A47-19 Less Is More: Successful Observation of Traumatic Pneumothorax With Subcutaneous Emphysema in a Stable Elderly Patient

Abstract Introduction Traumatic pneumothorax accompanied by subcutaneous emphysema and multiple rib fractures often prompts tube thoracostomy, even in hemodynamically stable patients. However, mounting evidence supports selective observation when physiologic stability is maintained. We present a case illustrating successful conservative management of a traumatic pneumothorax with extensive soft-tissue emphysema in an elderly patient. Case Report An 83-year-old man with a history of bladder cancer status post urostomy presented after a ground-level fall while emptying his urostomy bag. He was not on anticoagulation. On arrival, he was normotensive, afebrile, and maintained oxygen saturation above 95% on room air, complaining primarily of left-sided chest pain. CT imaging revealed a 30% left pneumothorax without mediastinal deviation, a trace left hemothorax, and acute nondisplaced fracture of the left fourth rib, minimally displaced fractures of ribs six through nine laterally, and a posterior seventh-rib fracture. Moderate left-sided chest wall and neck subcutaneous emphysema were noted. Given his stable blood pressure and oxygenation status and family preference to avoid invasive intervention, Trauma Surgery and Pulmonary/Critical Care opted for conservative management. The patient was placed on a non-rebreather mask to promote nitrogen washout and enhance pleural air resorption. Analgesia was optimized, and incentive spirometry encouraged. During the initial 48 hours, he experienced several episodes of vomiting related to pain; one episode contained streaks of blood, prompting concern for Boerhaave’s syndrome. Repeat chest imaging was not suggestive of esophageal perforation. With supportive care, his pain and nausea improved, diet was advanced, and serial imaging demonstrated gradual resolution of both the pneumothorax and subcutaneous emphysema. No further complications occurred. Conclusion This case demonstrates that conservative observation can be a safe and effective strategy for select patients with traumatic pneumothorax, even in the presence of multiple rib fractures and soft-tissue emphysema. When patients remain hemodynamically stable and adequately oxygenated, a non-rebreather mask, pain control, and close radiographic and clinical monitoring may obviate the need for tube thoracostomy. The non-rebreather mask delivers high-concentration oxygen and promotes nitrogen washout, accelerating pleural air absorption and lung re-expansion without invasive intervention. This approach reinforces the principle that, in critical care medicine, a carefully chosen ‘less-is-more’ strategy can achieve excellent outcomes while minimizing procedural risks This abstract is funded by: None