TENSION PNEUMOTHORAX

Luke R. Scalcione, MS III

Scott Q. Nguyen, M.D.
Celia M. Divino, M.D.
Mount Sinai School of Medicine

Mrs. Greenwich
47 y/o female pedestrian struck is brought to
the ER by EMS c/o SOB and Chest Pain

History
What other points of the history do
you want to know?

History, Mrs. Greenwich

A-M-P-L-E TRAUMA HISTORY
Allergies: NKDA
Medications:

1- Sulfasalazine 500 mg bid

2- Methotrexate 7.5 mg qweek
3- Hydroxychloroquine 300 mg daily
4- Prednisolone 10 mg daily

PMH:

RA (Dx: 1999) currently treated w/ DMARD

therapy

Last Meal: 1800

Events Surrounding Injury:

Time of injury: 2100

Mechanism of injury: Pedestrian struck crossing
intersection of busy street. Pedestrian struck on
right aspect of body. Patient rolled over hood of
taxi and fell to ground.
Estimated taxi velocity: 10 mph decelerating

Characterization of
Symptoms:
Chest pain worsening on inspiration
w/ localized thorax tenderness over
ribs 6-7, visible right thorax
abrasions, non radiating pain,
dyspnea
Temporal sequence
Abrupt onset SOB (3 minutes s/p
accident).

What is your Differential

Diagnosis?

Differential Diagnosis
Based on History and Presentation

Pneumothorax
Musculoskeletal Pain
Rib Fractures
MI
Acute Pulmonary Embolism

Physical Examination

What would you look for?

Physical Examination, Mrs. Greenwich

Vital Signs:

Tc= 98.7 BP= 98/60 HR=115 RR= 26 Sat 89% RA

PRIMARY SURVEY:
AIRWAY:

No altered mental status

No airway obstruction noted
No maxillofacial fractures noted
Gag reflex intact

BREATHING:
Tachypnea; RR=26
Decreased breath sounds and hyper
resonance over the entire R lung field
tracheal deviation to the L of midline
poor respiratory excursion
no flail movement of chest wall
local tenderness over R flank at ribs 6-7
chest wall asymmetry
notable JVD 8cm above the sternal
angle

CIRCULATION:

No obvious signs of gross

hemorrhage
Hypotensive; BP= 98/60;
MAP= 72.67 (1/3 systolic + 2/3
diastolic)
Tachycardia; HR=115
cold/moist extremities w/
decreased pulse pressure
capillary refill >5 sec

SECONDARY SURVEY:
NOT ASSESSED AT THIS
TIME IMMEDIATE
INTERVENTION
NECESSARY

Would you like to revise your

Differential Diagnosis?

Revised Differential
Tension Pneumothorax
Rib Fractures

Laboratory

What would you obtain?

Laboratory
NO LAB STUDIES AT THIS TIME
IMMEDIATE INTERVENTION
NECESSARY
See Discussion Section for expected labs

Interventions at this point?

Interventions at this point

Supplemental O2
Decompression Needle Thoracostomy

Needle Thoracostomy, Discussion

Procedure
1.
2.
3.
4.
5.
6.
7.

Use a large bore needle w/ catheter (14-16 gauge)

Identify 2nd intercostal space at midclavicular line (1-2 cm lateral to the
sternal angle). This will minimize likelihood of IMA injury
Prepare area with Betadine
Insert needle directly superior to the 3rd rib. This prevents injury to
neurovascular bundle located on the inferior aspect of each rib.
Insert needle perpendicular to the chest wall, approximately 3-6 cm in
depth
Stop advancement of needle upon hearing opening hiss/pressure
release of pleural space.
Remove needle; leave catheter in place

What next?

What next?

Tube Thoracostomy
1.
2.
3.
4.
5.
6.
7.
8.

Identify and prepare the area w/ Betadine at ICS 4 or 5 along the mid-axillary or
anterior axillary line
Anesthetize the area (subcutaneous tissue, intercostal muscles) with Lidocaine.
Some physicians use opioid analgesia or a combination of an opioid + Benzo.
Make a 2 cm incision
Insert a large blunt clamp over superior aspect of rib (preventing damage to the
neurovascular bundle that lies on the inferior border of the rib). Apply gentle
pressure until the parietal pleura is pierced.
Open clamp to establish a tract for the chest tube.
Bluntly dissect w/ finger.
Clamp proximal end of tube tangentially w/ Clamp. Insert tube over superior
aspect of rib into pleural space.
Insert the chest tube past the last hole. Note the last hole disrupts the continuity
of the radiopaque linethis facilitates radiographic placement confirmation.
Suture chest tube w/ Silk sutures.

What next?

What next?
Portable Chest X-Ray
(confirm chest tube placement)

Management
All patients with tension pneumothorax
must be admitted to an inpatient
service.
What should be done next?

Management
Monitor patient continuously with arterial O2 saturation
watch for sudden desaturations
F/U CXR may be ordered to assess re-expansion of lung and
resolution of pneumothorax. Important: re-expansion
pulmonary edema may occur with rapid lung re-expansion s/p
tube thoracostomy. This is a potential life threatening situation
which can lead to cardiovascular collapse.
Keep chest tube on water seal. Chest tube may be removed
when indication for placing it has resolved. F/U CXR must be
ordered immediately s/p chest tube removal and 24 hrs postremoval to assess for presence of a reoccurring pneumothorax.

Discussion
Etiology of Tension Pneumothorax
Trauma (blunt or penetrating): disruption of the parietal or visceral pleura.
Fractures: most prevalent as a result of rib fractures, however also seen in
displaced thoracic spine fractures.
Barotrauma: ventilator dependent patients on large volume PEEP may
rupture peripheral alveoli sacs secondarily disrupting the visceral pleura.
Index of suspicion is raised when larger peak airway pressures are needed
to achieve a specific tidal volume.
Iatrogenic: secondary to trauma induced by
Bronchoscopy
Chest compressions during CPR
Central venous catheter placement
Conversion of Simple Pneumothorax -> Tension Pneumothorax

Discussion
Pathophysiology of Simple Pneumothorax
Air enters the pleural space during inspiration. The pleural space increases in volume
thus compressing the ipsilateral lung. The ipsilateral lung collapses. During expiration
intrathoracic pressure increases, the diaphragm relaxes, and air is pushed out of the
pleural space. Note mediastinal structures remain relatively fixed.

Discussion
Pathophysiology of Tension Pneumothorax
Disruption of the lung parenchyma or parietal pleura acts like a one
way valve. During inspiration air is drawn into the pleural space.
During expiration the tissue flap/valve prevents air from escaping.
Subsequent inspirations additively draw more air into the pleural
space. Increasing intrapleural pressures result in collapse of ipsilateral
lung and deviation of mediastinal structures contralaterally

Discussion
Complications:
Cardiovascular Collapse: the implications of a tension
pneumothorax are profound. Displacement of mediastinal
structures contralaterally causes kinking of the SVC and
IVC. Venous return to the heart is severely compromised
resulting in decreased cardiac output. Shock and
hypoperfusion ensue.

Lab Results, Mrs. Greenwich

If Lab Tests were ordered at presentation the following
are expected:

ABG:

7.32/50/60/24/ 89 % RA
138

102 18

Chem 7

110
3.7

Cardiac Enzymes:

25

TnI: 0
TnT: 0
CKMB: 1.2

1.2

Lab Results, Discussion

ABGs: Often seen in tension pneumothorax is a varying
degree of acidemia, hypercarbia, and hypoxia. Note in acute
respiratory acidosis increases in PaCO2 by 10mmHg will
decrease pH by 0.08 (i.e. PaCO2 40->50 lowers pH 7.4>7.32). The reduction in PaO2 is caused by alveolar
hypoperfusion secondary to atelectasis, low
ventilation/perfusion ratios, and anatomic shunts.

Chem 7: Principally used for the CO2 value. More

accurate for calculations of compensated respiratory
acidosis than HCO3- values in ABGs which represents an
average of computed PaCO2 levels.

Cardiac Enzymes: necessary to r/o acute MI and

resulting cardiogenic shock, must have serial reading to
accurately r/o acute MI

Discussion
If CXR was ordered at presentation the
following are expected:

Tension Pneumothorax Left

Subpulmonic Pneumothorax Right
SQ AIR
Pulmonary
Contusion
Deep Chest Tube
Persistant
Subpulmonic
Pneumothorax

May not see mediastinal shift if pneumothorax is bilateral!

Discussion
Do not delay treatment of a Tension Pneumothorax. CXR can be taken for
confirmatory measures after decompression needle thoracostomy or tube
thoracostomy. The diagnosis of a Tension pneumothorax is made clinically
when one has a high index of suspicion.
Findings on CXR:
Large radiodense lung field
Absent lung markings on ipsilateral side
Contralateral deviation of trachea and mediastinal structures
If tension pneumothorax involves left lung the left hemidiaphragm may
be depressed/flattened. The liver prevents this radiographic finding on the
right side

QUESTIONS ??????

Summary
Tension Peumothorax is a life threatening condition which
may quickly lead to cardiovascular collapse and shock.
Immediate intervention must be initiated if there is a high
clinical suspicion of a tension pneumothorax.
Intervention includes decompression needle thoracostomy
followed by chest tube thoracostomy, followed by a portable
chest x-ray to confirm tube placement and re-expansion of
collapsed lung fields.
Laboratory and diagnostics may confirm the diagnosis of a
tension pneumothorax (i.e. ABG, CXR) however the diagnosis
lies predominantly on clinical presenting symptoms.

References
Check out these sites
Needle Thoracostomy photo courtesy of
http://www.biodigital.org/voz2/slide8.htm
Tube Thoracostomy photos courtesy of http://www.vesalius.com
CXR w/ 2 Chest Tubes photo courtesy of
http://www.trauma.org/imagebank/chest/images/chest0037.html
Pathophysiology of Pneumothorax photos courtesy of
http://home.ewha.ac.kr/~chestsg/dong/poster/99/2.htm
CXR of tension pneumothorax courtesy of
http://www.emedicine.com/med/topic2793.htm

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The preceding educational materials were made available through the

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