Tension pneumothorax

Question 1

What is a tension pneumothorax?

Answer 1

where air is trapped in the pleural cavity under positive pressure, displacing mediastinal structures and compromising cardiopulmonary function

Question 2

What causes a tension pneumothorax?

Answer 2

air enters the pleural cavity through a one-way valve and cannot escape - air continues to enter pleural space as someone breathes

disrupted visceral pleura, parietal pleural or tracheobronchial tree can cause it. air enters pleural space on inspiration but cannot exit

Question 3

What is the approach to a tension pneumothorax and why?

Answer 3

treated as a life-threatening medical emergency, as can lead to compression of medistinal organs if not treated immediately

Question 4

What are 5 examples of causes of tension pneumothorax?

Answer 4

1. Penetrating trauma from RTAs
2. Iatrogenic procedures e.g central line insertion
3. post-CPR
4. mechanical ventilation
5. Lung biopsy

Question 5

What are the sequelae of a tension pneumothorax?

Answer 5

• progressive accumulation of air in the pleural space and increasing positive pressure within the chest
• leads to collapse of ipsilateral lung and compression of contralateral lung, trachea, heart and superior vena cava
• therefore impaired respiratory function, reduced venous return to the heart and reduced cardiac output → hypoxia and hemodynamic instability

Question 6

What type of pneumothoraces can become a tension pneumothorax?

Answer 6

any type of pneumothorax can become tension pneumothorax

Question 7

How is a diagnosis of tension pneumothorax made?

Answer 7

it is a clinical diagnosis and medical emergency requiring immediate chest decompression (shouldn’t do cxr)

Question 8

What are 7 signs on examination of tension pneumothorax?

Answer 8

1. Haemodynamic instability: tachypnoea, tacyhcardia, hypotension, raised JVP
2. Tracheal deviation away from affected side
3. Decreased chest expansion
4. Increased resonance on percussion
5. Decreased breath sounds
6. Decreased vocal resonance
7. Surgical emphysema

Question 9

What is the management of tension pneumothorax?

Answer 9

• large-bore needle inserted into 2nd intercostal space in midclavicular line
• followed by chest drain insertion

Question 10

What is the purpose of a chest drain insertion following large-bore needle drainage of a tension pneumothorax?

Answer 10

to reduce risk of immediate recurrence of tension pneumothorax

Question 11

If initial decompression of a tension pneumothorax fails, what can be done next?

Answer 11

consider using a longer needle (especially in muscular/adipose patients)

Question 12

Where is the chest drain tube placed in tension pneumothorax?

Answer 12

5th intercostal space in mid-axillary line (safe triangle)

best to go just above the rib

Question 13

What will be the clinical appearance of a patient with pneumothorax?

Answer 13

distressed and tachypnoeic, with cyanosis, profuse sweating, marked tachycardia and hypotension

Question 14

What are the 3 steps of management of a tension pneumothorax?

Answer 14

1. give maximal O2 to reverse hypoxia (don’t leave pt unattended)
2. insert 18G (green) cannula or largest available, perpendicular to chest wall, into second intercostal space, MCL on affected side - should be almost immediate relief. leave until air ceases to rush out
3. insert chest drain as soon as possible

Question 15

What should be done if no air rushes out when a cannula is inserted in tension pneumothorax?

Answer 15

means the patient doesn’t have a tension pneumothorax, cannula should be removed