Today, a topic about which you may already believe you know all you need to know–chances are you don't. What we were taught about tension pneumo by textbooks and trauma courses may not be right. To discuss tension pneumothorax, there is no better guest than…
Dr. Simon Leigh-Smith
Consultant in Emergency Medicine, Defence Medical Services & NHS Lothian, Surgeon Commander Royal Navy, Clinical Lead for Pre-Hospital Care and Medic 1
Simon graduated from Liverpool in 1990 and had a varied training / experience including Commando, Para, GP, Emergency Medicine and Pre-Hospital/Retrieval before Consultant appointment in 2006. He has worked in Liverpool, Plymouth, Edinburgh, Portsmouth, London, Sydney, Kuwait, Iraq, Belize, Norway, Antarctic, South Atlantic, Iraq and Afghanistan. He has a strong interest in Tension Pneumothorax, Human Factors in team working and the delivery of excellent pre-hospital care to major trauma and critical illness. He loves all the usual ‘adventure sports’ but after he sailed around Cape Horn his wife and 2 daughters were glad to hear that he no longer wanted to sail around the world! He tries to exercise his Hungarian Vizsla (dog) whilst mountain biking but often feels guilty leaving her behind to go for long road rides…..
Tension Pneumothorax is 2 Diseases rather than 1
Awake/Spontaneously Breathing Patients
- Purely hypoxemic
- No hypotension until just before collapse
- May have long periods of compensation (though can also progress in minutes)
Ventilated Patients
- Sudden, both resp and cardiovascular disease
- Will be hypoxemic and hypotensive
Classic Signs are Rubbish
- Tracheal deviation is unreliable
- Breath Sounds are unreliable
- Chest wall observation signs are variable
- Need to go with clinical suspicion or ultrasound, radiograph, or empiric decompression
More on the Perils of Needle Decompression
A Countervailing View
Simon's Publications
- Clinical Presentation of Patients With Tension Pneumothorax: A Systematic Review1
- Tension pneumothorax – time for a re-think.
- Slides from Full Lecture
Additional Reading and Info
- Pulmonary Artery Pressures with Tension
- Decreased cardiac index as an indicator of tension pneumothorax in the ventilated patient
Additional New Information
More on EMCrit
Podcast 62 – Needle vs. Knife II: Needle Thoracostomy?(Opens in a new browser tab)
Additional Resources
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This seems to put to rest the concept that a spontaneously breathing patient cannot tension! This is critically important for providers who deal with non intubated thoracic trauma patients. This does create a bit of a challenge for the prehospital provider with limited ability to determine the presence of pneumothorax. While “when in doubt, decompress” sounds good. We do need to pay attention to downstream complications of the inappropriate decompression.
Love this post & looking forwards to more. The concept of finger thoracotomy is hugely important and still not widely adopted among many critical care staff for management of arresting or peri-arrest patient with probable/definite PTX. I daresay there is a third form of pneumothorax which is a PTX in a patient on APRV. This is rare (because APRV is pretty gentle and causes a relatively low risk of PTX). However, I’ve seen a couple and this seems to behave in an entirely different fashion than patients on standard volume-cycled ventilation. I’m going to research this some more and probably… Read more »
What would we expect the CO2 do as they progress through compensation and then decompensation? I would expect initially with an increasing RR the CO2 would fall, but as they decompensate and O2% falls the CO2 would start to climb. Does that make sense or what actually happens?