Updated: 1/12/2021

Tension Pneumothorax

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Snapshot
  • A 56-year-old male with a history of chronic obstructive pulmonary disease presents with pleuritic chest pain and trouble breathing. Vital signs are significant for a blood pressure of 88/54 mmHg and a pulse of 115/min. On exam, there is jugular venous distension, decreased breath sounds on the right side, with wheezes. A chest radiograph is obtained.
 
Introduction
  • Tension pneumothorax results from positive pressure build-up secondary to a flap valve mechanism (or one-way valve) resulting in total lung collapse
    • tracheal shifting to opposite end
    • expansion of chest wall
  • Increased intrathoracic pressure restricts cardiac output
    • may result in shock and death
  • Etiologies include
    • penetrating and blunt chest trauma
    • infection
    • positive-pressure mechanical ventilation
    • iatrogenic
      • placement of central venous line 
      • epidural thoracic catheter placement
Presentation
  • Symptoms
    • acute-onset, unilateral, pleuritic chest pain
    • dyspnea/acute respiratory distress
    • syncope
  • Physical exam
    • tachypnea and tachycardia
    • unilateral decreased or absent breath sounds  
    • hyperresonance
    • decreased or absent tactile fremitus
    • falling O2 saturation
    • deviated trachea
    • JVD
    • hypotension
    • subcutaneous emphysema
Evaluation
  • Ultrasound
    • fast with no radiation exposure
    • requires a bedside ultrasound readily available
    • guidance for tube placement
  • Chest radiography (CXR)
    • do not obtain CXR if tension pneumothorax is suspected - immediately decompress the pleural space
    • best observed in end-expiratory films
      • shows unilateral absence lung parenchyma
      • and contralateral mediastinal shift
Differential
  • Primary spontaneous pneumothorax, secondary pneumothorax, acute asthma, inhalation of foreign object, myocardial infarction, ruptured aortic aneurysm
  • Tracheobronchial rupture 
    • if a recurrent pneumothorax that recurs after chest tube placement
Treatment/Management
  • Non-operative
    • do not resolve spontaneously
      • unlike small, simple pneumothoraces
    • supplemental O2 therapy
      • following operative intervention may be required
  • Operative
    • immediate needle decompression   
      • second intercostal space at the midclavicular line with 14 or 16-gauge needle
    • followed by chest tube placement   
Prognosis, Prevention, and Complications
  • Prognosis
    • shock and death will result if not immediately recognized and treated
  • Prevention
    • no preventive measures can be taken for initial insult
    • chest tube placement following needle decompression prevents recurrence
  • Complications
    • shock and death if left untreated
 

 

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(M2.PL.17.4827) A 27-year-old male presents to the emergency department after a motor vehicle collision. The patient was an unrestrained driver in a head-on collision. The patient appears intoxicated and is complaining of severe pain. He has a past medical history of cocaine, heroin, and MDMA use, and he is not currently taking any medications. His temperature is 99.5°F (37.5°C), blood pressure is 80/50 mmHg, pulse is 160/min, respirations are 15/min, and oxygen saturation is 95% on room air. An EKG is obtained as seen in Figure A. Laboratory values are ordered as below:

Serum:
Na+: 140 mEq/L
Cl-: 100 mEq/L
K+: 4.1 mEq/L
HCO3-: 24 mEq/L
BUN: 20 mg/dL
Glucose: 110 mg/dL
Creatinine: 1.1 mg/dL
Ca2+: 10.1 mg/dL

Hemoglobin: 10 g/dL
Hematocrit: 23%
Leukocyte count: 5,000 cells/mm^3 with normal differential
Platelet count: 150,000/mm^3

On physical exam the patient is notably short of breath. Cardiac exam is notable for a rapid rate and thready pulses as well as jugular venous distention (JVD). Pulmonary exam reveals unilateral breath sounds. A neurological exam is deferred due to patient non-compliance. Which of the following is the next best step in management?

QID: 109455
FIGURES:
1

IV fluids

28%

(8/29)

2

Norepinephrine

3%

(1/29)

3

Needle decompression

48%

(14/29)

4

Cardioversion

14%

(4/29)

5

Defibrillation

3%

(1/29)

M 7 D

Select Answer to see Preferred Response

(M2.PL.14.151) A 79-year-old man is admitted to the intensive care unit for hospital acquired pneumonia, a COPD flare, and acute heart failure requiring intubation and mechanical ventilation. On his first night in the intensive care unit, his temperature is 99.7°F (37.6°C), blood pressure is 107/58 mm Hg, and pulse is 150/min which is a sudden change from his previous vitals. Physical exam is notable for jugular venous distension and a rapid heart rate. Which of the following is the best next step in management for the most likely diagnosis?

QID: 104157
1

Chest radiograph

20%

(3/15)

2

FAST exam

13%

(2/15)

3

Needle thoracostomy

60%

(9/15)

4

Thoracotomy

7%

(1/15)

5

Tube thoracostomy

0%

(0/15)

M 7 E

Select Answer to see Preferred Response

Evidence (6)
EXPERT COMMENTS (12)
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