Tension pneumothorax Flashcards
If the patient is spontaneously breathing and is not peri-arrest/in cardiac arrest
- Decompress the affected side(s) using a specific chest decompression device.
a) The preferred site is the 5th intercostal space in the anterior axillary line.
b) Decompress in the 2nd intercostal space in the midclavicular line if the
preferred site is not feasible. - Decompress the affected side(s) using finger thoracostomy in the 5th intercostal space in the anterior axillary line, if a specific chest decompression device is not available or decompression with a device was not successful. Consider administering 1 mg/kg of ketamine IV (up to a maximum of 100 mg) prior to the procedure.
If the patient is ventilated or is peri-arrest/in cardiac arrest
- Decompress the affected side(s) using finger thoracostomy in the 5th intercostal space in the anterior axillary line, ensuring your finger clearly reaches the pleura.
- Dress thoracostomy wounds using a colostomy bag or a standard dressing.
what is Pneumothorax
the presence of air within the pleural space.
how dose Traumatic pneumothorax occur
following blunt trauma, noting that even in the setting of penetrating trauma a pneumothorax is not always present. Traumatic pneumothorax can be further broken down into open (where the chest wall is open to the outside), and closed (where the chest wall is intact and the pleural hole has been made by sudden compression of the chest like a Valsalva effect, or due to puncture by a fractured rib).
Primary spontaneous (idiopathic) pneumothorax occurs when
the lung tissue is normal. The classic presentation is a tall young male with sudden onset of dyspnoea and pleuritic chest pain, often at the shoulder tip. It often occurs secondary to rupture of a congenital weakness (bleb) of the pleura.
Secondary spontaneous pneumothorax occurs secondary to
abnormal lung tissue. The pleural rupture occurs as a consequence of lung disease, for example COPD, asthma or autoimmune lung disease.
The signs and symptoms of pneumothorax can include:
ū Dyspnoea.
ū Chest pain.
ū Reduced air entry on the affected side.
ū Hyperresonant percussion note on the affected side.
ū Loss of lung sliding over the affected area on ultrasound.
ū Hypoxia. This is a late sign and usually only occurs when the pneumothorax
is large.
Tension pneumothorax is a cause of obstructive shock that occurs when a
pneumothorax is under positive pressure that is high enough to impair venous return to the right heart.
Tension pneumothorax occurs when
the volume of air within the pleural space progressively increases with each inspiration, but is unable to escape during expiration because the pleural tear acts as a one-way valve. With each breath the pressure within the pleural space increases until it is higher than the venous pressure within the superior and inferior vena cava, resulting in
a progressive fall in venous return to the right heart and cardiac arrest if not treated.
The signs and symptoms of tension pneumothorax include:
ū Progressively worsening shock. This is an important defining feature. If the patient does not have progressively worsening shock they do not have tension pneumothorax.
ū Progressively worsening dyspnoea.
ū Distended jugular veins. This occurs as a result of impaired venous return
to the right heart. Very rarely, distended jugular veins may not be present if the patient has both tension pneumothorax and severe hypovolaemic shock.
ū Tracheal deviation away from the affected side. This is an extremely late sign as it requires very high pressure within the thorax and is rarely seen.
The most common chest injuries that are misdiagnosed as tension pneumothorax are:
ū
ū
Pulmonary contusion in the presence of hypovolaemic shock. Pulmonary contusions are common and will cause reduced air entry and hypoxia. The jugular veins will be flat and the percussion note will usually be normal, but may be dull if the contusion is very severe.
Haemothorax in the presence of hypovolaemic shock. The jugular veins will be flat and the percussion note will be dull.
Pneumothorax in the presence of hypovolaemic shock. The jugular veins will be flat and the percussion note will be hyperresonant.
preferred decompression location
Decompression in the 5th intercostal space in the anterior axillary line is safer and easier than decompression in the 2nd intercostal space in the midaxillary line because there is usually less distance to the pleura.
