Tension pneumothorax

Background

• Death occurs from hypoxic respiratory arrest (V-Q mismatch), not circulatory arrest

Clinical Features

• Unilateral diminished or absent breath sounds
• Hypotensionor evidence of hypoperfusion
• Distended neck veins
  • May not occur if patient is hypovolemic
• Tracheal deviation (late sign)

Differential Diagnosis

Pneumothorax Types

• Tension pneumothorax
• Spontaneous pneumothorax
  • Catamenial pneumothorax
• Traumatic pneumothorax
  • Iatrogenic pneumothorax

Thoracic Trauma

• Airway/Pulmonary
  • Bronchial injury
  • Diaphragm injury
  • Hemothorax
  • Pulmonary contusion
  • Tracheal injury
  • Trachobronchial injury
  • Traumatic pneumothorax
    • Tension pneumothorax
• Cardiac/Vascular
  • Cardiac contusion
  • Cardiac trauma
  • Cardiac tamponade
  • Commotio cordis
    • Traumatic aortic transection
• Musculoskeletal
  • Clavicle fracture
    • Clavicle fracture (peds)
  • Flail chest
  • Rib fracture
  • Scapula fracture
  • Scapulothoracic dissociation
  • Sternoclavicular dislocation
  • Sternum fracture
• Other
  • Esophageal injury or Perforation
  • Pneumomediastinum
  • Traumatic asphyxia

Shortness of breath

Emergent

• Pulmonary
  • Airway obstruction
  • Anaphylaxis
  • Aspiration
  • Asthma
  • Cor pulmonale
  • Inhalation exposure
  • Noncardiogenic pulmonary edema
  • Pneumonia
  • Pneumocystis Pneumonia (PCP)
  • Pulmonary embolism
  • Pulmonary hypertension
  • Tension pneumothorax
  • Idiopathic pulmonary fibrosis acute exacerbation
• Cardiac
  • Cardiac tamponade
  • Cardiogenic pulmonary edema (CHF)
  • Myocardial Infarction
  • Pericarditis
• Other Associated with Normal/↑ Respiratory Effort
  • Abdominal distension
  • Anemia
  • CO Poisoning
  • Diabetic ketoacidosis (DKA)
  • Diaphragm injury
  • Electrolyte abnormalities
  • Epiglottitis
  • Flail chest
  • Hypotension
  • Metabolic acidosis
  • Pneumonia
  • Pneumothorax/hemothorax
  • Renal Failure
  • Sepsis
  • Toxic ingestion
• Other Associated with ↓ Respiratory Effort
  • Guillain-Barre syndrome
  • Multiple sclerosis
  • Myasthenia Gravis
  • Lambert-Eaton Syndrome
  • Organophosphate toxicity
  • Stroke (Main)
  • Tick paralysis

Non-Emergent

• ALS
• Ascites
• Uncorrected ASD
• Congenital heart disease
• COPD exacerbation
• Fever
• Hyperventilation
• Neoplasm
• Obesity
• Panic attack
• Pleural effusion
• Polymyositis
• Porphyria
• Pregnancy
• Rib fracture
• Spontaneous pneumothorax
• Thyroid Disease

Evaluation

Left sided tension pneumothorax with mediastinal shift

Ideally a clinical diagnosis treated emergently (without delay for studies)

• CXR
• Lung ultrasound

Management

• Immediate needle thoracostomy
  • 14ga IV in midclavicular line just above the rib at the second intercostal space
• Always followed by Chest Tube placement

Adult Chest Tube Sizes

Chest Tube Size	Type of Patient	Underlying Causes
Small (8-14 Fr)	Most spontaneous pneumothorax (primary and secondary) Most iatrogenic pneumothorax	Alveolar-pleural fistulae (small air leak) Iatrogenic air
Medium (20-28 Fr)	Pneumothorax on mechanical ventilation Non-traumatic tension pneumothorax Malignant effusion	Bronchial-pleural fistulae (large air leak) Malignant fluid
Large (36-40 Fr)	Traumatic pneumothorax Empyema	Bleeding (Hemothorax/hemopneumothorax) Thick pus

Disposition

• Admit

Special Instructions

Flying

• Can consider flying 2 weeks after full resolution of traumatic pneumothroax

See Also

• Pneumothorax (main)

References

Authors

Ross Donaldson, Daniel Ostermayer, Neil Young