Best Case Ever 81 Tension Hydrothorax From Emergency Medicine Cases

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Posted on December 29, 2020 by Tom Wade MD

Today I reviewed Best Case Ever 81 Tension Hydrothorax [Link is to podcast and show notes], February, 2020, from Emergency Medicine Cases.

The point of this case according to presenter is to emphasize the usefulness of POCUS in diagnosing the hydrothorax. But for me, the most useful aspect of the case was the reminder never to miss compensated shock just because the blood pressure is normal.

The case was of a school-aged child with mottling, prolonged cap refill, tachycardia, and a still normal blood pressure. It is very important to realize that the child was in compensated shock. His normal blood pressure should reassure the clinician.

He was found to have a massive left sided pleural effusion that was worsening his shock.

But ultimately it turned out that his underlying problem was septic shock from an underlying infection.

His shock was worsened by his tension hydrothorax that was caused by a parapneumonic effusion.

He was treated with fluid boluses and antibiotics for his septic shock and thoracostomy drainage for the obstructive component of shock due to his tension hydrothorax.

Here are the show notes:

What is tension hydrothorax?

Tension hydrothorax is a massive pleural effusion presenting with hemodynamic abnormalities secondary to mediastinal compression. Massive is defined as occupying greater than 2/3rd of the hemithorax, with 10% of pleural effusions being massive.


Causes of tension hydrothorax

Tension hydrothorax can result from a number of causes, including: Trauma, chylothorax, pancreatitis, cirrhosis, parapneumonic effusions, and autoimmune diseases, but by far the most common cause is malignancy.


Indications for tube thoracostomy for hydrothorax

  • Associated pneumothorax or hemothorax
  • Respiratory and/or hemodynamic instability
  • Grade III–V parapneumonic effusions

While there are no absolute contraindications to tube thoracostomy in patients with tension hydrothorax, adherence of the lung to the chest wall and history of pleurodesis are relative contraindications, in which case a thoracentesis may be indicated.

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