Journal of Accident and Tension pneumothorax: report of two cases presenting J Accid Emerg Med: first published as 10.1136/emj.11.1.43 on 1 March 1994. Downloaded from Emergency Medicine 1993 with acute abdominal symptoms 10, 43-44 G.W. HOLLINS,1 T. BEATTIE,1 1. HARPER2 & K. LITTLE2

Departments of Accident and Emergency 1 Aberdeen Royal Infirmary, Foresterhill, Aberdeen and 2Royal Infirmary of Edinburgh, Lauriston Place, Edinburgh

INTRODUCTION diagnoses were peptic ulcer disease or acute pancreatitis. Work-up appropriate to these diag- Tension pneumothorax constitutes a medical noses was commenced. An erect chest radiograph emergency and rapid diagnosis should be possible revealed a large pneumothorax with mediastinal on the basis of history and clinical examination. shift to the left. Following drainage using a large Following treatment with the delivery of high con- bore needle there was immediate resolution of his centration oxygen and the insertion of a large bore symptoms and all abdominal signs. An intercostal needle into the pleural space of the affected side, chest drain was formally sited and full expansion of the diagnosis can be confirmed radiologically and his right lung was achieved after 36 h. He was dis- an intercostal chest drain formally sited.1'2 We report charged home after 3 days. two cases where diagnosis was not made on the basis of history and examination alone. Both cases Case 2 presented with symptoms and signs suggestive of an acute intra-abdominal pathology and the diag- A 37-year-old male computer operator presented nosis was only made on radiological grounds. with a 1-week history of general malaise associated with mild neck and back pain. On the evening of presentation he became acutely unwell with sudden CASE REPORTS onset, band-like upper abdominal pain, which http://emj.bmj.com/ radiated through to the back and was aggravated by Case 1 movement and inspiration. He also complained of A 25-year-old barman presented having collapsed marked nausea but there were no other respiratory in the street. He gave a history of sudden onset, or gastrointestinal symptoms. Previous medical his- severe epigastric and low retrosternal chest pain. tory included unspecified lung damage following an This was of stabbing quality and radiated through to episode of decompression sickness 8 years pre- on September 30, 2021 by guest. Protected copyright. the back. It was aggravated by movement and deep viously and childhood asthma. He had been a pro- inspiration and there was associated dyspnoea. fessional diver in the North Sea until 2 years prior There were no other respiratory or gastrointestinal to presentation. symptoms. There was no relevant previous medical, Examination revealed him to be very distressed. social or family history and he was on no regular He was pale and sweating with a pulse of 120 beats medication. min- 1 and a blood pressure of 150/100mmHg. Examination revealed him to be in severe pain. Chest examination was normal. Examination of his He was distressed and clutched his epigastrium. He abdomen revealed marked epigastric tenderness was pale and sweaty with a pulse of 150 beats with guarding and rebound. Palpation of his left Correspondence: min-1 and a blood pressure of 170/110 mmHg. upper quadrant elicited left shoulder tip pain. Mr T. Beattie, Examination of his respiratory system revealed no The differential diagnoses were again peptic ulcer Department of abnormalities. Abdominal examination revealed disease and acute pancreatitis. It was only when an Accident and rigidity with maximal tenderness in the epigastrium erect chest radiograph was performed that a large Emergency, in Aberdeen Royal and bruising was also noted this area. Bowel left pneumothorax with mediastinal shift to the right Infirmary, Foresterhill, sounds were active. was noted. Following drainage with a large-bore Abereen AB9 2ZG Given the above findings, the major differential needle there was rapid resolution of his symptoms. An intercostal chest drain was formally sited achieving obtained from a group of experienced chest phys- J Accid Emerg Med: first published as 10.1136/emj.11.1.43 on 1 March 1994. Downloaded from full re-expansion of his lung and the patient was icians, six of whom examine for the MRCP. In the discharged after 4 days. second study, performed in an accident and emerg- ency (A&E) setting, Dunlop et al.7 indicated that DISCUSSION clinical signs obtained in the A&E department corre- lated poorly with the ultimate diagnosis on radio- Various non-surgical conditions have been de- graph. In conclusion we present two cases of tension scribed which can present with severe acute pneumothorax which presented with misleading abdominal pain including cardiothoracic pathology histories and examination findings. We would rec- such as myocardial infarction and basal pneumonia. ommend that chest pathology, including pneumo- Traumatic pneumothorax resulting from lacerated thorax, be considered in the differential'diagnosis of lung has also been associated with intra-abdominal acute abdominal pain and consequently full and signs.4 However, to our knowledge, spontaneous careful examination of the chest be undertaken. To pneumothorax has never been previously docu- delay the emergency treatment of tension pneumo- mented as presenting with acute abdominal pain. thorax until a chest radiograph is available could be Pneumothorax is typically associated with chest fatal. pain and dyspnoea. The pain is usually acute in onset, pleuritic in nature and reasonably well local- REFERENCES ized to the side involved.5 The pain may settle to a dull ache within hours although often it is exacer- 1. American College of Surgeons (1984) Advanced bated by exertion. Up to 80% of patients experience Trauma and Life Support Course. Student's Manual, dyspnoea although this often settles within 24 h.5 74. Other minor symptoms include cough and general 2. Serementis M.G. (1970) The management of spon- malaise. Occasionally patients with uncomplicated taneous pneumothorax. Chest 57, 65-68. 3. Cuschieri A. (1988) The acute abdomen and disorders spontaneous pneumothorax may be asymptomatic. of the peritoneal cavity. In: Essential Surgical Practice The signs of tension pneumothorax include 2nd edition (eds Cuschieri A., Giles G. & Moosa A.) marked dyspnoea, cyanosis, tachycardia and hypo- pp. 1233. John Wright & Sons, Bristol. tension. The trachea is usually deviated to the 4. Clane A. (ed.) (1986) Hamilton Bailey's Demonstration contralateral side and the affected side of the chest of Physical Signs in Clinical Surgery 12th edition, demonstrates increased resonance to percussion pp. 331. John Wright & Sons, Bristol. and decreased air entry and breath sounds. 5. O'Neil S.J. (1987) Spontaneous pneumothorax: http://emj.bmj.com/ The history and examination findings in these two Aetiology, management and complications. Irish cases led to differential diagnoses of gastrointestinal Medical Journal 80(11), 306-31 1. pathology. Undoubtedly one should question the 6. Spiteri M.A., Cook D.G. & Clark S.W. (1988) Reliability examination of the chest which failed to yield any of eliciting physical signs in examination of the chest. signs consistent with the ultimate diagnosis. Two Lancet 1, 873-875. that of 7. Dunlop M.G., Beattie T.F., Preston P.G. & Steedman recent reports have revealed examination on September 30, 2021 by guest. Protected copyright. D.J. (1989) Clinical assessment an radiography fol- be unreliable. et al.6 com- the chest may Spiteri lowing blunt chest trauma. Archives of Emergency mented that their study had highlighted poor re- Medicine 6(2), 125-127. liability in eliciting chest signs. These findings were

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