Patients at risk:
(1) trauma to the chest, blast injury
(2) after subclavian vein catheter insertion
(3) intermittent positive pressure ventilation in a patient with a simple pneumothorax
Clinical findings:
(1) dyspnea, tachypnea and respiratory distress
(2) distended neck veins, tachycardia, hypotension, unconsciousness and/or cardiac arrest
(3) deviation of the trachea, away from the affected side
(4) hyper-resonance to percussion over the affected hemithorax
(5) decreased to absent breath sounds over the affected hemithorax
(6) increase in inflation pressure for patients receiving intermittent positive pressure ventilation
(7) chest X-ray shows a pneumothorax with deviation of mediastinal structures away from the affected side
Management: This should not be delayed to wait for imaging studies.
(1) Start supplemental oxygen by facial mask.
(2) Insert a 16 gauge IV vascular catheter in the second intercostal space in the midclavicular line just above the third rib.
(3) If a tension pneumothorax is present, there should be an escape of gas through the catheter and there should be improvement in the patient's clinical findings.
(4) If a tension pneumothorax is demonstrated, insert a chest tube on the affected side.
(5) Obtain an upright chest X-ray to visualize tube placement and look for fluid accumulation.
Problematic areas:
(1) Bilateral tension pneumothorax may not result in tracheal deviation.
(2) The presence of hemothorax may reduce resonance over the affected hemithorax.
