Increased work of breathing b. Unilaterally diminished breath sounds c. Pleuritic chest pain d. Hypotension that worsens with inspiration. Chest. Devanand A, Koh MS, Ong TH, Low SY, Phua GC, Tan KL, et al. 2006. Medscape Education. Respiration. Comparison of the efficacy of novel two covering methods for spontaneous pneumothorax: a multi-institutional study. Clinical Presentation of Patients With Tension Pneumothorax: A Systematic Review. POCUS has sensitivity and specificity ranging from 90-100% for detecting pneumothorax. Am Rev Respir Dis. If a chest tube is malpositioning or becomes plugged, it can cease to function, and the pneumothorax can recur. Well-tolerated primary pneumothorax can take 12 weeks to resolve. (2018) Journal of Ultrasound in Medicine. 2009 Mar. Murray and Nadel's Textbook of Respiratory Medicine. Recent studies have shown that pleurodesis can decrease the rate of recurrence.[35][36]. Eur Respir J. [QxMD MEDLINE Link]. A pneumothorax is an abnormal collection of air in the pleural space between the lung and the chest wall. 2000 Aug. 55 (8):666-71. Bedside sonography for detection of postprocedure pneumothorax. {"url":"/signup-modal-props.json?lang=us"}, Gaillard F, Bickle I, Sharma R, et al. Surgeon-performed ultrasound for pneumothorax in the trauma suite. [13], Tension pneumothoraces can developin 1to 2% of cases initially presenting with idiopathic spontaneous pneumothoraces. Although tension pneumothorax may be a difficult diagnosis to make and may present with considerable variability in signs, respiratory distress and chest pain are generally accepted as being universally present, and tachycardia and ipsilateral air entry on auscultation are also common findings. Anesth Analg. 2011 May. The presentation of patients with pneumothorax varies depending on the type of pneumothorax. [QxMD MEDLINE Link]. Mary C Mancini, MD, PhD, MMM Rapid detection of pneumothorax by ultrasonography in patients with multiple trauma. Rim T, Bae JS, Yuk YS. This book is distributed under the terms of the Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International (CC BY-NC-ND 4.0) Close radiographic view of a patient with spontaneous primary pneumothorax due to a left upper lobe bleb (same patient as in the previous image). During a pneumothorax, communication develops between the pleural space and the lung, resulting in air movement from the lung into the pleural space. [QxMD MEDLINE Link]. [Traumatic Intercostal Lung Hernia Repaired by Video-assisted Thoracoscopic Surgery;Report of a Case]. [QxMD MEDLINE Link]. Pathogenesis and treatment of primary spontaneous pneumothorax: an overview. Imaging Chest x-ray [6] [8] Indications: all patients suspected of having pneumothorax Unable to process the form. Yamashita H, Tsukayama H, Tanno Y, Nishijo K. Adverse events related to acupuncture. You are not required to obtain permission to distribute this article, provided that you credit the author and journal. ( A tension pneumothorax will have the same features as a simple pneumothorax with a number of additional features, helpful in identifying tension. If the heart rate is faster than 135 beats/min, tension pneumothorax is likely, Hypotension - This should be considered as an inconsistently present finding; although hypotension is typically considered a key sign of a tension pneumothorax, studies suggest that hypotension can be delayed until its appearance immediately precedes cardiovascular collapse, Jugular venous distention - This is generally seen in tension pneumothorax, although it may be absent if hypotension is severe, Cardiac apical displacement - This is a rare finding, Radiograph of a patient with a small spontaneous primary pneumothorax. 56 (3):527-30. This can be used as a bedside technique to detect pneumothorax, which may be useful in unstable patients. [QxMD MEDLINE Link]. [QxMD MEDLINE Link]. Gupta D, Hansell A, Nichols T, Duong T, Ayres JG, Strachan D. Epidemiology of pneumothorax in England. Noppen M, Baumann MH. [QxMD MEDLINE Link]. Pneumothorax - Physiopedia 20 (3):281-4. Hyper-expansion. Chest. Philadelphia: Elsevier Saunders; 2016. 2005 Dec. 44 (12):1538-41. Radiograph demonstrating tension and traumatic pneumothorax. Dulchavsky SA, Schwarz KL, Kirkpatrick AW, Billica RD, Williams DR, Diebel LN, et al. 255 (3):440-5. Zhao DY, Zhang GL. [QxMD MEDLINE Link]. Gunji Y, Akiyoshi T, Sato T, Kurihara M, Tominaga S, Takahashi K, et al. Clinical signs of a tension pneumothorax in the ventilated patient are comparably rapid, with arterial and mixed venous peripheral capillary oxygen saturation immediately decreasing 5. [QxMD MEDLINE Link]. [Full Text]. However, the risk of lung re-expanding quickly increases the risk of pulmonary edema. Although historic emphasis has been placed on tracheal deviation in the setting of tension pneumothorax, tracheal deviation is a relatively late finding caused by midline shift. [QxMD MEDLINE Link]. Experience with 114 patients. Feldman AL, Sullivan JT, Passero MA, Lewis DC. Tension pneumothorax is a potentially life-threatening condition that medical professionals must treat as a medical emergency. Atraumatic pneumothoraces are further divided into primary (unknown etiology) and secondary (patient with an underlyingpulmonary disease). Symptoms of spontaneous pneumothorax might appear when a person is at rest. Pneumothorax - Pulmonary Disorders - MSD Manual Professional Edition Idiopathic Pulmonary Fibrosis: Who Gets an Antifibrotic? Ultrasound findings includethe absence of lung sliding and the presence of a lung point. This chest radiograph shows pneumomediastinum (radiolucency noted around the left heart border) in this patient who had a respiratory and circulatory arrest in the emergency department after experiencing multiple episodes of vomiting and a rigid abdomen. General Thoracic Surgery. Late signs include distended neck veins, tracheal deviation, and cyanosis. Iatrogenic pneumothorax is a traumatic pneumothorax that results from injury to the pleura, with air introduced into the pleural cavity secondary to a diagnostic or therapeutic medical intervention. Review the management options available for tension pneumothorax. Zhang M, Liu ZH, Yang JX, Gan JX, Xu SW, You XD, et al. Symptoms and Signs of Thoracic Trauma. The chest pain is described as severe and/or stabbing, radiates to the ipsilateral shoulder and increases with inspiration (pleuritic). 1989 Jun. [Clinical analysis on 38 cases of pneumothorax induced by acupuncture or acupoint injection]. Tension pneumothorax is an uncommon condition with a malignant course that might result in death if left untreated. Fluorescein-enhanced autofluorescence thoracoscopy in patients with primary spontaneous pneumothorax and normal subjects. The diagnosis may become evident only if the patient is receiving positive-pressure ventilation. Video courtesy of Therese Canares, MD, and Jonathan Valente, MD, Rhode Island Hospital, Brown University. a. 2008 Feb. 76 (2):198-206. Greenberg MI. [Full Text]. Curr Opin Pulm Med. With tension pneumothorax, patients will have signs of hemodynamic instability with hypotension and tachycardia. This will cause the lung to collapse on the ipsilateral side. [QxMD MEDLINE Link]. https://profreg.medscape.com/px/getpracticeprofile.do?method=getProfessionalProfile&urlCache=aHR0cHM6Ly9lbWVkaWNpbmUubWVkc2NhcGUuY29tL2FydGljbGUvNDI0NTQ3LWNsaW5pY2Fs, Respiratory distress (considered a universal finding) or respiratory arrest, Tachypnea (or bradypnea as a preterminal event), Asymmetric lung expansion - A mediastinal and tracheal shift to the contralateral side can occur with a large tension pneumothorax, Distant or absent breath sounds - Unilaterally decreased or absent lung sounds is a common finding, but decreased air entry may be absent even in an advanced state of the disease, Lung sounds transmitted from the unaffected hemithorax are minimal with auscultation at the midaxillary line, Hyperresonance on percussion - This is a rare finding and may be absent even in an advanced state of the disease, Adventitious lung sounds (crackles, wheeze; an ipsilateral finding), Tachycardia - This is the most common finding. 27 (3):470-6. Prospective evaluation of thoracic ultrasound in the detection of pneumothorax. Symptoms may include shortness of breath, weakness, or altered mental status. 2006 Mar. (2004) ISBN:0781736552. Pneumothorax, chylothorax, hemothorax, and fibrothorax. Worsening pneumothorax Positive-pressure ventilation can lead to increased air in the chest cavity without a route of escape, worsening a pneumothorax and possibly leading to a tension pneumothorax. Pneumothorax Clinical Presentation - Medscape This rise in pressure further compresses the lung and decreases its volume. 23 Likewise, hypotension and a markedly widened pulse pressure should raise concerns for. van den Brande P, Staelens I. [QxMD MEDLINE Link]. Is Lung Damage More Extensive in Marijuana or Cigarette Smokers? Successful management of occult pneumothorax without tube thoracostomy despite positive pressure ventilation. It is difficult to determine the actual incidence of tension pneumothorax as by the time trauma patients are transported to trauma centers, they have already received decompressive needle thoracotomies. 2004 Oct. 128 (4):502-8. Up to 15% of recurrences can be on the contralateral side. Radiograph of a new left-sided pneumothorax in a patient on mechanical ventilation, requiring high inflation pressures. Note the right-sided pneumothorax induced by the incorrectly positioned small-bowel feeding tube in the right-sided bronchial tree. Leigh-Smith S, Harris T. Tension pneumothorax--time for a re-think?. 5 (3):181-2. 1993 Feb. 103 (2):433-8. While this is a commonly considered cause of shock in obvious trauma, it can also occur non-traumatically in ventilated patients, or in the setting of occult trauma. [QxMD MEDLINE Link]. After intubation, the patient experienced marked hypoxemia (SpO2=75%), hypotension . Baumann MH, Strange C. Treatment of spontaneous pneumothorax: a more aggressive approach?. [QxMD MEDLINE Link]. [QxMD MEDLINE Link]. Presentation is variable and may initially have no symptoms. A tension pneumothorax causes progressive difficulty with ventilation as the normal lung is compressed. [QxMD MEDLINE Link]. Treasure Island (FL): StatPearls Publishing; 2023 Jan-. Acta Pathol Jpn. Tension pneumothorax has been reported during surgery with both single- and double-lumen tubes. Pneumothorax in polysubstance-abusing marijuana and tobacco smokers: three cases. 5. Shatz DV, de la Pedraja J, Erbella J, Hameed M, Vail SJ. Givens ML, Ayotte K, Manifold C. Needle thoracostomy: implications of computed tomography chest wall thickness. Advanced trauma life support (ATLS): the ninth edition. Ann Emerg Med. Hypotension worsens with inspiration due to increased intrathoracic pressure. [QxMD MEDLINE Link]. Thoracoscopic pleurodesis for primary spontaneous pneumothorax with high recurrence risk: a prospective randomized trial. Thorax. (2005) Emergency medicine journal : EMJ. Knowledge of necessary emergency thoracic decompression procedures is essential for all healthcare professionals. Which of the following pulse pressures indicate early hypovolemic shock? Some options are abrasive scratchpad, dry gauze, or stripping of parietal pleura. This activity reviews the presentation of tension and traumatic pneumothoraces, outlines evaluation and management strategies, and highlights the importance of early intervention and the role of the interprofessional team in evaluating and improving care for patients with this condition. [QxMD MEDLINE Link]. The rate of iatrogenic pneumothoraces is increasing in US hospitals as intensive care modalities have increasingly become dependent on positive pressure ventilation and central venous catheters. Huang TW, Lee SC, Cheng YL, Tzao C, Hsu HH, Chang H, Chen JC. 2009 Jun. Tension Pneumothorax - an overview | ScienceDirect Topics The diagnosis of tension pneumothorax must be made immediately through clinical assessment as waiting for imaging, if not readily available, maydelaymanagement and increase mortality.[8][18][20]. Chest. ISBN:110702191X. Distended neck veins and tracheal deviation are also often present. This is a life-threatening emergency that needs urgent management. The most common underlying abnormality in secondary spontaneous pneumothorax is chronic obstructive pulmonary disease (COPD), and cystic fibrosis carries one of the highest associations, with more than 20% reporting spontaneous pneumothorax. 2001 Feb. 119 (2):590-602. The incidence is 5to 7 per 10,000 hospital admissions. Clin Oncol (R Coll Radiol). Nevertheless, tension pneumothorax should always be a consideration when acute compromise occurs. This can occur within minutes. Immediately life threatening injuries - Trauma Victoria Hashmi S, Rogers SO. Smoking and the increased risk of contracting spontaneous pneumothorax. 2008 Jan. 64 (1):111-4. Blunt trauma related chest wall and pulmonary injuries: An overview [Guideline] British Thoracic Society Fitness to Dive Group, Subgroup of the British Thoracic Society Standards of Care Committee. These signs should be carefully observed by inspection. Can J Surg. Tension Pneumothorax - Injuries and Poisoning - Merck Manuals Consumer Arao K, Mase T, Nakai M, Sekiguchi H, Abe Y, Kuroudu N, Oobayashi O. Concomitant Spontaneous Tension Pneumothorax and Acute Myocardial Infarction. 9 (1):[QxMD MEDLINE Link]. However, these observations are neither sensitive nor specific for making the diagnosis of pneumothorax or ruling out the possibility of pneumothorax. Numerous techniques exist, and the literature is replete with opinions, but in the first instance relieving the tension, even if not draining the pneumothorax, is life-saving. Chest radiograph depicting tension and traumatic pneumothorax. 10 (6):1372-9. Ultrasound is about 94% sensitive and 100% specific with a skilled operator. 2006 Sep. 28 (3):637-50. 5 (2):183-6. Radiograph of an older man who was admitted to the intensive care unit (ICU) postoperatively. Marked depression of the right hemidiaphragm is noted, and mediastinal shift is to the left side, suggestive of tension pneumothorax. Thorax. [QxMD MEDLINE Link]. [QxMD MEDLINE Link]. Obstructive shock - Wikipedia Radiograph of a patient with a complete right-sided pneumothorax due to a stab wound. [QxMD MEDLINE Link]. [QxMD MEDLINE Link]. The incidence is about 1to 13% but can increase up to 30% in certain situations. [Full Text]. In severe cases, the increased pressure can alsocompress the heart, the contralateral lung, and the vasculature leading to hemodynamic instability and cardiac arrest in some cases. Causes of tension pneumothorax Trauma to the chest, including a punctured lung, is the usual cause of a tension pneumothorax. Brian J Daley, MD, MBA, FACS, FCCP, CNSC is a member of the following medical societies: American Association for the Surgery of Trauma, Eastern Association for the Surgery of Trauma, Southern Surgical Association, American College of Chest Physicians, American College of Surgeons, American Medical Association, Association for Academic Surgery, Association for Surgical Education, Shock Society, Society of Critical Care Medicine, Southeastern Surgical Congress, Tennessee Medical AssociationDisclosure: Nothing to disclose. J Subst Abuse. [9][10][14][11][15], Before understanding the pathophysiology of tension pneumothorax, it is essential to understand normal lung physiology. [33]. Respir Med. McPherson JJ, Feigin DS, Bellamy RF. Occasionally, the tension pneumothorax may be tolerated and its diagnosis delayed for hours to days after the initial insult. AJR Am J Roentgenol. In: StatPearls [Internet]. All material on this website is protected by copyright, Copyright 1994-2023 by WebMD LLC. The Five Deadly Causes of Chest Pain Other than Myocardial - JEMS 2009 Oct. 52 (5):E173-9. 2006 Mar-Apr. Rebecca Bascom, MD, MPH Professor of Medicine, Department of Medicine, Division of Pulmonary, Allergy, and Critical Care Medicine, Pennsylvania State College of Medicine, Milton S Hershey Medical Center; Graduate Faculty Member, Pennsylvania State University College of Medicine and The Huck Institutes of the Life Sciences [Full Text]. 125 (6):2345-51. J Med Genet. 32 (6):1003-9. The common symptoms and signs of tension pneumothorax include: Respiratory distress. Pneumothorax can result in tension physiology as well though the hemodynamic compromise from this, when a patient is on mechanical ventilation, is usually quicker than with hemothorax. Cardiopulmonary imaging. This condition usually occurs when intrathoracic pressures become elevated, such as with an exacerbation of asthma, coughing, vomiting, childbirth, seizures, and a Valsalva maneuver. J Thorac Cardiovasc Surg. [QxMD MEDLINE Link]. Is routine tube thoracostomy necessary after prehospital needle decompression for tension pneumothorax? Symptomatic patients will present with sharp pleuritic pain that can radiate to the ipsilateral back or shoulder. 2022 Apr 15. [QxMD MEDLINE Link]. Mediators Inflamm. Central venous catheterization in the subclavian or internal jugular vein, Barotrauma due to positive pressure ventilation, Conversion of spontaneous pneumothorax to tension, A thin line representing the edge of the visceral pleura, Effacement of lung markingsdistally to this line, The mediastinal shift away from the pneumothorax in tension pneumothorax, Tracheal deviation to the contralateral side of tension pneumothorax, Flattening of the hemidiaphragm on the ipsilateral side (tension pneumothorax), Damage to the neurovascular bundle during tube thoracostomy, Pain and skin infection at the site of tube thoracotomy. Metersky ML, Colt HG, Olson LK, Shanks TG. Patients can be placed on positive pressure ventilation after a chest tube is placed. Radiograph of a patient in the intensive care unit (ICU) who developed pneumopericardium as a manifestation of barotrauma. [Full Text]. In any patient presenting with chest trauma,airway, breathing, and circulation should be assessed. 10 (4):R112. - answerA) increased work of breathing B) unilaterally diminished breath sounds C) pleuritic chest pain D) hypotension that worsens with inspiration *** D ) Ann Thorac Surg. Unlike the obvious patient presentations oftentimes used in medical training courses to describe a tension pneumothorax, actual case reports include descriptions of the diagnosis of the condition being missed or delayed because of subtle presentations that do not always present with the classically described clinical findings of this condition or the complexity of the patient with critical illness or injury. (2013) Acupuncture in medicine : journal of the British Medical Acupuncture Society. [QxMD MEDLINE Link]. Spontaneous pneumothorax. Occasionally, it can have a subtle presentation too. 3 (1): 1. [QxMD MEDLINE Link]. Simple aspiration versus chest-tube insertion in the management of primary spontaneous pneumothorax: a systematic review. [QxMD MEDLINE Link]. Hypotension that worsens with inspiration Hypotension that worsens with inspiration is associated with tension pneumothorax due to compression of the heart and great vessels (obstructive shock). Catheter aspiration for simple pneumothorax. [1][2]It is a severe condition that results when air is trapped in the pleural space under positive pressure, displacing mediastinal structures and compromising cardiopulmonary function. During video-assisted thoracic surgery (VATS), pneumothorax is treated with pleurodesis. 1998 Nov 11. 2004 Mar. Am Surg. Ann Surg. Anesth Analg. British Thoracic Society Fitness to Dive Group, Subgroup of the British Thoracic Society Standards of Care Committee. Lippincott Williams & Wilkins. For example, intravenous antibiotics are included in the treatment of a pneumothorax that developed as a. Close radiographic view of a small pneumothorax in a patient with idiopathic pulmonary fibrosis, following video-assisted thoracoscopic surgery (VATS) lung biopsy (same patient as in the previous image). It results in the re-expansion of the collapsed lung. 10. Intensive Care Med. Pneumomediastinum from barotrauma may result in tension pneumothorax and obstructive shock. When examining a patient for suspected tension pneumothorax, any clue may be helpful, as subtle thoracic size and thoracic mobility differences may be elicited by performing careful visual inspection along the line of the thorax. Risk factors and treatment. [QxMD MEDLINE Link]. Pearls and Pitfalls in Emergency Radiology: Variants and Other Difficult Diagnoses. Rapid Ultrasound for Shock and Hypotension (RUSH) Chest. Barton ED, Rhee P, Hutton KC, Rosen P. The pathophysiology of tension pneumothorax in ventilated swine. Bense L, Lewander R, Eklund G, Hedenstierna G, Wiman LG. A pilot study to derive clinical variables for selective chest radiography in blunt trauma patients. 2000 Oct. 26 (10):1434-40. Henry M, Arnold T, Harvey J., Pleural Diseases Group, Standards of Care Committee, British Thoracic Society. Erik D Barton, MD, MS Associate Director, Assistant Professor, Department of Surgery, Division of Emergency Medicine, University of Utah Health Sciences Center, Erik D Barton, MD, MS is a member of the following medical societies: American College of Emergency Physicians, American College of Sports Medicine, American Medical Association, and Society for Academic Emergency Medicine, Marc D Basson, MD, PhD, MBA, FACS Professor, Chair, Department of Surgery, Assistant Dean for Faculty Development in Research, Michigan State University College of Human Medicine, Marc D Basson, MD, PhD, MBA, FACS is a member of the following medical societies: Alpha Omega Alpha, American College of Surgeons, American Gastroenterological Association, Phi Beta Kappa, and Sigma Xi, H Scott Bjerke, MD, FACS Clinical Associate Professor, Department of Surgery, University of Missouri-Kansas City School of Medicine; Medical Director of Trauma Services, Research Medical Center; Clinical Professor, Department of Surgery, Kansas City University of Medicine and Biosciences, H Scott Bjerke, MD, FACS is a member of the following medical societies: American Association for the History of Medicine, American Association for the Surgery of Trauma, American College of Surgeons, Association for Academic Surgery, Eastern Association for the Surgery of Trauma, Midwest Surgical Association, National Association of EMS Physicians, Pan-Pacific Surgical Association, Royal Society of Medicine, Southwestern Surgical Congress, andWilderness Medical Society, Paul Blackburn, DO, FACOEP, FACEP Attending Physician, Department of Emergency Medicine, Maricopa Medical Center, Paul Blackburn, DO, FACOEP, FACEP is a member of the following medical societies: American College of Emergency Physicians, American College of Osteopathic Emergency Physicians, American Medical Association, and Arizona Medical Association, Jeffrey Glenn Bowman, MD, MS Consulting Staff, Highfield MRI, Andrew K Chang, MD Associate Professor, Department of Emergency Medicine, Albert Einstein College of Medicine, Montefiore Medical Center, Andrew K Chang, MD is a member of the following medical societies: American Academy of Emergency Medicine, American Academy of Neurology, American College of Emergency Physicians, and Society for Academic Emergency Medicine, John Geibel, MD, DSc, MA Vice Chair and Professor, Department of Surgery, Section of Gastrointestinal Medicine, and Department of Cellular and Molecular Physiology, Yale University School of Medicine; Director, Surgical Research, Department of Surgery, Yale-New Haven Hospital, John Geibel, MD, DSc, MA is a member of the following medical societies: American Gastroenterological Association, American Physiological Society, American Society of Nephrology, Association for Academic Surgery, International Society of Nephrology, New York Academy of Sciences, and Society for Surgery of the Alimentary Tract, Disclosure: AMGEN Royalty Consulting; ARdelyx Ownership interest Board membership, Tunc Iyriboz, MD Chief, Division of Clinical Image Management, Assistant Professor, Department of Radiology, Hershey Medical Center, Pennsylvania State University, Tunc Iyriboz, MD is a member of the following medical societies: American College of Radiology, American Medical Association, and Radiological Society of North America, Seema Jain Pennsylvania State University College of Medicine, Rick Kulkarni, MD Attending Physician, Department of Emergency Medicine, Cambridge Health Alliance, Division of Emergency Medicine, Harvard Medical School, Rick Kulkarni, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Emergency Medicine, American College of Emergency Physicians, American Medical Association, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine, Eric L Legome, MD Chief, Department of Emergency Medicine, Kings County Hospital Center; Associate Professor, Department of Emergency Medicine, New York Medical College, Eric L Legome, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Emergency Medicine, American College of Emergency Physicians, Council of Emergency Medicine Residency Directors, and Society for Academic Emergency Medicine, Pinaki Mukherji, MD Assistant Professor, Attending Physician, Department of Emergency Medicine, Montefiore Medical Center, Pinaki Mukherji, MD is a member of the following medical societies: American College of Emergency Physicians, Robert E O'Connor, MD, MPH Professor and Chair, Department of Emergency Medicine, University of Virginia Health System, Robert E O'Connor, MD, MPH is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, American College of Physician Executives, American Heart Association, American Medical Association, Medical Society of Delaware, National Association of EMS Physicians, Society for Academic Emergency Medicine, and Wilderness Medical Society, Benson B Roe, MD Emeritus Chief, Division of Cardiothoracic Surgery, Emeritus Professor, Department of Surgery, University of California at San Francisco Medical Center, Benson B Roe, MD is a member of the following medical societies: Alpha Omega Alpha, American Association for Thoracic Surgery, American College of Cardiology, American College of Surgeons, American Heart Association, American Medical Association, American Society for Artificial Internal Organs, American Surgical Association, California Medical Association, Society for Vascular Surgery, Society of Thoracic Surgeons, and Society of University Surgeons, Joseph A Salomone III, MD Associate Professor and Attending Staff, Truman Medical Centers, University of Missouri-Kansas City School of Medicine; EMS Medical Director, Kansas City, Missouri, Joseph A Salomone III, MD is a member of the following medical societies: American Academy of Emergency Medicine, National Association of EMS Physicians, and Society for Academic Emergency Medicine, Daniel S Schwartz, MD, FACS Assistant Clinical Professor of Cardiothoracic Surgery, Mount Sinai School of Medicine; Chief of Thoracic Surgery, Huntington Hospital, Daniel S Schwartz, MD, FACS is a member of the following medical societies: American College of Chest Physicians, American College of Surgeons, Society of Thoracic Surgeons, and Western Thoracic Surgical Association, Robert L Sheridan, MD Assistant Chief of Staff, Chief of Burn Surgery, Shriners Burns Hospital; Associate Professor of Surgery, Department of Surgery, Division of Trauma and Burns, Massachusetts General Hospital and Harvard Medical School, Robert L Sheridan, MD is a member of the following medical societies: American Academy of Pediatrics, American Association for the Surgery of Trauma, American Burn Association, and American College of Surgeons, Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference, Milos Tucakovic, MD Fellow, Department of Internal Medicine, Sections of Pulmonary Disease, Allergy and Critical Care Medicine, Milton S Hershey Medical Center, Pennsylvania State College of Medicine, Milos Tucakovic, MD is a member of the following medical societies: American College of Physicians and American Medical Association.
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