1 Article Title

2 Unexpected fatal tension pneumothorax: a case report regarding a patient with multiple

3 trauma on aeromedical transportation

5 Abstract

6 A 45 year-old male driver was assessed by the road rescue team following a car crash.He

7 was in shock, had a deep second-grade burn, multiple bone fractures, and chest

8 wounds.After stabilization, he was delivered to the nearest local clinic by an

9 ambulance.The physician decided to transfer him to the nearest hospital at air

10 distance of 128miles, due to the lack of sufficient facilities and urgent need for ICU

11 care.In coordination with the hospital and aeromedical crew a Bell 214C medical

12 helicopter was requested.Aeromedical transfer was initiated when the patient

13 preparation accomplished by the aeromedical team.A few minutes into the flight, his

14 clinical condition deteriorated and with the suspicion of tension pneumothorax, needle

15 thoracostomy was performed.Cross wind and frequent melicopter movements

16 interfered with tube thoracostomy, leading the aeromedical crew decision to

17 land.Following completion of tube thoracostomy and during endotracheal intubation,

18 his heart rhythm converted to bradycardia and then asystole.Unfortunately, despite 30

19 minutes of CPR, the patient died.The forensic report stated that a glassy foreign body

20 led to penetrating chest wall injury and left lung perforation, possibly causing the

21 tension pneumothorax, cardiopulmonary arrest, and death.

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23 Keywords: Chest Trauma, Penetrating Chest Injury, Tension Pneumothorax,

24 Aeromedical Transportation

25

26 Introduction

27 Thoracic trauma accounts for one-quarter of trauma deaths.Tension pneumothorax(TP)

28 is also one of the main causes of death in these victims[1].TP develops when a

29 disruption involves the visceral pleura, parietal pleura, or the tracheobronchial tree.The

30 disruption occurs when a one-way valve forms, allowing air inflow into the pleural

31 space, and prohibiting air outflow.The volume of this nonabsorbable intrapleural air

32 increases with each inspiration.As a result, pressure rises within the affected

33 hemithorax; ipsilateral lung collapses and causes hypoxia.Further pressure causes the

34 mediastinum shift toward the contralateral side and compresses both, the contralateral

35 lung and the vasculature entering the right atrium of the heart.This leads to worsening

36 hypoxia and compromised venous return.Researchers still are debating the exact

37 mechanism of cardiovascular collapse but, generally the condition may develop from a

38 combination of mechanical and hypoxic effects.The mechanical effects manifest as

39 compression of the superior and inferior vena cava because the mediastinum deviates

40 and the intrathoracic pressure increases.Hypoxia leads to increased pulmonary vascular

41 resistance via vasoconstriction.If untreated, the hypoxemia, metabolic acidosis, and

42 decreased cardiac output lead to cardiac arrest, obstructive shock and death[2].

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43 Diagnosis is usually based on clinical findings, including but not limited to respiratory

44 distress and/or decreased patient lung compliance if assisting ventilation.The time

45 should not be taken to obtain a chest radiograph(CXR)

46 or computerized tomography(CT) scan(for paraclinical confirmation) if the patient is

47 symptomatic and tension pneumothorax is suspected, as this delay in performing

48 potentially life-saving interventions could prove deadly.Immediate chest decompression

49 with needle thoracostomy(as a temporizing procedure) or tube thoracostomy(as

50 definitive treatment) is necessary.Otherwise, mechanical circulatory obstruction results

51 in initial tachycardia and hypotension, progressing to bradycardia and potentially

52 ventricular fibrillation(VF), pulseless electrical activity(PEA), asystole, and death.Because

53 this condition occurs infrequently, a high index of suspicion and knowledge of basic

54 emergency thoracic decompression is important for all healthcare personnel[1].

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56 Case Report

57 A 45 year-old male driver was assessed by a rescue team at 10:06 following a car crash

58 and gas cylinder explosion on a remote road.He was confused, in shock, had a deep

59 second-grade burn covering 25% of his body surface area, multiple bone fractures, and

60 chest wounds.After stabilization, he was delivered to the local clinic by an ambulance at

61 11:30.The physician decided to transfer him to the nearest hospital at air distance of

62 128miles, due to the lack of facilities and urgent need for ICU care.In coordination with

63 the hospital and aeromedical crew(AMC) a Bell 214C medical helicopter was

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64 requested.Because of severe pain in the left hemithorax and shoulder, a supine CXR was

65 ordered, but was normal.Due to proximity of sunset and adverse weather conditions,

66 the AMC halted further assessment and the flight began.A few minutes later, his clinical

67 condition deteriorated, as he exhibited tachypnea, bradycardia, hypotension and

68 unconsciousness.On suspicion of TP, AMC performed needle thoracostomy with a 14-

69 gauge IV catheter, inserted anteriorly into the third intercostal space.Cross winds led to

70 intense cabin movement that interfered with performing tube thoracostomy while in

71 flight, so the AMC decided to land.Mountainous terrain prevented this immediately,

72 however, and subsequent search for a suitable landing zone took an additional five

73 minutes.Chest tube size 36-F was subsequently placed laterally in the fifth intercostal

74 space.During endotracheal intubation via tube size 8, cardiac rhythm of tachycardia

75 was converted to bradycardia and then asystole.Despite 30 minutes of CPR and

76 Epinephrine infusion, return of spontaneous circulation(ROSC) was never achieved, and

77 the patient was pronounced deceased at 17:31.The forensic report indicated a massive

78 spleen haemorrhage and a penetrating injury on the left hemithorax along the mid-

79 clavicular line, across the fourth intercostal space and lung perforation by a glassy

80 foreign body with dimensions of 5×3.2×1.4mm.This may cause TP,cardiopulmonary

81 arrest and death.

82

83 Discussion

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 84 The chest takes up one quarter of the total body mass and is often exposed to injury

85 during trauma.Current data from the United States reveals more than 16,000 deaths

86 annually as a result of various forms of chest trauma.After the head and extremities,

87 chest trauma is the third most common injury[3].Chest trauma is also associated with

88 the highest morbidity and mortality depending on the mechanism of injury.Patients in

89 all age categories are at risk for chest trauma, which can result from blunt or

90 penetrating injury.Penetrating injury is less common, but it can be acutely life-

91 threatening and may be more deadly.Gunshot and stabbing account for 10% and 9.5%

92 of penetrating chest injuries in the United States.This incidence changes worldwide, is

93 more frequent in urban areas(due to assaults, GSW incidents, etc) and is as high as 95%

94 in countries engaged in war or gang violence[4].

95 The clinician evaluating and managing chest injury must understand the function of vital

96 thoracic organs, which will optimize the use of less invasive interventions.Quick

97 thinking, adequate knowledge regarding the mechanisms of injury, early diagnosis and

98 timely, effective interventions are very important in successful management and may

99 save the patient’s life.

100 The first three stages of trauma assessment involve Evaluation, Recognition, and

101 Intervention of potential injuries.Following a consistent method of “Trauma Protocol”

102 evaluation reduces the chance of missed injuries.The primary survey identifies life-

103 threatening injuries(such as to the heart and lungs).These injuries are usually serious

104 and should be considered early at the time of clinical assessment since they have the

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105 highest mortality if missed.Potential injuries that should be ruled out include: large

106 hemothorax and/or pneumothorax, pericardial effusion(with or without tamponade)

107 and hemoperitoneum.When the initial exam and additional imaging are complete, other

108 injuries also need to be considered; rib fractures, small hemothorax and/or

109 pneumothorax, pulmonary contusion and chest wall contusion.There are physical exam

110 findings that increase suspicion of chest trauma.Contusions of the chest wall in the

111 pattern of seatbelts, point tenderness over the ribs, decreased breath sounds over the

112 hemothorax, tachypnea, hypoxia, alone or conjunction with other findings suggest

113 thoracic trauma.Since CXR is achieved in the supine position, small and medium-sized

114 pneumothoraces and/or hemothoraces may be missed.The extended-Focused

115 Assessment with Sonography in Trauma(eFAST) can provide pulmonary views and

116 also evaluates pneumothorax and/or hemothorax.Chest CT scan is more sensitive and

117 specific.However, this requires the patient to be stable for transport and local

118 availability and clinical stability to complete the exam.Other methods include

119 endoscopy, bronchoscopy, and electrocardiography to complete evaluation when

120 needed.When the ABCs(airway, breathing, circulation) have been concidered, life-

121 threatening injuries require rapid intervention, such as emergency needle

122 thoracostomy(as a temporizing procedure) or tube thoracostomy by chest tube

123 insertion or emergency department thoracotomy(as definitive management)[2-4].

124 Between 18% and 40% of chest injuries can be treated with a chest tube alone[3].For

125 cases of hemothorax, adequate drainage is suggested to prevent retained hemothorax

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126 which can lead to empyema requiring video-assisted thoracoscopic surgery.The majority

127 of chest injuries can be managed non-operatively, but 15% of patients require operative

128 management as soon as possible.In cases where cardiac arrest is imminent, emergency

129 department thoracotomy(EDT) may be indicated for resuscitation.The best survival

130 results are seen in patients who undergo EDT for thoracic stab injuries who arrive with

131 signs of life[4].

132 In the prehospital management of penetrating chest injuries, any penetrating chest

133 injury or foreign body should be stabilized in the position that it is found, using the palm

134 of a gloved or finger at first, followed by an occlusive dressing, pad, a piece of cloth, a

135 commercially prepared product such as an Asherman or Bolin chest seal or with supplies

136 that are available.If you cover the wound on all sides, one must remain highly vigilant,

137 with frequent clinical reassessments, for potential development of tension

138 pneumothorax.Any penetrating object should be stabilized but not removed.Poking or

139 plugging the wound with other objects could result in the foreign body becoming

140 further lodged in the patient's body.The patient should be positioned to minimize any

141 potential movement of the foreign body while maintaining cervical spine precautions as

142 applicable[1].

143 Explosion of fuel tanks, in addition to heat damage, produces secondary blast injuries

144 with high-speed debris carried with blast wind and most often result in penetrating

145 injuries from small shrapnel and explosive projectiles at the encountered body surface

146 in victims who have been at the explosion vicinity[5].Detection of projectile foreign

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147 bodies can be difficult in some cases, depending on the type and location of the wound

148 and the timing and mechanism of injury.Reasons for failure to detect a foreign body

149 include incomplete, inadequate or misleading history of the injury, inadequate wound

150 exploration, failure to obtain radiographs or radiolucency of the foreign body.Plastic and

151 organic foreign bodies(such as wood) are generally radiolucent.A common

152 misconception held by physicians about glass foreign bodies is that only leaded glass is

153 radiopaque on radiographs.In fact, the two factors of lead content and density

154 determine the final radiodensity of glass[6].Following CXR, CT scan is usually the next

155 choice to evaluate radiolucent foreign bodies and the complications of which due to its

156 ability to provide volumetric information and detailed spatial resolution of anatomy and

157 pathology[7].In suspicious symptomatic patients with normal radiography and those

158 who require immediate AMT with any diagnostic procedures, it is necessary to

159 proactively place a chest tube before the beginning of AMT[1,8].

160 Other Indications for tube thoracostomy include traumatic pneumothorax (except

161 asymptomatic or apical pneumothorax), moderate-to-large pneumothorax, respiratory

162 symptoms regardless of size of pneumothorax, increasing size of pneumothorax after

163 conservative therapy, recurrent pneumothorax, patients requiring ventilator support or

164 general anesthesia, associated hemothorax and bilateral pneumothorax[1].

165 The Bell 214C that was utilized is well-suited for our regional transport needs.It has

166 proven capable of withstanding our hot ambient environmental temperatures, has a

167 speed up to 140 knots, can fly day or night, and can perform to an altitude of 16,400

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168 feet if necessary.Versatility is another advantage, allowing for utilization of various types

169 of medical equipment onboard to meet extensive patient care needs.

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171 Conclusion

172 It is imperative to perform a thorough pre-flight patient assessment, crew decision-

173 making, and patient preparation including potential lifesaving clinical interventions prior

174 to initiation of air medical transport.It is the Authors' hope that through proactive

175 clinical education, potentially tragic events may be avoided in the future.

176

177 Rererences

178 1. Walls R.M, Hockberger R.S, Gausche-Hill M, Bakes K, Kaji A.H, Baren J.M, VanRooyen

179 M, Erickson T.B, Zane R.D, Jagoda A.S. editors. Rosen’s Emergency Medicine Concepts

180 and Clinical Practice. Philadelphia: Elsevier; 2018.

181

182 2. Jalota R, Sayad E. Tension Pneumothorax. In: StatPearls. Treasure Island (FL):

183 StatPearls Publishing; August 11, 2020.

184

185 3. David J. Dries.Chest Trauma: From Outside to Inside. Air Medical Journal. April 24,

186 2020; 39(3):157-161. DOI: https://doi.org/10.1016/j.amj.2020.03.004

187

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188 4. Jain A, Sekusky AL, Burns B. Penetrating Chest Trauma. In: StatPearls. Treasure Island

189 (FL): StatPearls Publishing; November 16, 2020.

190

191 5. Ajay K. Singh , Noah G. Ditkofsky, John D. York, Hani H. Abujudeh, Laura A. Avery, John

192 F. Brunner, et al. Blast Injuries: From Improvised Explosive Device Blasts to the Boston

193 Marathon Bombing. RadioGraphics. 2016; 36:295–307

194 https://doi.org/10.1148/rg.2016150114

195

196 6. Jarraya M, Hayashi D, de Villiers RV, et al. Multimodality imaging of foreign bodies of

197 the musculoskeletal system.AJR Am J Roentgenol.2014;203:W92-w102

198

199 7. Tseng HJ, Hanna TN, Shuaib W, Aized M, Khosa F, Linnau KF. Imaging Foreign Bodies:

200 Ingested, Aspirated, and Inserted. Ann Emerg Med. 2015;66(6):570-582.

201 http://dx.doi.org/10.1016/j.annemergmed.2015.07.499

202

203 8. Beninati W, Polk JD, Fallon WF. Civilian Air Medical Transport Aeromedical

204 Evacuation.In: Hurd WW, Beninati W. Aeromedical Evacuation, 2th ed. Switzerland:

205 Springer, 2019;41-56.

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