Review Question - QID 104157

This patient has a history of COPD (dilated/distended lungs) and is being mechanically ventilated with sudden hemodynamic compromise and JVD suggesting a diagnosis of a tension pneumothorax. A tension pneumothorax should first be stabilized with a needle thoracostomy.

A pneumothorax is considered to cause tension when intrathoracic pressure becomes high enough to compress the lung and mediastinal structures to a degree that causes clinically signficant changes in oxygenation and cardiac function. Causes of a tension pneumothorax vary from mechanical ventilation/barotrauma to other forms of thoracic trauma. Clinically, patients will present with tachycardia, tachypnea, and hypotension secondary to decreased venous return (preload), which results from increased intrathoracic pressure. Physical exam may show distended neck veins, tracheal shift away from the pneumothorax, decreased breath sounds on the affected side, and hyperresonance to percussion. High suspicion for pneumothorax in an unstable patient in the appropriate clinical setting warrants decompression of the pleural space with needle thoracostomy since progression to cardiovascular collapse can be fatal.

Incorrect Answers:
Answer 1: Chest radiograph would be performed in the management of a tension pneumothorax after needle decompression and tube thoracostomy has been performed.

Answer 2: FAST exam would be the best initial step in management for a suspected pericardial effusion causing tamponade which would present with hypotension, tachycardia, JVD, muffled heart sounds, electrical alternans, and bilateral breath sounds. This patient most likely has a tension pneumothorax given his history of COPD and mechanical ventilation. While it is true that a FAST exam can look for lung sliding, immediate stabilization with needle throacostomy is indicated to stabilize the patient.

Answer 4: Thoracotomy is an aggressive procedure where the chest is opened and the pericardium is incised to relieve tamponade, the heart is compressed with manual cardiac massage, and the aorta is clamped if there is significant hemorrhage.

Answer 5: Tube thoracostomy would be performed after needle decompression in a tension pneumothorax or as the best initial step in management for a spontaneous pneumothorax.

Bullet Summary:
The best initial step in management for a tension pneumothorax is needle thoracostomy.