Dr.

Berlian Idriansyah Idris, SpJP(K), FIHA, MPH, DSc

1995 - 2002 Dokter umum: FKUI

2003 2007 Master of Public Health, Doctor of
Science: Erasmus MC, the Netherlands
2007 - 2012 Spesialis Jantung dan Pembuluh Darah:
FKUI
2012 2013 Fellow Interventional Cardiology:
Vietnam & Thailand
Dokter di RS OMNI Alam Sutera dan RS Medika BSD
Berlian I. Idris
 Causes of cardiac arrest

Hs Hypovolemia
Ts Toxins

Hypoxia Tamponade

Tension
Hydrogen ion pneumothorax
(acidosis)
Thrombosis (coronary)
Hyperkalemia
Thrombosis (pulmonary)
Hypothermia
(Trauma)

(Hypoglycemia)
 Cardiac arrest etiology
Goteberg (Swedia) 1981 - 2000: 25% (n= 1360) of
5415 out of hospital arrest patients had non
cardiac etiology, from these,
24% surgical or accident
20% obstructive pulmonary disease
13% drug abuse
43% another cause
Helsinki (Finland) Jan 1, 1994 Dec 31, 1995:
34.1% (n= 276) of 809 out of hospital arrest
patients had non cardiac etiology
Engdahl J, et al. Resuscitation 2003. 57(1): 33-41
Kuisma M, et al. Eur Heart J. 1997. 18:1122-8
 Epidemiology
No exact prevalence/incidence of tension
pneumothorax, especially as a cause of
cardiac arrest
Pneumothorax is a common complication of
blunt trauma, due to a fractured rib

Kulshrestha P, et al. J Trauma. 2004;57(3):576.

Berlian I. Idris
 Tension pneumothorax
Life threatening emergency
Progressive air pressure within chest impairing
venous return.
Resulting from a wound in the chest wall
which acts as a valve that permits air to enter
the pleural cavity but prevents its escape
Air enters via a defect in the visceral pleura or
the parietal pleura
http://www.merriamwebster.com/medical/tension+pneumothorax
 Causes of pneumothorax
Primary spontaneous
Rupture of an apical bleb
Secondary due to pre-existing lung abnormality
Pulmonary fibrosis
Asthma
Vasculitis
Pulmonary metastases close to edge of lung
Traumatic
Blunt trauma with rib fractures
Penetrating chest trauma
 Clinical features
Reduced lung volume:
Progressive respiratory distress; anxiety or agitation
Hyperresonance
Unilateral absence of breath sounds
Reduced venous return
Tachycardia
Hypotension
Neck vein distention
 Clinical features
Mediastinal shift
Tracheal deviation
Cyanosis
ECG: narrow QRS complex and rapid heart rate.
Cardiac arrest: pulseless electrical activity

NOT AN X-RAY DIAGNOSIS

 CXR features
White line of visceral pleura parallel to chest
wall
No lung markings lateral to the line
There may be associated rib fractures
Do not confuse the line with skin fold or with
scapula
The most sensitive test if in doubt is a CXR
taken in expiration
R

Right lung more translucent than left

Faint line just visible (zoomed view to follow)
Pencil-thin white line
running parallel to chest wall
No lung markings lateral to
the line

Blade of right scapula

 Life saving measure:
needle chest decompression
NEEDLE CHEST DECOMPRESSION
THANK YOU
 Tube Thoracostomy
1. Identify and prepare the area w/ Betadine at ICS 4 or 5 along the mid-
axillary or anterior axillary line
2. Anesthetize the area (subcutaneous tissue, intercostal muscles) with
Lidocaine. Some physicians use opioid analgesia or a combination of an
opioid + Benzo.
3. Make a 2 cm incision
4. Insert a large blunt clamp over superior aspect of rib (preventing damage to
the neurovascular bundle that lies on the inferior border of the rib). Apply
gentle pressure until the parietal pleura is pierced.
5. Open clamp to establish a tract for the chest tube.
6. Bluntly dissect w/ finger.
7. Clamp proximal end of tube tangentially w/ Clamp. Insert tube over
superior aspect of rib into pleural space.
8. Insert the chest tube past the last hole. Note the last hole disrupts the
continuity of the radiopaque linethis facilitates radiographic placement
confirmation. Suture chest tube w/ Silk sutures.
 NEEDLE CHEST DECOMPRESSION

Locate 2d intercostal space at midclavicular line

Insert 14-gauge catheter-over-needle into chest cavity
over superior edge of rib
Listen for gush of air and observe for improvement of
symptoms
Tape catheter in place with cap or valve in place to
prevent re-entry of air
May also place Asherman chest seal over catheter
Dress open chest wound if present
 Tension
pneumothorax
Tension pneumothorax shifts in the
intrathoracic structure and can
rapidly lead to cardiovascular
collapse and death.

ECG: Narrow QRS complex and rapid

heart rate.

Physical signs: JVD, tracheal

deviation, unequal breath sounds,
difficulty with ventilation, and no
pulse felt with CPR.

Treatment: Needle decompression.