Tension pneumothorax resident survival guide

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]

Overview

Tension pneumothorax is a medical emergency caused by accumulation of air in the pleural cavity. Air enter the intrapleural space through the lung parenchyma, or through a traumatic communication from the chest wall.

Causes

Life Threatening Causes

Life-threatening causes include conditions which may result in death or permanent disability within 24 hours if left untreated. Tension pneumothorax is a life-threatening condition and must be treated as such irrespective of the underlying causes.

Common Causes

• Mechanical ventilation
• Trauma
• Central venous catheter
• Cardiopulmonary resuscitation
• Emphysema
• Chronic obstructive pulmonary disease
• Asthma

Management

Shown below is an algorithm depicting the management of tension pneumothorax.

Characterize the symptoms: ❑ Breathlessness ❑ Chest pain ❑ Cyanosis ❑ Sweating ❑ Anxiety ❑ Fatigue ❑ Air way pressure alarm: if on mechanical ventilation

Examine the patient: Vital signs ❑ Respiratory rate: ❑ Severe tachypnea ❑ Heart rate: ❑ Tachycardia ❑ Blood pressure ❑ Hypotension Focused chest examination Inspection ❑ Reduced lung expansion on the affected side ❑ Enlarged involved hemithorax ❑ Jugular venous distension Palpation ❑ Trachea shifted to the opposite side ❑ Decreased tactile vocal fremitus Percussion ❑ Hyperresonance Auscultation ❑ Diminished breath sounds on the affected side

First aid: ❑ Airway, breathing, and circulation ❑ Sucking chest wounds immediately coveraged with an occlusive or pressure bandage ❑ 100% oxygen administration

Categorize the Patient

Hemodynamically Stable

Hemodynamically Unstable

Confirm diagnosis Imaging studies ❑ Chest x-ray ❑ Erect position in inspiration ❑ Air in the pleural cavity ❑ Contralateral deviation of mediastinum ❑ Increased thoracic volume ❑ Ipsilateral flattening of heart border ❑ Mid diaphragmatic depression ❑ Chest CT scanning ❑ For uncertain or complex cases ❑ Ultrasonography ❑ Digital imaging

Emergency needle decompression ❑ Aseptic preparation ❑ Use two alcohol-based skin disinfectant ❑ Use 14-16 G intravenous cannula ❑ Site: 2nd intercostal space, mid-clavicular line

❑ Admit the patient ❑ Insert chest drain ❑ Leave the cannula in place until bubbling is confirmed in the underwater seal system

Do`s

• Serial chest radiographs every 6 hrs on the first day after injury to rule out pneumothorax is ideal.

References

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