Tension Pneumothorax

Define "tension pneumothorax".

A tension pneumothorax occurs secondary to blunt or penetrating injury of the lung which results in a one-way valve being created. Air leaks from the lung out into the pleural space and is unable to escape, resulting in increased intrapleural pressure. Intrapleural pressure eventually increases to the point where it interferes with venous return, resulting in blood pooling in capacitance vessels with ensuing cardiovascular collapse and shock.

Tension pneumothorax

When should thoracic radiographs be performed in a patient with suspected pneumothorax?

• The initial presumptive diagnosis of pneumothorax should be based on physical examination findings of respiratory distress, tachypnea and muffled heart and lung sounds on thoracic auscultation.
• Thoracic radiographs should only be performed once the patient's immediate respiratory distress has been alleviate and the patient is relatively stable.
• Thoracocentesis should be performed prior to chest radiographs and based on physical examination findings.
• Thoracocentesis in these patients is both diagnostic (confirming suspicions of pneumothorax or hydrothorax) and therapeutic (relieving the pneumothorax and improving venous return).

• hyperlucent, overly expanded hemithorax
• mediastinal shift to the opposite side
• radiographic signs of pneumothorax - heart elevated from the sternum, lung lobes retracted from the thoracic wall

How should tension pneumothorax be treated?

The most immediate goal in the treatment of tension pneumothorax is to alleviate the increased intrapleural pressure. This is most quickly accomplished by performing thoracocentesis using a 20 g needle in the 7th or 8th intercostal space. Once the pleural space has been evacuated, if pneumothorax recurs or is persistent, a tube thoracostomy should be performed.

Chest tap setup with 60 ml syringe, 3-way stopcock, IV extension tube, and 20 gauge 1" needle.

Thoracocentesis at the 7th intercostal, midthoracic space

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