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Classic signs include decreased breath sounds, distended neck veins, and non-midline trachea. These are
VERY uncommon. More common changes suggestive of tension pneumothorax include hypotension,
tachycardia, narrowing pulse pressure, and oxygen desaturation. Under anesthesia, these patients may exhibit
a rise in airway pressures. Awake, they may become tachypnic.
In the exam state that CXR should not have been taken as tension pneumothorax is a
clinical diagnosis and surgical emergency.
Rx
o Needle decompression (thoracocentesis) – 2nd or 3rd intercostal space mid clavicular
line with a large bore (16/18French gauge) needle.
o Immediately decompress the tension pneumothorax by inserting a large-bore cannula
into the pleural cavity of the affected side, through the second intercostal space, in the
midclavicular line.
o Follow with a wide-bore chest drain, or thoracostomies in an intubated and ventilated
patient.
Indications for performing emergency decompression : the presence of tension
pneumothorax with decompensation as evidenced by more than one of the following:
Respiratory distress and cyanosis
Loss of radial pulse (late shock)
Decreasing level of consciousness
o Procedure:
1. Equipment: i. Adult use 14 gauge, 3.25 inch needle; ii. Pediatric use 16-18 gauge, 2
inch needle
2. Place patient on continuous cardiac monitoring and pulse oximetry
3. Patient position:
Place trauma patient in a head-up, supine position
All other patients should be placed in 45-degree, sitting position
3. Locate site: Second or third inter-costals space, midclavicular line
4. If time permits, prep site with antiseptic solution
5. Insert the needle just over the top of the rib at a 90° angle to the rib. As the needle
enters the pleural space, there will be a “pop”. If a tension pneumothorax is present,
there will be a hiss of air as the pneumothorax is decompressed
6. Advance the catheter into the skin and remove the needle.
7. Secure the catheter in place. Allow air to escape freely.
8. Support with 100% oxygen and transport without delay
9. Immediately after decompression, insert a chest tube.
10. If no air escapes then patient doesn’t have tension pneumothorax therefore remove
needle.
Very rare
Can cause severe cardiac and respiratory compromise
Trachea will remain central but air entry is poor into both lungs.