Tension pneumothorax resident survival guide: Difference between revisions

Jump to navigation Jump to search
No edit summary
 
(120 intermediate revisions by 3 users not shown)
Line 1: Line 1:
<div style="width: 80%;">
<div style="width: 80%;">
__NOTOC__
__NOTOC__
{{CMG}}; {{AE}} {{MM}}; {{TS}}
{{CMG}}; {{AE}} {{HQ}}, {{MM}}, {{TS}}, {{Rim}}
 
{{SK}} Collapsed lung; air around the lung; air outside the lung


{| class="infobox" style="margin: 0 0 0 0; border: 0; float: right; width: 100px; background: #A8A8A8; position: fixed; top: 250px; right: 21px; border-radius: 0 0 10px 10px;" cellpadding="0" cellspacing="0";
{| class="infobox" style="margin: 0 0 0 0; border: 0; float: right; width: 100px; background: #A8A8A8; position: fixed; top: 250px; right: 21px; border-radius: 0 0 10px 10px;" cellpadding="0" cellspacing="0";
Line 13: Line 11:
! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | [[Tension pneumothorax resident survival guide#Causes|Causes]]
! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | [[Tension pneumothorax resident survival guide#Causes|Causes]]
|-
|-
! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | [[Tension pneumothorax resident survival guide#Diagnosis|Diagnosis]]
! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left |[[Tension pneumothorax resident survival guide#FIRE: Focused Initial Rapid Evaluation|FIRE]]
|-
! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left |[[Tension pneumothorax resident survival guide#Complete Diagnostic Approach|Diagnosis]]
|-
|-
! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | [[Tension pneumothorax resident survival guide#Treatment|Treatment]]
! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | [[Tension pneumothorax resident survival guide#Treatment|Treatment]]
Line 22: Line 22:
|}
|}


==Overview==
=Overview=
Tension pneumothorax is a medical emergency resulting from the accumulation of air in the [[pleural cavity]].  Air enters the [[intrapleural space]] as a result of disruption in the [[parietal pleura]], [[visceral pleura]] or [[tracheobronchial tree]].  This disruption results in the formation of a one way valve which allows the air to enter in the pleural cavity (during inspiration) but prevents its escape (during expiration).  Subsequently, pressure inside the [[pleural cavity]] rises above the atmospheric pressure and results in respiratory and cardiovascular failure.  [[Tension pneumothorax]] can occur as a result of [[trauma]], [[ventilation]], [[resuscitation]] and preexisting lung disease.<ref name="pmid20696690">{{cite journal| author=MacDuff A, Arnold A, Harvey J, BTS Pleural Disease Guideline Group| title=Management of spontaneous pneumothorax: British Thoracic Society Pleural Disease Guideline 2010. | journal=Thorax | year= 2010 | volume= 65 Suppl 2 | issue=  | pages= ii18-31 | pmid=20696690 | doi=10.1136/thx.2010.136986 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20696690  }} </ref>  Commonly, the patient presents with severe [[dyspnea]] and [[chest pain]].  It should be managed immediately with emergency needle decompression.
Tension pneumothorax is a life threatening condition that results from the accumulation of air in the [[pleural cavity]].  Air enters the [[intrapleural space]] through an injured [[parietal pleura]], [[visceral pleura]] or [[tracheobronchial tree]] that forms a one way valveThe one way valve allows the air to enter in the pleural cavity (during inspiration) but prevents its escape (during expiration).  Subsequently, the intrapleural pressure rises and results in respiratory and cardiovascular failure.  [[Tension pneumothorax]] can occur as a result of [[trauma]], [[ventilation]] or [[resuscitation]].<ref name="pmid20696690">{{cite journal| author=MacDuff A, Arnold A, Harvey J, BTS Pleural Disease Guideline Group| title=Management of spontaneous pneumothorax: British Thoracic Society Pleural Disease Guideline 2010. | journal=Thorax | year= 2010 | volume= 65 Suppl 2 | issue=  | pages= ii18-31 | pmid=20696690 | doi=10.1136/thx.2010.136986 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20696690  }} </ref>  The cardinal symptoms and signs of [[tension pneumothorax]] are severe [[dyspnea]], [[chest pain]], [[hypotension]], [[hypoxia]], [[tachycardia]] and [[jugular vein distention]].  [[Tension pneumothorax]] should be managed immediately with emergency needle decompression followed by insertion of a [[chest tube]].


==Causes==
==Causes==
Line 37: Line 37:
* [[Emphysema]]
* [[Emphysema]]
* [[Mechanical ventilation]]
* [[Mechanical ventilation]]
* [[Trauma]]
* [[Trauma]]<ref name="pmid20696690">{{cite journal| author=MacDuff A, Arnold A, Harvey J, BTS Pleural Disease Guideline Group| title=Management of spontaneous pneumothorax: British Thoracic Society Pleural Disease Guideline 2010. | journal=Thorax | year= 2010 | volume= 65 Suppl 2 | issue=  | pages= ii18-31 | pmid=20696690 | doi=10.1136/thx.2010.136986 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20696690  }} </ref>
 
 
Click '''[[Pneumothorax causes|here]]''' for the complete list of causes.
 
==FIRE: Focused Initial Rapid Evaluation==
A Focused Initial Rapid Evaluation (FIRE) as shown below should be performed to identify patients in need of immediate intervention.
 
<span style="font-size:85%">Boxes in red signify that an urgent management is needed.</span>
 
{{Family tree/start}}
{{familytree  | | | A01 | | | A01=<div style="text-align: left; width: 22em"> '''Identify cardinal findings that increase the pretest probability of tension pneumothorax:'''</div> <div style="text-align: left; width: 22em"> ❑ [[Chest pain]] <br>❑ [[Dyspnea]]<br>❑ [[Hypoxia]] <br>❑ [[Hypotension]]<br>❑ [[Tachycardia]] <br> ❑ [[Jugular venous distension]]<br>
❑ Absent [[breath sounds]] on the affected side <br>
❑ [[Percussion#Hypperresonance|Hyperresonance]] on the affected side <br>
❑ Hyperexpansion of the the affected side <br>
❑ [[Tracheal deviation]] towards the unaffected side<ref name="pmid20696690">{{cite journal| author=MacDuff A, Arnold A, Harvey J, BTS Pleural Disease Guideline Group| title=Management of spontaneous pneumothorax: British Thoracic Society Pleural Disease Guideline 2010. | journal=Thorax | year= 2010 | volume= 65 Suppl 2 | issue=  | pages= ii18-31 | pmid=20696690 | doi=10.1136/thx.2010.136986 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20696690  }} </ref></div>}}
{{familytree  | | | |!| | | }}
{{familytree  | | | A02 | | A02= <div style="text-align: left; width: 22em">Does the patient have high probability of tension pneumothorax?</div>}}
{{familytree  | |,|-|^|-|.| | | | |}}
{{familytree  | B01 | | B02 | | | | B01=<div style=" width: 22em"> <div style="background: #FA8072"> {{fontcolor|#F8F8FF|'''Yes'''}} </div> </div>| B02=<div style=" width: 25em">'''No'''</div>}}
{{familytree  | |!| | | |!| | | | | | | }}
{{familytree  | B03 | | B04 | | | | | |B03=<div style="float: left; text-align: left; width: 20em; background: #FA8072; padding:1em;"> {{fontcolor|#F8F8FF| '''❑ Immediately [[Tension pneumothorax resident survival guide#Treatment|<span style="color:white;">insert a 14-16 Gauge needle </span>]] in the 2nd [[intercostal space|<span style="color:white;">intercostal space</span>]] at the [[midclavicular line|<span style="color:white;">midclavicular line</span>]] of the affected hemithorax'''}} </div> |B04=<div style="float: left; text-align: left; width: 22em; padding:1em;">❑ '''[[Tension pneumothorax resident survival guide#Complete Diagnostic Approach of tension pneumothorax|Continue with the complete diagnostic approach below]]''' </div>}}
{{familytree  | |!| | | | | | | | | | | | | }}
{{familytree  | B06 | | | | | | | | | | | |B06=<div style=" width: 22em"> <div style="background: #FA8072"> {{fontcolor|#F8F8FF|'''❑ Insert chest drain immediately after needle decompression'''}} </div> </div>}}
{{Family tree/end}}
<br>


==Diagnosis==
==Complete Diagnostic Approach==
Shown below is an algorithm depicting the diagnostic approach of [[tension pneumothorax]] based on the British Thoracic Society Pleural Disease Guideline 2010.<ref name="pmid20696690">{{cite journal| author=MacDuff A, Arnold A, Harvey J, BTS Pleural Disease Guideline Group| title=Management of spontaneous pneumothorax: British Thoracic Society Pleural Disease Guideline 2010. | journal=Thorax | year= 2010 | volume= 65 Suppl 2 | issue=  | pages= ii18-31 | pmid=20696690 | doi=10.1136/thx.2010.136986 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20696690  }} </ref><br>
A complete diagnostic approach should be carried out after a focused initial rapid evaluation is conducted and following initiation of any urgent intervention.<ref name="pmid20696690">{{cite journal| author=MacDuff A, Arnold A, Harvey J, BTS Pleural Disease Guideline Group| title=Management of spontaneous pneumothorax: British Thoracic Society Pleural Disease Guideline 2010. | journal=Thorax | year= 2010 | volume= 65 Suppl 2 | issue=  | pages= ii18-31 | pmid=20696690 | doi=10.1136/thx.2010.136986 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20696690  }} </ref><br>
<span style="color:red">Tension pneumothorax requires '''immediate''' intervention.  It should be diagnosed based on the history and physical examination findings.</span> <br>


<span style="font-size:85%">'''DVT''': Deep venous thrombosis; '''CT''': Computed tomography </span><br>
{{familytree/start |summary=Diagnostic approach}}
{{familytree/start |summary=Diagnostic approach}}
{{familytree | | | |A01 | | | | |A01= <div style="float: Left; text-align: left; width: 40em; padding:1em;">'''Characterize the symptoms:'''<br>
{{familytree | | | |A01 | | | | |A01= <div style="float: Left; text-align: left; width: 40em; padding:1em;">'''Characterize the symptoms:'''<br>
Line 52: Line 75:
❑ [[Anxiety]]<BR>
❑ [[Anxiety]]<BR>
❑ [[Fatigue]]<BR>
❑ [[Fatigue]]<BR>
Decreased [[Altered mental status classification#Classification|level of consciousness]] (in late stages)<br>
❑ [[Altered mental status]] (in late stages)<br>
</div>}}
</div>}}
{{familytree | | | | |!| | | | | | | | | }}
{{familytree | | | | |!| | | | | | | | | }}
Line 58: Line 81:
❑ Recent invasive procedures<br>
❑ Recent invasive procedures<br>
:❑ [[Thoracentesis]]<br>
:❑ [[Thoracentesis]]<br>
:❑ [[Central venous catheter]] insertion<br>
:❑ [[Central venous catheter]] <br>
:❑ [[Bronchoscopy]]<br>
:❑ [[Bronchoscopy]]<br>
:❑ [[Biopsy|Pleural biopsy]]<br>
:❑ [[Biopsy|Pleural biopsy]]<br>
Line 64: Line 87:
❑ [[Cardiopulmonary resuscitation]]<br>
❑ [[Cardiopulmonary resuscitation]]<br>
❑ Presence of [[Drain (surgery)|chest drains]]<br>
❑ Presence of [[Drain (surgery)|chest drains]]<br>
❑ [[Hyperbaric oxygen]] treatment<br>
❑ [[Hyperbaric oxygen|Hyperbaric oxygen treatment]]<br>
❑ [[Trauma|Chest wall trauma]] </div>}}
❑ [[Trauma|Chest wall trauma]] </div>}}


Line 70: Line 93:
{{familytree | | | | B01 | | | | |B01= <div style="float: Left; text-align: left; width: 30em; padding:1em;">'''Examine the patient:'''<BR>
{{familytree | | | | B01 | | | | |B01= <div style="float: Left; text-align: left; width: 30em; padding:1em;">'''Examine the patient:'''<BR>
'''Appearance of the patient'''<br>
'''Appearance of the patient'''<br>
Patient with [[tension pneumothorax]] is severely distressed with [[labored respirations]].
❑ [[Distress|Severe distress]] and [[labored respiration]]


'''Vital signs'''<BR>
'''Vital signs'''<BR>


❑ [[Pulse]]:<BR>
❑ [[Tachycardia]]<BR>
:❑ Rate
❑ [[Hypotension]] <BR>
::❑ [[Tachycardia]]<BR>
❑ [[Tachypnea]]<BR>
:❑ Rhythm<br>
❑ [[Pulsus paradoxus]]
::❑ Regular
:❑ Strength
::❑ Weak
❑ [[Blood pressure]]<BR>
:❑ [[Hypotension]] <BR>
❑ [[Respiratory rate]]<BR>
:❑ [[Tachypnea]]<BR>


'''Skin'''<br>
'''Skin'''<br>
Line 94: Line 110:
❑ [[Jugular venous distension]] (absent in severe [[hypotension]])<BR>
❑ [[Jugular venous distension]] (absent in severe [[hypotension]])<BR>


'''Respiratory examination:'''<ref name="pmid20696690">{{cite journal| author=MacDuff A, Arnold A, Harvey J, BTS Pleural Disease Guideline Group| title=Management of spontaneous pneumothorax: British Thoracic Society Pleural Disease Guideline 2010. | journal=Thorax | year= 2010 | volume= 65 Suppl 2 | issue=  | pages= ii18-31 | pmid=20696690 | doi=10.1136/thx.2010.136986 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20696690  }} </ref><BR>
'''Respiratory examination'''<BR>


'''Inspection'''<BR>
'''''Inspection'''''<BR>
Enlarged involved [[hemithorax]]<BR>
Enlargement of the involved side of the chest <BR>
❑ [[Intercostal space]] widening on the affected [[hemithorax]]<br>
❑ [[Intercostal space]] widening on the affected side<br>
'''Palpation'''<BR>
'''''Palpation'''''<BR>
❑ Reduced [[lung expansion]] on the affected side <BR>
❑ Reduced lung expansion on the affected side <BR>
❑ [[Trachea]] shifted to the contralateral side<BR>
❑ [[Tracheal deviation]] to the contralateral side<BR>
❑ Decreased [[vocal fremitus]] over the affected [[hemithorax]]<BR>
❑ Decreased [[vocal fremitus]] over the affected side<BR>
❑ Displacement of the [[apex beat]]<BR>
❑ Displacement of the [[apex beat]]<BR>
'''Percussion'''<BR>
'''''Percussion'''''<BR>
❑ [[Percussion|Hyperresonance]] over the affected [[hemithorax]]<BR>
❑ [[Percussion|Hyperresonance]] over the affected side<BR>
'''Auscultation'''<BR>
'''''Auscultation'''''<BR>
❑ Diminished [[breath sounds]] on the affected side<BR>
❑ Diminished [[breath sounds]] on the affected side<BR>


'''Additional findings in ventilated patients:'''<br>
'''Additional findings in ventilated patients'''<br>


❑ Decreased [[oxygen saturation]]<br>
❑ Decreased [[oxygen saturation]]<br>
❑ Increase in inflation pressure <br>
❑ Increase in inflation pressure <br>
❑ Increase in [[peak airway pressure]]<br>
❑ Increase in [[Mechanical ventilation initial ventilator settings|peak airway pressure]]<br>
❑ Airway pressure alarm in mechanically ventilated patients<br></div>}}
❑ Airway pressure alarm in [[mechanical ventilation|mechanically ventilated]] patients<br></div>}}


{{familytree | | | | |!| | | | | | | | | }}
{{familytree | | | | |!| | | | | | | | | }}
{{familytree | | | | E01 | | | | | E01=<div style="float: Left; text-align: left; width: 40em; padding:1em;"> '''Consider alternative diagnosis:'''<br>
{{familytree | | | | E01 | | | | | E01=<div style="float: Left; text-align: left; width: 40em; padding:1em;"> '''Consider alternative diagnosis:'''<br>
❑ [[Acute myocardial infarction]] <br>
❑ [[Acute myocardial infarction]] <br>
:❑ Substernal chest discomfort or chest tightness
:❑ Substernal [[chest discomfort]], [[chest pain|pain]] or tightness
:❑ Radiation of [[chest pain]] to the left arm or jaw
❑ [[Cardiac tamponade resident survival guide|Pericardial tamponade]] <br>
❑ [[Cardiac tamponade resident survival guide|Pericardial tamponade]] <br>
:❑ [[Chest pain]]
:❑ [[Hypotension]]
:❑ [[Cough]]
:❑ [[Tachycardia]]
:❑ [[Pleuritic pain]]
:❑ [[Muffled heart sounds]]
:❑ [[Cyanosis]]
:❑ [[Jugular vein distention]]
:❑ [[Dysphagia]]
:❑ [[Pulsus paradoxus]]
:❑ [[Anorexia]]
:❑ [[Dyspnea]]
:❑ [[Fatigue]]
:❑ [[Orthopnea]]
:❑ [[Fever]]
:❑ [[Presyncope|Near syncope]]
:❑ [[Loss of consciousness]]
:❑ [[Cool extremities]]
:❑ [[Peripheral cyanosis]]
:❑ [[Peripheral edema]]
:❑ [[Low urine output]]
 
❑ [[Pulmonary embolism]]<br>
❑ [[Pulmonary embolism]]<br>
:❑ Presence of [[Pulmonary embolism risk factors|risk factors for pulmonary embolism]]<br>
:❑ Presence of [[Pulmonary embolism risk factors|risk factors for pulmonary embolism]]<br>
:❑ Physical exam is suggestive of [[DVT]]</div>}}
:❑ Localized warmth, [[tenderness]], [[edema]] and [[erythema]] in the leg suggestive of [[DVT|deep vein thrombosis]]</div>}}
{{familytree | | |,|-|^|-|.| | }}
{{familytree | | |,|-|^|-|.| | }}
{{familytree | | J01 | | J02 | |J01=Hemodynamically unstable |J02= Hemodynamically stable}}
{{familytree | | J01 | | J02 | |J01=❑ '''High probability of tension pneumothorax''' |J02= ❑ '''Low probability of tension pneumothorax and patient is hemodynamically stable''' }}
{{familytree | | |!| | | |!| | | | | }}
{{familytree | | |!| | | |!| | | | | }}
{{familytree | | M01 | | M02 | |M01=<span style="color:red">Proceed with '''immediate''' needle decompression</span>|M02= <div style="float: Left; text-align: left; width: 40em; padding:1em;">  
{{familytree |boxstyle=background: #FA8072; color: #F8F8FF;| | M01 | | |!| | M01=❑ Proceed with '''immediate''' [[Tension pneumothorax resident survival guide#Treatment|<span style="color:white;">needle decompression </span>]]}}
<span style="color:red"> Proceed with imaging studies to confirm the diagnosis in patients who are stable and not in advanced stages of tension</span> <br>
{{familytree | | | | | | M02 | M02= <div style="float: Left; text-align: left; width: 40em; padding:1em;"> '''Order imaging studies:'''<BR>
'''Imaging studies:'''<BR>
Order [[chest X-ray]] looking for:<BR>
Perform [[chest X-ray]]<BR>
:❑ Perform serial chest X-ray every 6 hours to rule out [[pneumothorax]] in cases of [[trauma]].<ref name="pmid19561940">{{cite journal| author=Sharma A, Jindal P| title=Principles of diagnosis and management of traumatic pneumothorax. | journal=J Emerg Trauma Shock | year= 2008 | volume= 1 | issue= 1 | pages= 34-41 | pmid=19561940 | doi=10.4103/0974-2700.41789 | pmc=PMC2700561 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19561940  }} </ref><BR>
[[File:Pneumothorax CXR.jpg|250px]]<BR>
<SMALL>''Picture courtesy of Wikidoc.org''</SMALL><br>
Left-sided [[tension pneumothorax]]<BR>
:❑ Air in the [[pleural cavity]]<BR>
:❑ Air in the [[pleural cavity]]<BR>
:❑ Contralateral deviation of [[mediastinum]]<BR>
:❑ Contralateral [[deviation of trachea]]<BR>
:❑ Increased thoracic volume<BR>
:❑ Increased thoracic volume<BR>
:❑ Ipsilateral flattening of heart border<BR>
:❑ Ipsilateral flattening of heart border<BR>
:❑ Mid diaphragmatic depression<BR>
:❑ Mid diaphragmatic depression<BR>
Chest CT scanning<BR>
<SMALL>Shown below is an image of a chest X-ray depicting tension pneumothorax in the left lung.</SMALL><br>
:For uncertain or complex cases
[[File:Pneumothorax CXR.jpg|250px]]<BR>
Perform serial chest X-ray every 6 hours to rule out [[pneumothorax]] in cases of [[trauma]]<ref name="pmid19561940">{{cite journal| author=Sharma A, Jindal P| title=Principles of diagnosis and management of traumatic pneumothorax. | journal=J Emerg Trauma Shock | year= 2008 | volume= 1 | issue= 1 | pages= 34-41 | pmid=19561940 | doi=10.4103/0974-2700.41789 | pmc=PMC2700561 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19561940  }} </ref><BR>
Order chest [[CT scan]] for uncertain or complex cases <br>
<SMALL>Shown below is an image of CT scan depicting left-sided pneumothorax.  A chest tube is in place, the lumen (black) can be seen adjacent to the pleural cavity (black) and ribs (white).</SMALL><br>
[[File:Pneumothorax CT.jpg|250px]]<BR>
[[File:Pneumothorax CT.jpg|250px]]<BR>
<SMALL>''Picture courtesy of Wikidoc.org''</SMALL><br>
<BR>
Left-sided pneumothorax.  A chest tube is in place, the lumen (black) can be seen adjacent to the pleural cavity (black) and ribs (white).<BR>
Order [[ultrasonography]] in supine trauma patients among whom a [[chest X-ray]] can not be performed <BR></div> }}
❑ [[Ultrasonography]] (indicated in supine trauma patients)<BR></div> |L02=<div style="float: Left; text-align: left; width: 25em; padding:1em;">❑ Administer high concentration oxygen<br>
❑ Perform emergent needle decompression (14-16 G)<br>
❑ Instantaneous escape of air confirms the diagnosis of [[tension pneumothorax]]</div>}}
{{familytree | | | | | | | | | | | }}
{{familytree | | | | | | | | | | | }}
{{familytree/end}}
{{familytree/end}}


==Treatment==
==Treatment==
Shown below is an algorithm depicting the treatment approach to [[tension pneumothorax]] based on the British Thoracic Society Pleural Disease Guideline 2010.<ref name="pmid20696690">{{cite journal| author=MacDuff A, Arnold A, Harvey J, BTS Pleural Disease Guideline Group| title=Management of spontaneous pneumothorax: British Thoracic Society Pleural Disease Guideline 2010. | journal=Thorax | year= 2010 | volume= 65 Suppl 2 | issue=  | pages= ii18-31 | pmid=20696690 | doi=10.1136/thx.2010.136986 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20696690  }} </ref><br>
{{familytree/start}}
<span style="font-size:85%">'''ABC''': Airway, breathing and circulation</span><br>{{familytree/start |summary= Treatment}}
{{familytree | | | | E01 | | | | | | | | | | | | | | E01= <div style="float: Left; text-align: left; width: 40em; padding:1em;">'''Perform emergency needle decompression:'''<ref name="pmid20696690">{{cite journal| author=MacDuff A, Arnold A, Harvey J, BTS Pleural Disease Guideline Group| title=Management of spontaneous pneumothorax: British Thoracic Society Pleural Disease Guideline 2010. | journal=Thorax | year= 2010 | volume= 65 Suppl 2 | issue= | pages= ii18-31 | pmid=20696690 | doi=10.1136/thx.2010.136986 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20696690 }} </ref><br>
{{familytree | | | | C01 | | | | |C01= <div style="float: Left; text-align: left; width: 40em; padding:1em;">'''Initial supportive measures:'''<BR>
Wear a gown, face mask and eye shield <br>
❑ Assess airway, breathing, and circulation ([[ABC (medical)|ABC]])<BR>
❑ Immediately cover penetrating chest wounds with an occlusive or pressure bandage in trauma patients<BR>
❑ Administer 100% oxygen <ref name="pmid19561940">{{cite journal| author=Sharma A, Jindal P| title=Principles of diagnosis and management of traumatic pneumothorax. | journal=J Emerg Trauma Shock | year= 2008 | volume= 1 | issue= 1 | pages= 34-41 | pmid=19561940 | doi=10.4103/0974-2700.41789 | pmc=PMC2700561 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19561940 }} </ref><BR>
Seek expert consultation (thoracic surgeon)<br></div>}}
{{familytree | | | | |!| | | | | |}}
{{familytree | | | | E01 | | | | | | | | | | | | | | E01=<div style="float: Left; text-align: left; width: 40em; padding:1em;">'''Perform emergency needle decompression:'''
❑ Ensure aseptic preparation<BR>
❑ Ensure aseptic preparation<BR>
:❑ Use alcohol-based skin disinfectants (two applications)<BR>
❑ Determine the site of insertion of the [[needle]]
❑ Use 14-16 G intravenous cannula<BR>
:❑ '''2nd [[intercostal space]] at the [[midclavicular line]]''' of affected hemithorax, OR <BR>
❑ Determine the site
:❑ 4th or 5th [[intercostal space]] on mid or anterior axillary line, if the initial decompression failed because of a thick [[chest wall]]<ref name="pmid20696690">{{cite journal| author=MacDuff A, Arnold A, Harvey J, BTS Pleural Disease Guideline Group| title=Management of spontaneous pneumothorax: British Thoracic Society Pleural Disease Guideline 2010. | journal=Thorax | year= 2010 | volume= 65 Suppl 2 | issue=  | pages= ii18-31 | pmid=20696690 | doi=10.1136/thx.2010.136986 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20696690  }} </ref>
:❑ 2nd [[intercostal space]], [[midclavicular line]](of affected hemithorax)<BR>
❑ Insert a 14-16 gauge [[needle]] with a [[catheter]] at a 90° angle<BR>
:❑ 4th or 5th [[intercostal space]] on mid or anterior axillary line, if initial decompression is failed because of thick [[chest wall]]<ref name="pmid20696690">{{cite journal| author=MacDuff A, Arnold A, Harvey J, BTS Pleural Disease Guideline Group| title=Management of spontaneous pneumothorax: British Thoracic Society Pleural Disease Guideline 2010. | journal=Thorax | year= 2010 | volume= 65 Suppl 2 | issue=  | pages= ii18-31 | pmid=20696690 | doi=10.1136/thx.2010.136986 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20696690  }} </ref>
❑ Remove the [[needle]] and leave the [[catheter]] in place<br>
<span style="color:red">Don't repeat needle aspiration unless there were technical difficulties.</span><br>
❑ Secure the [[catheter]] in place while preparing for [[tube thoracostomy]] (chest drain) <br>
<span style="color:red">Don't remove the cannula, until the chest drain is inserted and is functioning properly.</span><br>
❑ Confirm the diagnosis by observing instantaneous escape of air as the needle is inserted<br>
❑ Confirm the diagnosis by observing instantaneous escape of air <BR>
❑ Check for any improvement of the patient's status<br>
❑ Watch how to do a needle decompression {{#ev:youtube|UvHJ4pjNh2Q|400|How to do a needle decompression}}
<span style="color:red">Don't remove the catheter, until a chest drain is inserted and is functioning properly.</span><br>
<br>
''Shown below is a video depicting the steps for needle decompression'' <br>
{{#ev:youtube|UvHJ4pjNh2Q|400|How to do a needle decompression}}
<SMALL>''Video adapted from Youtube.com''</SMALL>
<SMALL>''Video adapted from Youtube.com''</SMALL>
</div>}}
</div>}}
{{familytree | | | | |!| | | | | | | }}
{{familytree | | | | |!| | | | | | | }}
{{familytree | | | | H02 | | | | | | | | | |H02= <div style="float: Left; text-align: left; width: 40em; padding:1em;"> ''' Insert chest drain:'''<BR>
{{familytree | | | | H02 | | | | | | | | | |H02= <div style="float: Left; text-align: left; width: 40em; padding:1em;"> ''' Insert a chest tube (tube thoracostomy) immediately after needle decompression:'''<BR>
❑ Obtain the [[informed consent]]<BR>
❑ Use imaging guidance<BR>
:❑ A recent [[chest X-ray]]<BR>
❑ Administer adequate analgesics <BR>
❑ Administer initial parenteral dose of [[Cephalosporin|first-generation cephalosporins]] only in patients with chest wall trauma (to decrease the risk of [[empyema]] and [[pneumonia]])<br>
❑ Make sure that the following equipments are available:
❑ Make sure that the following equipments are available:
:❑ 1% [[lignocaine]]
:❑ 1% [[lidocaine]]
:❑ [[Iodine]] or [[chlorhexidine]] solution in [[alcohol]]
:❑ [[Iodine]] or [[chlorhexidine]] solution in [[alcohol]]
:❑ Sterile drapes, gown, gloves
:❑ Sterile drapes, gown, gloves
:❑ Needles, syringes, gauze swabs
:❑ [[Needles]], [[syringes]], gauze [[swab]]s
:❑ Scalpel, suture (0 or 1-0 silk)
:❑ [[Scalpel]], [[suture]] (0 or 1-0 silk)
:❑ [[Chest tube]] kit
:❑ [[Chest tube]] kit
:❑ Closed system drain (including water) and tubing
:❑ Closed system drain (including water) and tubing
:❑ Dressing
:❑ [[Dressing (medical)|Dressing]]
:❑ Clamp
:❑ Clamp
Ensure [[asepsis]]<br>
Administer adequate analgesics <BR>
❑ Determine the insertion site<br>
❑ Determine the insertion site at the '''anterior axillary line over the 4th or 5th rib''' <br>
:❑ Superiorly: the base of the [[axilla]]<BR>
❑ Insert the chest drain <br>
:❑ Anteriorly: lateral edge of [[pectoralis major]]<BR>
❑ Remove the catheter inserted during needle decompression after the confirmation that the chest drain is functioning properly <BR>
:❑ Laterally: lateral edge of [[latissimus dorsi]]<BR>
:❑ Inferiorly: the line of the fifth intercostal space<BR>
❑ Insert chest tube immediately after the needle decompression<br>
[[Chest tube|Insert the chest tube]]<br>
❑ Remove the cannula after bubbling is observed in the chest drain underwater seal system (chest drain is functioning properly)<BR>
❑ Check chest tubes frequently, as they can become plugged or malpositioned <BR>
❑ Check chest tubes frequently, as they can become plugged or malpositioned <BR>
Chest drain is removed after re-expansion of the affected lung <br></div>}}
Remove the chest tube after re-expansion of the affected lung is confirmed by a [[chest X-ray]]<br></div>}}
{{familytree | | | | |!| | | | | | }}
{{familytree | | | | |!| | | | | | }}
{{familytree | | | | I01 | | | | | | | | | | | | | | I01=<div style="float: Left; text-align: left; width: 40em; padding:1em;"> '''Follow up'''<BR>
{{familytree | | | | I01 | | | | | | | | | | | | | | I01=<div style="float: Left; text-align: left; width: 40em; padding:1em;"> '''Follow up:'''<BR>
All patients should be followed up by chest physician<BR>
Refer the patient to a respiratory physician if pneumothorax does not respond within 48 hours<BR>
❑ Advise to return to hospital if increasing breathlessness develops<BR>
❑ Advise to return to the hospital if increasing breathlessness develops<BR>
❑ Advise to avoid air travel<BR>
❑ Advise to avoid air travel until the full resolution of the pneumothorax is confirmed by a chest X-ray<BR>
❑ Advise to avoid diving <BR>
❑ Advise to avoid diving permanently unless the patient is treated with [[Pneumothorax surgery|surgical pleurectomy]]<BR>
</div>}}
</div>}}
{{familytree/end}}
{{familytree/end}}


==Do's==
==Do's==
*Suspect [[tension pneumothorax]] with blunt and penetrating trauma to the chest.
* Suspect [[tension pneumothorax]] in the case of blunt and penetrating trauma to the chest.
*Suspect [[tension pneumothorax]] in patients on mechanical ventilation, who have a rapid onset of hemodynamic instability or cardiac arrest, and require increasing peak inspiratory pressures.
* Immediately cover penetrating chest wounds with an occlusive or pressure bandage in trauma patients with suspected [[tension pneumothorax]].
*Serial chest radiographs every 6 hrs on the first day after injury to rule out pneumothorax is ideal.<ref name="pmid19561940">{{cite journal| author=Sharma A, Jindal P| title=Principles of diagnosis and management of traumatic pneumothorax. | journal=J Emerg Trauma Shock | year= 2008 | volume= 1 | issue= 1 | pages= 34-41 | pmid=19561940 | doi=10.4103/0974-2700.41789 | pmc=PMC2700561 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19561940  }} </ref>
* Suspect [[tension pneumothorax]] among patients on mechanical ventilation who develop a rapid onset of hemodynamic instability or [[cardiac arrest]] and require an increase in the peak inspiratory pressure.
*Give adequate analgesia to patients before chest tube insertion, as the procedure is extremely painful.
* Order serial chest radiographs every 6 hours on the first day following chest [[trauma]] to rule out [[pneumothorax]].<ref name="pmid19561940">{{cite journal| author=Sharma A, Jindal P| title=Principles of diagnosis and management of traumatic pneumothorax. | journal=J Emerg Trauma Shock | year= 2008 | volume= 1 | issue= 1 | pages= 34-41 | pmid=19561940 | doi=10.4103/0974-2700.41789 | pmc=PMC2700561 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19561940  }} </ref>
*Refer the patient to respiratory specialist within 24 hours of admission.
* Refer the patient to a respiratory specialist within 24 hours of admission.
*Order chest X-ray before tube removal to confirm reexpansion of the affected lung.
* Order a [[chest X-ray]] before chest tube removal to confirm the re-expansion of the affected lung.


==Don'ts==
==Don'ts==
*Don't remove the needle from the 2nd [[intercostal space]] unless the patient is stable.
*Don't remove the catheter from the 2nd [[intercostal space]] unless a chest tube is appropriately placed.
*Don't use large bore chest drains.<ref name="pmid20696690">{{cite journal| author=MacDuff A, Arnold A, Harvey J, BTS Pleural Disease Guideline Group| title=Management of spontaneous pneumothorax: British Thoracic Society Pleural Disease Guideline 2010. | journal=Thorax | year= 2010 | volume= 65 Suppl 2 | issue=  | pages= ii18-31 | pmid=20696690 | doi=10.1136/thx.2010.136986 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20696690  }}</ref>
*Don't use large bore chest tubes.<ref name="pmid20696690">{{cite journal| author=MacDuff A, Arnold A, Harvey J, BTS Pleural Disease Guideline Group| title=Management of spontaneous pneumothorax: British Thoracic Society Pleural Disease Guideline 2010. | journal=Thorax | year= 2010 | volume= 65 Suppl 2 | issue=  | pages= ii18-31 | pmid=20696690 | doi=10.1136/thx.2010.136986 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20696690  }}</ref>
*Don't leave the chest drain more than 7 days, as it will increase the risk of infection.
*Don't leave the chest tube more than 7 days, as it will increase the risk of infection.
 
==References==
==References==
{{Reflist|2}}
{{Reflist|2}}
Line 247: Line 233:
[[Category:Emergency medicine]]
[[Category:Emergency medicine]]
[[Category:Medicine]]
[[Category:Medicine]]
[[Category:Primary care]]
[[Category:Resident survival guide]]
[[Category:Resident survival guide]]
[[Category:Signs and symptoms]]


{{WikiDoc Help Menu}}
{{WikiDoc Help Menu}}
{{WikiDoc Sources}}
{{WikiDoc Sources}}
</div>
</div>
<headertabs />

Latest revision as of 20:02, 18 February 2018

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Hamid Qazi, MD, BSc [2], Mohamed Moubarak, M.D. [3], Twinkle Singh, M.B.B.S. [4], Rim Halaby, M.D. [5]

Tension Pneumothorax Resident Survival Guide Microchapters
Overview
Causes
FIRE
Diagnosis
Treatment
Do's
Don'ts

Overview

Tension pneumothorax is a life threatening condition that results from the accumulation of air in the pleural cavity. Air enters the intrapleural space through an injured parietal pleura, visceral pleura or tracheobronchial tree that forms a one way valve. The one way valve allows the air to enter in the pleural cavity (during inspiration) but prevents its escape (during expiration). Subsequently, the intrapleural pressure rises and results in respiratory and cardiovascular failure. Tension pneumothorax can occur as a result of trauma, ventilation or resuscitation.[1] The cardinal symptoms and signs of tension pneumothorax are severe dyspnea, chest pain, hypotension, hypoxia, tachycardia and jugular vein distention. Tension pneumothorax should be managed immediately with emergency needle decompression followed by insertion of a chest tube.

Causes

Life Threatening Causes

Tension pneumothorax is a life-threatening condition and must be treated as such irrespective of the underlying cause.

Common Causes


Click here for the complete list of causes.

FIRE: Focused Initial Rapid Evaluation

A Focused Initial Rapid Evaluation (FIRE) as shown below should be performed to identify patients in need of immediate intervention.

Boxes in red signify that an urgent management is needed.

 
 
Identify cardinal findings that increase the pretest probability of tension pneumothorax:
Chest pain
Dyspnea
Hypoxia
Hypotension
Tachycardia
Jugular venous distension

❑ Absent breath sounds on the affected side
Hyperresonance on the affected side
❑ Hyperexpansion of the the affected side

Tracheal deviation towards the unaffected side[1]
 
 
 
 
 
 
 
 
 
 
 
 
Does the patient have high probability of tension pneumothorax?
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Yes
 
No
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
❑ Immediately insert a 14-16 Gauge needle in the 2nd intercostal space at the midclavicular line of the affected hemithorax
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
❑ Insert chest drain immediately after needle decompression
 
 
 
 
 
 
 
 
 
 
 


Complete Diagnostic Approach

A complete diagnostic approach should be carried out after a focused initial rapid evaluation is conducted and following initiation of any urgent intervention.[1]

 
 
 
Characterize the symptoms:

Dyspnea
Chest pain
Cyanosis
Sweating
Anxiety
Fatigue
Altered mental status (in late stages)

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Identify the precipitating factors:

❑ Recent invasive procedures

Thoracentesis
Central venous catheter
Bronchoscopy
Pleural biopsy

Mechanical ventilation
Cardiopulmonary resuscitation
❑ Presence of chest drains
Hyperbaric oxygen treatment

Chest wall trauma
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Examine the patient:

Appearance of the patient
Severe distress and labored respiration

Vital signs

Tachycardia
Hypotension
Tachypnea
Pulsus paradoxus

Skin

Cyanosis

Neck

Jugular venous distension (absent in severe hypotension)

Respiratory examination

Inspection
❑ Enlargement of the involved side of the chest
Intercostal space widening on the affected side
Palpation
❑ Reduced lung expansion on the affected side
Tracheal deviation to the contralateral side
❑ Decreased vocal fremitus over the affected side
❑ Displacement of the apex beat
Percussion
Hyperresonance over the affected side
Auscultation
❑ Diminished breath sounds on the affected side

Additional findings in ventilated patients

❑ Decreased oxygen saturation
❑ Increase in inflation pressure
❑ Increase in peak airway pressure

❑ Airway pressure alarm in mechanically ventilated patients
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Consider alternative diagnosis:

Acute myocardial infarction

❑ Substernal chest discomfort, pain or tightness
❑ Radiation of chest pain to the left arm or jaw

Pericardial tamponade

Hypotension
Tachycardia
Muffled heart sounds
Jugular vein distention
Pulsus paradoxus

Pulmonary embolism

❑ Presence of risk factors for pulmonary embolism
❑ Localized warmth, tenderness, edema and erythema in the leg suggestive of deep vein thrombosis
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
High probability of tension pneumothorax
 
Low probability of tension pneumothorax and patient is hemodynamically stable
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
❑ Proceed with immediate needle decompression
 
 
 
 
 
 
 
 
 
 
Order imaging studies:

❑ Order chest X-ray looking for:

❑ Air in the pleural cavity
❑ Contralateral deviation of trachea
❑ Increased thoracic volume
❑ Ipsilateral flattening of heart border
❑ Mid diaphragmatic depression

Shown below is an image of a chest X-ray depicting tension pneumothorax in the left lung.

❑ Perform serial chest X-ray every 6 hours to rule out pneumothorax in cases of trauma[2]
❑ Order chest CT scan for uncertain or complex cases
Shown below is an image of CT scan depicting left-sided pneumothorax. A chest tube is in place, the lumen (black) can be seen adjacent to the pleural cavity (black) and ribs (white).


❑ Order ultrasonography in supine trauma patients among whom a chest X-ray can not be performed

Treatment

 
 
 
Perform emergency needle decompression:[1]

❑ Wear a gown, face mask and eye shield
❑ Ensure aseptic preparation
❑ Determine the site of insertion of the needle

2nd intercostal space at the midclavicular line of affected hemithorax, OR
❑ 4th or 5th intercostal space on mid or anterior axillary line, if the initial decompression failed because of a thick chest wall[1]

❑ Insert a 14-16 gauge needle with a catheter at a 90° angle
❑ Remove the needle and leave the catheter in place
❑ Secure the catheter in place while preparing for tube thoracostomy (chest drain)
❑ Confirm the diagnosis by observing instantaneous escape of air as the needle is inserted
❑ Check for any improvement of the patient's status
Don't remove the catheter, until a chest drain is inserted and is functioning properly.

Shown below is a video depicting the steps for needle decompression
{{#ev:youtube|UvHJ4pjNh2Q|400|How to do a needle decompression}} Video adapted from Youtube.com

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Insert a chest tube (tube thoracostomy) immediately after needle decompression:

❑ Make sure that the following equipments are available:

❑ 1% lidocaine
Iodine or chlorhexidine solution in alcohol
❑ Sterile drapes, gown, gloves
Needles, syringes, gauze swabs
Scalpel, suture (0 or 1-0 silk)
Chest tube kit
❑ Closed system drain (including water) and tubing
Dressing
❑ Clamp

❑ Administer adequate analgesics
❑ Determine the insertion site at the anterior axillary line over the 4th or 5th rib
❑ Insert the chest drain
❑ Remove the catheter inserted during needle decompression after the confirmation that the chest drain is functioning properly
❑ Check chest tubes frequently, as they can become plugged or malpositioned

❑ Remove the chest tube after re-expansion of the affected lung is confirmed by a chest X-ray
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Follow up:

❑ Refer the patient to a respiratory physician if pneumothorax does not respond within 48 hours
❑ Advise to return to the hospital if increasing breathlessness develops
❑ Advise to avoid air travel until the full resolution of the pneumothorax is confirmed by a chest X-ray
❑ Advise to avoid diving permanently unless the patient is treated with surgical pleurectomy

 
 
 
 
 
 
 
 
 
 
 
 
 

Do's

  • Suspect tension pneumothorax in the case of blunt and penetrating trauma to the chest.
  • Immediately cover penetrating chest wounds with an occlusive or pressure bandage in trauma patients with suspected tension pneumothorax.
  • Suspect tension pneumothorax among patients on mechanical ventilation who develop a rapid onset of hemodynamic instability or cardiac arrest and require an increase in the peak inspiratory pressure.
  • Order serial chest radiographs every 6 hours on the first day following chest trauma to rule out pneumothorax.[2]
  • Refer the patient to a respiratory specialist within 24 hours of admission.
  • Order a chest X-ray before chest tube removal to confirm the re-expansion of the affected lung.

Don'ts

  • Don't remove the catheter from the 2nd intercostal space unless a chest tube is appropriately placed.
  • Don't use large bore chest tubes.[1]
  • Don't leave the chest tube more than 7 days, as it will increase the risk of infection.

References

  1. 1.0 1.1 1.2 1.3 1.4 1.5 1.6 MacDuff A, Arnold A, Harvey J, BTS Pleural Disease Guideline Group (2010). "Management of spontaneous pneumothorax: British Thoracic Society Pleural Disease Guideline 2010". Thorax. 65 Suppl 2: ii18–31. doi:10.1136/thx.2010.136986. PMID 20696690.
  2. 2.0 2.1 Sharma A, Jindal P (2008). "Principles of diagnosis and management of traumatic pneumothorax". J Emerg Trauma Shock. 1 (1): 34–41. doi:10.4103/0974-2700.41789. PMC 2700561. PMID 19561940.


Template:WikiDoc Sources

<headertabs />