# Under-Recognized Life-Threatening Vasovagal Reflex During Chest Tube Insertion

## TL;DR

A rare but dangerous vasovagal reflex during chest tube insertion can lead to cardiac arrest in young patients with pneumothorax.

## Contribution

Highlights a potentially fatal vasovagal reflex during chest tube insertion in young patients with pneumothorax.

## Key findings

- A 23-year-old male developed pulseless electrical activity during chest tube insertion due to vasovagal reflex.
- Severe sinus bradycardia and cardiac arrest can occur despite stable initial conditions and pain control.
- Pre-administration of atropine is suggested as a preventive measure for this rare complication.

## Abstract

Chest tube insertion is a common and relatively safe procedure in an emergency setting. However, a potentially fatal complication, vasovagal reflex, may be under-recognized due to its generally mild severity. We present a case of pulseless electrical activity (PEA) requiring chest compression due to vasovagal reflex during chest tube insertion for spontaneous pneumothorax. A 23-year-old male who had a history of spontaneous pneumothorax presented with left chest pain to our emergency department. Based on point-of-care ultrasonography and chest radiography, we made a diagnosis of recurrent pneumothorax. Although he had stable vital signs and received adequate pain control, during chest tube insertion, he developed severe sinus bradycardia with a six-second pause, leading to PEA requiring chest compressions. After a few compressions, his heart rate increased and he regained consciousness. He underwent video-assisted thoracoscopic surgery for pneumothorax and was discharged without complications. Vasovagal reflex during chest tube insertion in young patients with spontaneous pneumothorax may cause severe bradycardia and cardiac arrest. Physicians should be aware of this rare but potentially fatal complication and be prepared with appropriate measures, such as pre-administration of atropine, before chest tube insertion.