Treatment of tension pneumothorax is immediate needle decompression by inserting a large-bore eg, or gauge needle into the 2nd intercostal space in the midclavicular line. Air will usually gush out. Because needle decompression causes a simple pneumothorax, tube thoracostomy should be done immediately thereafter.
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Videos Figures Images Quizzes Symptoms. Symptoms and Signs. If communication is created across the pleura, accumulation of air in the pleural space is referred to as a pneumothorax. Three subdivisions exist when categorizing a pneumothorax, depending on whether air has direct access to the pleural cavity. A simple pneumothorax has no communication between the atmosphere and the pleural space. With a communicating pneumothorax, air in the pleural cavity exchanges with atmospheric air through a defect in the chest wall.
A tension pneumothorax develops when air progressively accumulates under pressure within the pleural cavity. Primary spontaneous pneumothorax PSP conventionally refers to patients with no underlying lung disease, while those with established lung pathology are classified as secondary spontaneous pneumothorax SSP. Close observation is warranted to determine if needle aspiration or tube thoracostomy is indicated. According to Sahota et al, the reasons to not place any kind of drain are:.
A communicating pneumothorax needs rapid intervention to prevent worsening complications. The area of injury should be covered with an occlusive dressing to prevent the influx of air, but allow the egress of air from inside the chest cavity. Tension pneumothorax is a life-threating process that needs emergent treatment. Although widely recommended, the insertion site in 2ICS is not based on solid evidence Fitzgerald.
Unsuccessful needle decompression may be attributable to insufficient needle length, inaccurate needle positioning, catheter displacement, plugging of the catheter lumen, and kinking due to the small diameter of the catheter. For a general discussion, refer to the pneumothorax article. Presentation is variable and may initially have no symptoms. With time severe dyspnea, tachycardia and hypotension occur. Distended neck veins and tracheal deviation are also often present. Eventually, impaired venous return results in cardiac arrest and death.
This can occur within minutes. Clinical signs of a tension pneumothorax in the ventilated patient are comparably rapid, with arterial and mixed venous peripheral capillary oxygen saturation immediately decreasing 5.
In this situation, the ipsilateral lung will, if normal, collapse completely although a less than normally compliant lung may remain partially inflated. In either case, as the collection grows further, it exerts a positive mass effect on the mediastinum compression of vessels and heart and the opposite lung. A tension pneumothorax will have the same features as a simple pneumothorax with a number of additional features, helpful in identifying tension.
These additional signs indicate hyperexpansion of the hemithorax:. In the rare instance of bilateral tension pneumothoraces , there may be no cardiomediastinal shift 6,7. In addition to the sonographic features of pneumothorax, a RUSH exam often performed in the setting of hemodynamic instability the following features imply the presence of tension physiology 8 :. Treatment of a tension pneumothorax is one of the classic medical emergencies where life can be saved or lost on the basis of recognition and subsequent rapid decompression.
Numerous techniques exist, and the literature is replete with opinions, but in the first instance relieving the tension, even if not draining the pneumothorax, is life-saving.
A needle thoracostomy e. Please Note: You can also scroll through stacks with your mouse wheel or the keyboard arrow keys. Updating… Please wait.
Unstable patients or patients with bilateral pneumothorax Chest tube insertion with water seal with or without suction Order repeat CXR after chest tube insertion.
ICU transfer Consult thoracic surgery. Primary spontaneous pneumothorax stable patient Small pneumothorax apex-to-cupola distance Monitor closely. Order repeat CXR in 3—6 hours. If stable or improved, consider discharge. If worsening, start treatment for a large pneumothorax.
Secondary spontaneous pneumothorax stable patient Small pneumothorax apex-to-cupola distance Admission with monitoring for 24 hours Consider chest tube insertion to water seal or Heimlich valve until lung re-expands. Order repeat CXR after chest tube insertion. Consult thoracic surgery. Consider ICU transfer. Acute management checklist for traumatic pneumothorax All patients Assess for signs of instability; if present, perform immediate needle or finger thoracostomy followed by chest tube insertion.
Review the mechanism of injury; consider the risk of extrathoracic injuries. Ensure adequate analgesia , particularly in patients with associated rib fractures. Transfer to trauma center for: tension pneumothorax , hemopneumothorax, open pneumothorax , respiratory failure , or associated injuries requiring trauma center level of care. Stabilize patients as needed prior to interfacility transfer: e. Small pneumothorax Determine if the patient has any risk factors necessitating a chest tube : e.
If no risk factors are present, continue high-flow oxygen and observation. Moderate to large pneumothorax Insert a chest tube and connect to a water seal until the lung re-expands.
References Choi WI. Tuberc Respir Dis Seoul. Management of spontaneous pneumothorax: British Thoracic Society pleural disease guideline Tension pneumothorax--time for a re-think?. Emergency Medicine Journal. Management of spontaneous pneumothorax: an American College of Chest Physicians Delphi consensus statement..
Pleural ultrasonography versus chest radiography for the diagnosis of pneumothorax: review of the literature and meta-analysis.
Critical Care. The Deep Sulcus Sign. Is mediastinal shift on chest X-ray of pneumothorax always an emergency?. Emergency Medicine Australasia. Spontaneous pneumothorax: epidemiology, pathophysiology and cause. European Respiratory Review. Sonographic diagnosis of pneumothorax. Journal of Emergencies, Trauma, and Shock. Quantification of pneumothorax size on chest radiographs using interpleural distances: regression analysis based on volume measurements from helical CT..
American Journal of Roentgenology. Conservative versus Interventional Treatment for Spontaneous Pneumothorax.
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