TENSION PNEUMOTHORAX
Luke R. Scalcione, MS III
Scott Q. Nguyen, M.D.
Celia M. Divino, M.D.
Mount Sinai School of Medicine
Mrs. Greenwich
 47 y/o female pedestrian struck is brought to
the ER by EMS c/o SOB and Chest Pain
History
What other points of the history do
you want to know?
History, Mrs. Greenwich
A-M-P-L-E TRAUMA HISTORY
 Allergies: NKDA
 Medications:
•
•
•
•
1- Sulfasalazine 500 mg bid
2- Methotrexate 7.5 mg qweek
3- Hydroxychloroquine 300 mg daily
4- Prednisolone 10 mg daily
 PMH:
•
RA (Dx: 1999) currently treated w/ DMARD
therapy
 Last Meal: 1800
 Events Surrounding Injury:
•
•
•
Time of injury: 2100
Mechanism of injury: Pedestrian struck crossing
intersection of busy street. Pedestrian struck on
right aspect of body. Patient rolled over hood of
taxi and fell to ground.
Estimated taxi velocity: 10 mph decelerating
 Characterization of Symptoms:
Chest pain worsening on inspiration w/
localized thorax tenderness over ribs 6-7,
visible right thorax abrasions, non
radiating pain, dyspnea
Temporal sequence
• Abrupt onset SOB (3 minutes s/p
accident).

What is your Differential
Diagnosis?
Differential Diagnosis
Based on History and Presentation





Pneumothorax
Musculoskeletal Pain
Rib Fractures
MI
Acute Pulmonary Embolism
Physical Examination
What would you look for?
Physical Examination, Mrs. Greenwich
Vital Signs:
Tc= 98.7 BP= 98/60 HR=115 RR= 26 Sat 89% RA
 PRIMARY SURVEY:
• AIRWAY:
−
−
−
−
No altered mental status
No airway obstruction noted
No maxillofacial fractures noted
Gag reflex intact
• BREATHING:
− Tachypnea; RR=26
− Decreased breath sounds and hyper
resonance over the entire R lung field
− tracheal deviation to the L of midline 
− poor respiratory excursion
− no flail movement of chest wall
− local tenderness over R flank at ribs 6-7
− chest wall asymmetry
− notable JVD 8cm above the sternal
angle
• CIRCULATION:
‾ No obvious signs of gross
‾
‾
‾
hemorrhage
Hypotensive; BP= 98/60;
MAP= 72.67 (1/3 systolic + 2/3
diastolic)
Tachycardia; HR=115
cold/moist extremities w/
decreased pulse pressure
capillary refill >5 sec
‾
SECONDARY SURVEY:
• NOT ASSESSED AT THIS
TIME – IMMEDIATE
INTERVENTION
NECESSARY
Would you like to revise your
Differential Diagnosis?
Revised Differential
 Tension Pneumothorax
 Rib Fractures
Laboratory
What would you obtain?
Laboratory
 NO LAB STUDIES AT THIS TIME
IMMEDIATE INTERVENTION
NECESSARY
 See Discussion Section for expected labs
Interventions at this point?
Interventions at this point
 Supplemental O2
 Decompression Needle Thoracostomy
Needle Thoracostomy, Discussion

Procedure
1.
2.
3.
4.
5.
6.
7.
Use a large bore needle w/ catheter (14-16 gauge)
Identify 2nd intercostal space at midclavicular line (1-2 cm lateral to the
sternal angle). This will minimize likelihood of IMA injury
Prepare area with Betadine
Insert needle directly superior to the 3rd rib. This prevents injury to
neurovascular bundle located on the inferior aspect of each rib.
Insert needle perpendicular to the chest wall, approximately 3-6 cm in
depth
Stop advancement of needle upon hearing opening hiss/pressure release
of pleural space.
Remove needle; leave catheter in place
What next?
What next?

Tube Thoracostomy
1.
2.
3.
4.
5.
6.
7.
8.
Identify and prepare the area w/ Betadine at ICS 4 or 5 along the mid-axillary
or anterior axillary line
Anesthetize the area (subcutaneous tissue, intercostal muscles) with Lidocaine.
Some physicians use opioid analgesia or a combination of an opioid + Benzo.
Make a 2 cm incision
Insert a large blunt clamp over superior aspect of rib (preventing damage to the
neurovascular bundle that lies on the inferior border of the rib). Apply gentle
pressure until the parietal pleura is pierced.
Open clamp to establish a tract for the chest tube.
Bluntly dissect w/ finger.
Clamp proximal end of tube tangentially w/ Clamp. Insert tube over superior
aspect of rib into pleural space.
Insert the chest tube past the last hole. Note the last hole disrupts the continuity
of the radiopaque line—this facilitates radiographic placement confirmation.
Suture chest tube w/ Silk sutures.
What next?
What next?
 Portable Chest X-Ray
(confirm chest tube placement)
Management
All patient’s with tension pneumothorax
must be admitted to an inpatient
service.
What should be done next?
Management
 Monitor patient continuously with arterial O2 saturation—
watch for sudden desaturations
 F/U CXR may be ordered to assess re-expansion of lung and
resolution of pneumothorax. Important: re-expansion
pulmonary edema may occur with rapid lung re-expansion s/p
tube thoracostomy. This is a potential life threatening situation
which can lead to cardiovascular collapse.
 Keep chest tube on water seal. Chest tube may be removed
when indication for placing it has resolved. F/U CXR must be
ordered immediately s/p chest tube removal and 24 hrs postremoval to assess for presence of a reoccurring pneumothorax.
Discussion
Etiology of Tension Pneumothorax
 Trauma (blunt or penetrating): disruption of the parietal or visceral
pleura.
 Fractures: most prevalent as a result of rib fractures, however also
seen in displaced thoracic spine fractures.
 Barotrauma: ventilator dependent patients on large volume PEEP
may rupture peripheral alveoli sacs secondarily disrupting the
visceral pleura. Index of suspicion is raised when larger peak airway
pressures are needed to achieve a specific tidal volume.
 Iatrogenic: secondary to trauma induced by
 Bronchoscopy
 Chest compressions during CPR
 Central venous catheter placement
 Conversion of Simple Pneumothorax -> Tension Pneumothorax
Discussion
Pathophysiology of Simple Pneumothorax
Air enters the pleural space during inspiration. The pleural space increases in volume
thus compressing the ipsilateral lung. The ipsilateral lung collapses. During expiration
intrathoracic pressure increases, the diaphragm relaxes, and air is pushed out of the
pleural space. Note mediastinal structures remain relatively fixed.
Discussion
Pathophysiology of Tension Pneumothorax
Disruption of the lung parenchyma or parietal pleura acts like a one
way valve. During inspiration air is drawn into the pleural space.
During expiration the tissue flap/valve prevents air from escaping.
Subsequent inspirations additively draw more air into the pleural
space. Increasing intrapleural pressures result in collapse of ipsilateral
lung and deviation of mediastinal structures contralaterally
Discussion
Complications:
 Cardiovascular Collapse: the implications of a tension
pneumothorax are profound. Displacement of mediastinal
structures contralaterally causes kinking of the SVC and
IVC. Venous return to the heart is severely compromised
resulting in decreased cardiac output. Shock and
hypoperfusion ensue.
Lab Results, Mrs. Greenwich
If Lab Tests were ordered at presentation the following are
expected:
ABG:
7.32/50/60/24/ 89 % RA
138
102 18
Chem 7
Cardiac Enzymes:
110
3.7
25
TnI: 0
TnT: 0
CKMB: 1.2
1.2
Lab Results, Discussion
 ABGs: Often seen in tension pneumothorax is a varying
degree of acidemia, hypercarbia, and hypoxia. Note in acute
respiratory acidosis increases in PaCO2 by 10mmHg will
decrease pH by 0.08 (i.e. PaCO2 40->50 lowers pH 7.4>7.32). The reduction in PaO2 is caused by alveolar
hypoperfusion secondary to atelectasis, low
ventilation/perfusion ratios, and anatomic shunts.
 Chem 7: Principally used for the CO2 value. More
accurate for calculations of compensated respiratory
acidosis than HCO3- values in ABGs which represents an
average of computed PaCO2 levels.
 Cardiac Enzymes: necessary to r/o acute MI and
resulting cardiogenic shock, must have serial reading to
accurately r/o acute MI
Discussion
 If CXR was ordered at presentation the
following are expected:
Tension Pneumothorax Left
Subpulmonic Pneumothorax Right
SQ AIR
Pulmonary
Contusion
Deep Chest Tube
Persistant
Subpulmonic
Pneumothorax
May not see mediastinal shift if pneumothorax is bilateral!
Discussion
 Do not delay treatment of a Tension Pneumothorax. CXR can be taken for
confirmatory measures after decompression needle thoracostomy or tube
thoracostomy. The diagnosis of a Tension pneumothorax is made clinically
when one has a high index of suspicion.
 Findings on CXR:
 Large radiodense lung field
 Absent lung markings on ipsilateral side
 Contralateral deviation of trachea and mediastinal structures
 If tension pneumothorax involves left lung the left hemidiaphragm may
be depressed/flattened. The liver prevents this radiographic finding on the
right side
QUESTIONS ??????
Summary
 Tension Peumothorax is a life threatening condition which
may quickly lead to cardiovascular collapse and shock.
 Immediate intervention must be initiated if there is a high
clinical suspicion of a tension pneumothorax.
 Intervention includes decompression needle thoracostomy
followed by chest tube thoracostomy, followed by a portable
chest x-ray to confirm tube placement and re-expansion of
collapsed lung fields.
 Laboratory and diagnostics may confirm the diagnosis of a
tension pneumothorax (i.e. ABG, CXR) however the diagnosis
lies predominantly on clinical presenting symptoms.
References
 Check out these sites
• Needle Thoracostomy photo courtesy of
http://www.biodigital.org/voz2/slide8.htm
• Tube Thoracostomy photos courtesy of http://www.vesalius.com
• CXR w/ 2 Chest Tubes photo courtesy of
http://www.trauma.org/imagebank/chest/images/chest0037.html
• Pathophysiology of Pneumothorax photos courtesy of
http://home.ewha.ac.kr/~chestsg/dong/poster/99/2.htm
• CXR of tension pneumothorax courtesy of
http://www.emedicine.com/med/topic2793.htm
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