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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 (EMT / Level 2)
  • 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 (AP)
  • 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 (CCP, PSO)
CSP / PSO
  • Perform needle thoracocentesis in a patient with suspected pneumothorax and respiratory and/or haemodynamic compromise
CCP
  • 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.

References
References
Key Terms & Links
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