UNCONTROLLED WHEN PRINTED
Quick Chart
 Introduction
  • Pneumothorax develops secondary to a breach between the visceral and parietal pleura and is considered to be under tension when significant respiratory and/or cardiovascular compromise exists, leading to cardiac arrest if untreated.
  • The pleural defect acts as a one way valve trapping air and increasing pressure in the pleural cavity.
  • Tension pneumothorax presents in the spontaneously breathing patient with progressive respiratory deterioration. In the ventilated patient air flows into the pleura more rapidly under positive pressure resulting in rapid cardiorespiratory collapse.
 Clinical Presentation

Early and reliable signs of tension pneumothorax in the spontaneously breathing or ventilated patient

Awake (Spontaneously Breathing) Ventilated
  • Progressive respiratory deterioration
  • Falling SpO2
  • Tachypnoea
  • Tachycardia
  • Respiratory distress
  • Agitation
  • Reduced breath sounds (ipsilateral)
  • Hyper-resonance (ipsilateral)
  • Rapid cardiorespiratory collapse
  • Immediate SpO2 decrease
  • Decreased BP
  • Tachycardia
  • Increased ventilation pressure (harder to ventilate)
  • Reduced breath sounds (ipsilateral)
  • Hyper-resonance (ipsilateral)
Pre-terminal signs
  • Decreasing respiratory rate
  • Hypotension
  • Decreasing GCS when on O2
  • SpO2 <92% when on O2
Inconsistent signs Inconsistent signs
  • Tracheal deviation
  • Distended neck veins (raised jugular venous pressure)
  • Tracheal deviation
  • Distended neck veins (raised jugular venous pressure)
 Exclusion Criteria
Exclusion Criteria
 Risk Assessment
  • Decreased BP or cardiac output are not common in spontaneously breathing patients with tension pneumothorax, if this is detected hypovolaemia should be the primary consideration.
  • During positive pressure ventilation a higher flow of gas through the pleural defect takes place resulting in a more rapid increase in pleural cavity pressure and progression towards cardiorespiratory arrest.
  • A higher suspicion for tension pneumothorax should be maintained in the ventilated trauma patient.
  • The presence of a needle or chest tube does not mean the patient cannot re-develop a tension pneumothorax.
  • Tension pneumothorax may also persist if there is an injury to the major airways or bronchial tree.
 Management
Primary Care
Intermediate Care
  • Consider pain relief
  • Apply cardiac monitor where available
  • Monitor patient continuously, recording full observations every 10 minutes (or 5 minutes if time critical)
  • Transport Priority 1 if patient time critical, pre-notifying receiving facility
Advanced Care
  • Consider pain relief
  • Consider cardiac monitoring
  • Monitor patient continuously, recording full observations every 10 minutes (or 5 minutes if time critical)
  • Needle thoracocentesis in traumatic cardiac arrest with torso involvement
  • Consider ASMA consult for needle thoracocentesis in a patient with suspected tension pneumothorax and / or heamodynamic compromise
Critical & Extended Care

CSP / PSO

  • Perform needle thoracocentesis in a patient with suspected pneumothorax and respiratory and/or haemodynamic compromise

CCP only

  • Patients with suspected tension pneumothorax with respiratory and/or haemodynamic compromise OR receiving positive pressure ventilation (mechanical ventilation) with signs of pulmonary barotrauma to receive finger thoracostomy via blunt dissection as per clinical skill.

NOTE: Where trained and available ultrasound should be utilised to confirm presence of tension pneumothorax prior to skill attempt.

 Additional Information
  • The potential for exposure to blood and body fluids is HIGH. All precautions that serve to minimise risk to the clinician and the patient are to be applied.
Key Terms & Links
Settings
Extended Care:
Colour assist:

References
References

Document Control


Directorate
Clinical Services

Responsible Manager
Head of Clinical Services

Version

Published Date

Review Date

Clinical Resources Website

St John Ambulance Western Australia Ltd (ABN 55 028 468 715) (St John WA) operates ambulance and other pre-hospital clinical services. St John WA’s Clinical Resources, including its Clinical Practice Guidelines (Clinical Resources), are intended for use by credentialed St John WA staff and volunteers when providing clinical care to patients for or on behalf of St John WA, within the St John WA Clinical Governance Framework, and only to the extent of the clinician’s authority to practice.

Other users – Terms of Use

The content of the St John WA Clinical Resources is provided for information purposes only and is not intended to serve as health, medical or treatment advice. Any user of this website agrees to be bound by these Terms of Use in their use of the Clinical Resources.

St John WA does not represent or warrant (whether express, implied, statutory, or otherwise) that the content of the Clinical Resources is accurate, reliable, up-to-date, complete or that the information contained is suitable for your needs or for any particular purpose. You are responsible for assessing whether the information is accurate, reliable, up-to-date, authentic, relevant, or complete and where appropriate, seek independent professional advice.

St John WA expressly prohibits use of these Clinical Resources to guide clinical care of patients by organisations external to St John WA, except where these organisations have been directly engaged by St John WA to provide services. Any use of the Clinical Resources, with St John WA approval, must attribute St John WA as the creator of the Clinical Resources and include the copyright notice and (where reasonably practicable) provide a URL/hyperlink to the St John WA Clinical Resources website. 

No permission or licence is granted to reproduce, make commercial use of, adapt, modify or create derivative works from these Clinical Resources. For permissions beyond the scope of these Terms of Use, including a commercial licence, please contact medservices@stjohnambulance.com.au

Where links are provided to resources on external websites, St John WA:

  • Gives no assurances about the quality, accuracy or relevance of material on any linked site;
  • Accepts no legal responsibility regarding the accuracy and reliability of external material; and
  • Does not endorse any material, associated organisation, product or service on other sites.

Your use of any external website is governed by the terms of that website, including any authorisation, requirement or licence for use of the material on that website.

To the maximum extent permitted by law, St John WA excludes liability (including liability in negligence) for any direct, special, indirect, incidental, consequential, punitive, exemplary or other loss, cost, damage or expense arising out of, or in connection with, use or reliance on the Clinical Resources (including without limitation any interference with or damage to a user’s computer, device, software or data occurring in connection with such use).

Cookies

Please read this cookie policy carefully before using Clinical Resources from St John WA.

The cookies used on this site are small and completely anonymous pieces of information and are stored on your computer or mobile device. The data that the cookies contain identify your user preferences (such as your preferred text size, scope / skill level preference and Colour Assist mode, among other user settings) so that they can be recalled the next time that you visit a page within Clinical Resources. These cookies are necessary to offer you the best and most efficient possible experience when accessing and navigating through our website and using its features. These cookies do not collect or send analytical information back to St John WA.

Clinical Resources does integrate with Google Analytics and any cookies associated with this service enable us (and third-party services) to collect aggregated data for statistical purposes on how our visitors use this website. These cookies do not contain personal information such as names and email addresses and are used to help us improve your user experience of the website.

If you want to restrict or block the cookies that are set by our website, you can do so through your browser setting. Alternatively, you can visit www.internetcookies.com, which contains comprehensive information on how to do this on a wide variety of browsers and devices. You will find general information about cookies and details on how to delete cookies from your device. If you have any questions about this policy or our use of cookies, please contact us.

St John Ambulance Western Australia Ltd © Copyright 2020, All Rights Reserved

Terms of Use | Privacy Policy | Copyright Statement & Disclaimer