Medical Malpractice Insights: Airway or Tension Pneumothorax – Which do you treat first?

Here’s another case from Medical Malpractice Insights – Learning from Lawsuits, a monthly email newsletter for ED physicians. The goal of MMI-LFL is to improve patient safety, educate physicians, and reduce the cost and stress of medical malpractice lawsuits. To opt in to the free subscriber list, click here.

Chuck Pilcher, MD, FACEP

Editor, Med Mal Insights

Airway or tension pneumothorax: Which do you treat first?

The challenges of multiple simultaneous life-threatening injuries

Facts: A 35-year-old dairy worker is moving cows to the milking shed when he is viciously kicked in the left chest by an amorous bull. He is taken by EMS to a Level 2 trauma center where an immediate CXR shows 7 broken ribs, SQ air and a pneumothorax, possibly tension. The patient is intubated. A post-intubation CXR is deferred until a chest tube could also be placed. The second CXR reveals the ET well above the carina, the stomach is dilated, and the tension pneumothorax has now shifted the mediastinum. A second chest tube is inserted and the patient re-intubated – in that order – resulting in a 30-minute delay after the first intubation. A third CXR shows the L lung has re-expanded and the ET tube is now in place. The stomach remains markedly dilated. The patient is admitted and his injuries stabilized, but he eventually expires from hypoxic encephalopathy. A lawsuit is filed claiming failure to provide a timely airway.

Plaintiff: You intubated me, but I was without oxygen while you took 30 minutes to discover that the ET tube was in my esophagus, not my windpipe. You didn’t document any alternate method of confirming the ET tube placement. You put in a chest tube before looking at the CXR, then put in a second chest tube before providing me with a working airway. The basics of emergency medicine are the ABC’s: You should have assured that I had an “A”irway before putting in the chest tube.

Defense: After the first x-ray, I knew I had a lot to do. I didn’t have time to check the x-rays for esophageal intubation. I was busy saving your life. Besides, I’m not a radiologist. The radiologist is supposed to call me if they see something serious.

Result: Over the doctor’s objections, the Insurer agreed to a modest settlement with the patient’s wife and 5 children.

Takeaways:

• Sometimes there can be more than one airway problem, as in this case. Both the tension pneumothorax and the airway were appropriately addressed.
• The primary reason for a second, post-intubation CXR is to check tube placement.
• There are other ways to assess proper placement of an ET tube. These include US, evaluating for ET tube presence in the trachea and bilateral lung sliding. They should be used and documented.
• A working airway should be confirmed before moving on to secondary problems – though it’s difficult for any ED doc to consider a growing tension pneumothorax a “secondary problem.”
• Knowledge and experience increase the likelihood of properly prioritizing the needs of a patient with multiple challenges, but the plaintiff claim of “Airway First” is valid.

Reference: Confirming Placement of Endotracheal Tube. ACLS Training Center. Updated December 26, 2020. https://www.acls.net/confirming-placement-of-endotracheal-tube

Pituitary Apoplexy: Follow-up

Last month this column reported a case of “pituitary apoplexy,” a diagnosis to be considered whenever evaluating headache, especially “thunderclap headache.” Dr. Danya Khoujah has posted a quick summary of this uncommon condition on the U. of Maryland EM department educational listserv:

Pituitary apoplexy is a sudden hemorrhage or infarction of the pituitary.
* It occurs in patients with preexisting pituitary adenomas, but 3 out of 4 patients are unaware they have it.
* Patients may present with thunderclap headache, +/- visual field deficits or cranial nerve dysfunction and/or meningeal symptoms due to extravasation of blood into the subarachnoid space.
* CT is helpful to show the intrasellar mass, but the hemorrhage may be missed. It should be the initial test and, if positive, should be followed with an MRI. The latter has a sensitivity of over 90%.

Bottomline: Keep pituitary apoplexy in your differential when considering SAH or meningitis, especially in the presence of risk factors or thunderclap headache.

Reference:

1. Ishii, M. Endocrine Emergencies With Neurologic Manifestations. Continuum 2017;23(3):778–801. Abstract https://pubmed.ncbi.nlm.nih.gov/28570329/
2. Pituitary Apoplexy. Vaphiades, MS. Medscape eMedicine. Updated: Jun 03, 2022.