Punctured Lung Question

[Dulton]

I took a friend up to Muir the other day who had never been to that altitude before (previously he had been to 6K, but never higher). About two days after we returned he was having very severe chest pains and a very high heart rate. He went to the hospital and they told him he had a punctured lung that was partially collapsed. My question is this: is this a result of the pressure change at 10,000 feet or the fact that he was pushing himself too hard at that altitude. Any insight would be great because I've never heard of this happening before. Thanks in advance.

[Norman_Clyde]

The medical term for this is spontaneous pneumothorax. It tends to happen to two specific types of individuals. The first is people with a very tall, skinny build. Usually they say that their symptoms began after they performed some maneuver involving leaping upward, or reaching for something: basically a sudden lunging with arms over the head. Something about this maneuver in these folks will cause one of the lungs to spring a small leak. Then as they continue to breathe, the air leak causes a buildup of air inside the chest cavity, but outside the lung. This is very painful and causes shortness of breath. If the leak is big enough and only operates one way, air escaping out of the lung but unable to go back into it, then a person can develop a "tension pneumothorax" where the escaped air pushes the lungs and heart to the other side of the chest. This is lethal because it kinks the large blood vessels like garden hoses. This condition is treated by making an incision in the chest wall and passing a tube into the chest cavity to drain the air. The person has to be in the hospital for a few days until the leak seals up.

Fortunately, a spontaneous pneumothorax is usually very small, and a chest tube may not be required. I saw a guy with one of these a few weeks ago, and his went away on its own.

 

The second group of people at risk for these are people with emphysema, because they develop big blisters on their lungs that can pop with the above described physical maneuver, or even with very hard coughing. If your friend is out of shape and stressed himself maximally going to Muir, especially if he was coughing really hard, this could have been the cause-- but this sort of thing is impossible to anticipate, so I wouldn't feel too bad about it. Unless he had a previous history of the same thing, in which case he should be careful not to work himself too hard.

 

Most cases of pneumothorax, however, are trauma related. A big fall in the mountains can certainly produce one. If a person knows how to diagnose this condition in the field, they can save a life by passing a big needle into the pneumothorax to relieve the pressure. Besides basic airway protective maneuvers, this is one of the only interventions in the field that can be lifesaving. I carry a big spinal needle on climbing trips just in case I ever encounter this situation, though I hope not to come across it.

[mneagle]

It sounds most likely that your friend had a spontaneous pneumothorax. This occurs most commonly when a congenital bleb ruptures at the margin of the lung, releasing air into the chest cavity. Tall thin individuals are the classic owners of such blebs. There is no association with high altitude but there is an association with heavy exertion (e.g. weight lifters). It's interesting that your friend only experienced significant symptoms after descending. Usually what we worry about with altitude and pneumothoraces is when you are ascending. At lower atmospheric pressure the gas trapped in the chest expands and collapses the lung more as you go higher. We typically don't let anyone fly for this reason for the first week after one has healed.

[Dulton]

Thanks for all the information! I'm glad to hear that it is probably not altitude related, he's recovering pretty well too so that is GREAT! Thanks agian!

[Bronco]

Norman_Clyde said:

..........a person knows how to diagnose this condition in the field, they can save a life by passing a big needle into the pneumothorax to relieve the pressure. Besides basic airway protective maneuvers, this is one of the only interventions in the field that can be lifesaving. I carry a big spinal needle on climbing trips just in case I ever encounter this situation.....

 

Sweet! I bet the casing to a ball point pen would work too if you made the incision with a sharp knife kinda like a field tricheometry procedure (like on M*A*S*H) and then you don't have to carry the extra weight of the spinal needle. Don't forget your ductape to hold the tube in place!

[mbcracken]

Norman_Clyde said:

... I carry a big spinal needle on climbing trips just in case I ever encounter this situation, though I hope not to come across it.

 

What makes up your first aid kit? Does it depend on the length of the trip?

 

Thanks

-Mike

[iain]

he also carries a swingline stapler to reattach legs and stuff

[iain]

I like to carry a bunch of gauze to apply direct pressure. It is light. Kling and/or an ace wrap is helpful. bunch of rubber gloves. some form of antiseptic to clean things up afterwards.

[lummox]

Norman_Clyde said:

I carry a big spinal needle on climbing trips just in case I ever encounter this situation. . .

jesus christ, mary and joseph. thats hard core.

[Dru]

i carry an ice axe to administer euthanasia in circumstances like that

[lunger]

Steer clear of Dr. Clyde and his needle!

 

I had the pleasure of 2 go 'rounds w/ the congenially named pneumothorax. If you break ribs, look forward to the pleasure of a large-gauge hollow instrument impaling your chest between yer ribs, causing some mild discomfort.

 

First was in the field (long fall, impact ), second a few weeks later (spontaneous, of sorts). apparently a large percentage (> 50%) of those that get one can look forward to plasma seeping outta capillaries into the chest cavity, creating pressure, and eventually collapsing the lung. this fluid must be drained, and it can take a day, more or less.

 

for the second piercing, checked into the hospital, the drug-person didn't quite administer correctly , and i got to feel docboy cut, work gloved finger a bit into me wee chestie. at this point he was surprised by my lucid protest, "you should be barely aware". he waited with his finger stuck in my ribs like the proverbial dutch boy w/ the dike, while went for more drugs.

 

after they came running w/ some more hardcore and a machine that goes PING, i finally started fading as one o' those big-ass needles worked its way between tender, healing ribs. deeeeeluxe. more than you wanted to know--typed this while on hold with friggin' expedia, holy sheesh! they've spoilded my taste for vivaldi's four seasons thank you for holding

 

the moral of the story is self-evident. use more drugs.

or avoid hard impacts...

[Norman_Clyde]

Nothing like a first hand account!

 

I figured that when I mentioned my handy spinal needle trick, that others on this board, especially doctors like mneagle, would take me for a nut case: you know, axe in one hand, needle in the other, scanning the Muir snowfield for out-of-breath newbies to practice on. I'm not as altruistic as the doctor on a plane flight a few years back, who generously opened the chest of a fellow passenger with a DINNER FORK, no anesthesia thank you, to decompress a tension pneumothorax that had expanded at altitude. (The correct action would have been to have the pilot land the plane, which would have re-compressed the air in the chest.) I realize that I am unlikely to come across someone with a tension pneumothorax in the field. But I have a friend whose life was saved by a paramedic doing this very maneuver in the field (this guy had been in a helicopter crash in Alaska), so the premise is not entirely farfetched. The needle doesn't even weigh an ounce.

 

I don't carry much of an emergency kit otherwise. I put together a pretty complete one for Rainier a few years ago, but the drugs expire within a few months and it's kind of tricky to replace some of them. ("Yes, I know you prescribed IV morphine for my emergency kit a few months ago, but, uh, it's expired so I need some more.") I always carry a SAM splint (padded pliable aluminum) and a bandanna or two, plus gauze, band aids, etc. Ibuprofen is always handy. For most Washington climbs, it doesn't make sense to carry much more, in my opinion. I would be interested to hear from other medical types on this issue. Any takers?

[Trundle]

Pocketknife, Vicoden or Percocet and some gauze.... what else do you need?

[mbcracken]

What is the perfect backcountry kit? One that is not needed.

 

Not a true medical type, but some Ski Patrol a while back...

about 4 4X's,

a maxipad, (think about it)

anespetic gel,

duct tape(general repair necessity),

used to carry a suture needle and thread but now carry butterflies,

recently prescribed heavy pain meds,

personal meds,

a couple homemade large bandanas,

SAM splint,

Tylenol(Ibuprofen can interfere with the kidney functions and cause dehydration)

 

I like the spinal needle trick. I'll have to add that to my kit.

 

Anything more serious that can't be handled by my limited kit is really serious and would have a tough time treating in the back country.

 

-Mike

[Norman_Clyde]

I forgot to mention safety pins. 1001 uses. Keep them pinned inside the first aid bag.

[Rodchester]

How about using an ice screw? The new BD Exprtess screws would provide releif fast!!!

 

[jordop]

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Edited June 15, 2021 by jordop

[Norman_Clyde]

It would take more than T3s to take you to Kublai Khan with that kind of injury. Percocet might get you part of the way. These meds usually have an expiration date a year after issue. They're no doubt good for longer than that, but I wouldn't rely on pills more than 2 years old, especially if they've been subjected to extremes of temperature, like in someone's pack.

[iain]

I'm not a big fan of carrying narcotic painkillers around the mountains when just out recreationally.

[browntoe98]

I'd be inclined to go with the ball point pen method myself... just can't imagine more than one (legal) use for a spinal needle. So far as illegal goes, well I got this ex-wife...

 

But you really want to know what you're doing to needle a chest - it's not hard but doing it wrong kills people so incredibly quickly.

 

I carry percocet (oxycodone with acetominophen). I never want to be carried out some long approach with a busted tib/fib on ibuprophen and excedrin.

 

Excedrin (BTW) is the ultimate for that altitude headache...

[mneagle]

lunger said:

 

for the second piercing, checked into the hospital, the drug-person didn't quite administer correctly , and i got to feel docboy cut, work gloved finger a bit into me wee chestie. at this point he was surprised by my lucid protest, "you should be barely aware". he waited with his finger stuck in my ribs like the proverbial dutch boy w/ the dike, while went for more drugs.

 

after they came running w/ some more hardcore and a machine that goes PING, i finally started fading as one o' those big-ass needles worked its way between tender, healing ribs. deeeeeluxe. more than you wanted to know--typed this while on hold with friggin' expedia, holy sheesh! they've spoilded my taste for vivaldi's four seasons thank you for holding

 

the moral of the story is self-evident. use more drugs.

or avoid hard impacts...

 

Reminds me of one time at the VA hospital when a vet had a recurrence of a pneumothorax and I got called emergently to the bedside with his blood pressure in the toilet and impending respiratory failure. I told him, "this is going to suck." He made an effort to flop to the side and lift up his arm and said "go...for...it..." with a gasping voice. With no anesthesia at all I cut the old sutures out, stuck my finger through his chest wall and got the tube in. I thought the med student in the room was going to pass out. The guy let out a little groan but mostly just dealt with it. Vets rock.

[erik]

iain said:

I'm a big fan of narcotic painkillers recreationally.

 

iain, i think we need to have a talk.

 

 

[iain]

why? you in the market? I can usually get some pretty good vicadin deals off ebay... 5 vicadin perscriptions and the spinal needle is free! as for sticking needles in peoples' chests I don't think I really want that choice, though with a tension pneumothorax in the b.c. there really isn't much to lose I guess

[Bug]

After my wife had our little lovely ones she refused to take her vicadin. Tsk tsk. I take some every time I think I might break something. "How about a three egg omlet honey"?

 

As for Tylenol over Ibuprofin, I thought that Tylenol killed pain but did not do anything for inflamation, whereas Ibuprofin does both. Is this true Doc? Does drinking lots of water lessen the impact of Ibuprofin on the kidneys? How does that compare to Naproxin (alleve)?

[mneagle]

You are correct. NSAID's (non-steroidal anti-inflammatory drugs) such as ibuprofen, naproxen, relafen, etc are anti-inflammatory and analgesic drugs. Tylenol is analgesic only. Naproxen is stronger per weight than ibuprofen but causes some people more GI troubles. Being well hydrated does protect your kidneys, but if you have normal kidneys to start with you have little to fear from a short course of high dose NSAID's. I usually carry a vial of Toradol (an NSAID) and a small syringe to give an intramuscular shot for fast and very effective pain relief in case of a major injury. Narcotics make me puke my guts out.