16-gauge) needle into the 2nd intercostal space in the midclavicular line. Air
will usually gush out. Because needle decompression causes a simple pneumothorax, tube
thoracostomy should be done immediately thereafter.

HemoPneumothorax :
8. Compartment Syndrome
compartment syndrome:
 pain,
 pallor (pale skin tone),
 paresthesia (numbness feeling),
 pulselessness (faint pulse)
 and paralysis (weakness with movements).

10. Fraktur Basis Cranii (anterior, mid, posterior)

 Basis Cranii fossa Anterior : rinnorhea dan racoon eyes

Darah keluar beserta dengan likor serebrospinal dari hidunng atau kedua mata
dikelilingi lingkaran “biru” ( Brill Hematoma tau Racoon’s eyes), rusaknya Nervus
Olfactorius sehingga terjadi hyposmia sampai anosmia.

 Basis Cranii fossa Media : ottorhea dan battle’s sign

Darah keluar beserta likor serebrospinal dari telinga. Fraktur memecahkan arteri
carotis interna yang berjalan di dalam sinus cavernous sehingga terjadi hubungan
antara darah arteri dan darah vena (A-V shunt).

 Basis Cranii fossa Posterior :

Tampak warna kebiru-biruann di atas mastoid. Getaran fraktur dapat melewati
foramen magnum dan merusak medulla oblongata, sehingga pennderita dapat mati
seketika.