Emergency Care Essentials: Recognition and Emergency Management of
Date: June 11, 2002
by: Kevin High, RN, MPH, EMT
Pneumothorax is one of the more common injuries seen in trauma patients. Its
treatment is simple and straightforward; however a clinician must first be
able to recognize it. Failure to do so may result in the development of a
tension pneumothorax; and rapidly deteriorate into a life threatening
emergency. In this article we will look at simple pneumothorax and tension
pneumothorax and review their management and treatment.
Pneumothorax refers to an accumulation or collection of air in the pleural
space resulting in a partial or complete collapse of the affected lung. Most
often the lung tissue is actually lacerated resulting in an air leak. This
is referred to as a simple pneumothorax.
An open pneumothorax or "sucking chest wound" occurs when an opening in
the chest wall (usually from a penetrating object) allows air to move
through the chest wall instead of the trachea. The wound usually has to be
at least 2/3 the size of the trachea for this to occur. Air may move in and
out via the wound or a one way valve effect can occur thus trapping the air
inside the thoracic cavity.
A hemothorax is free blood in the pleural space that results from
bleeding lung tissue or blood vessel injury. A hemothorax may result in both
hypoxia and shock.
A tension pneumothorax is created when the air within the pleural space
cannot escape and completely collapses the affected lung. As this pocket of
air increases the lung collapses further, and the mediastinum and its
contents are displaced to the opposite side. For a simple pneumothorax to
progress to a tension pneumothorax a "one way valve" must exist ie: air is
not allowed to escape but increase in volume within the pleural space. This
volume of trapped air increases with each ventilation thus rapidly filling
the affected hemithorax. This air is under "tension" and cannot escape due
to the one way valve effect. The mediastinum shifts to the unaffected side
causing compression or torsion of the great vessels and inadequate
ventilation of the unaffected lung. The patient may present with dyspnea and
rapidly progress to cardiovascular collapse/arrest.
Tension pneumothorax is a life threatening emergency and lethal if not
recognized and definitively treated.
The most common etiologies are related to trauma
- Trauma (blunt or penetrating) - Involves disruption of the pleura and
often is associated with rib fractures (rib fractures not necessary for
tension pneumothorax to occur)
- Barotrauma secondary to positive-pressure ventilation, especially when
using high amounts of positive end-expiratory pressure (PEEP)
- Central line placement, usually subclavian or internal jugular
- Conversion of simple pneumothorax to tension pneumothorax
- Unsuccessful attempts to convert an open pneumothorax to a simple
pneumothorax in which the occlusive dressing functions as a 1-way valve
The following assessment focuses on recognition of pneumothorax/tension
1. Look at the patient. Do they appear in distress? Sick or not sick?
Are they dying in front of your eyes? Do they appear short of breath? (if
you have to ask they are probably not that short of breath)
2. Observe their thorax for any abnormalities (abrasions, wounds,
ecchymosis, etc) Do they have symmetrical chest wall movement? Don't
forget their back!
3. Auscultate breath sounds. Listen at the midaxillary line just below the
axilla, the apices and if possible the patient's back. Do you hear equal
bilateral breath sounds? If not are they diminished? On what side?
4. Palpate the patient's thorax. Feel for subcutaneous emphysema,
tenderness, or other abnormalities. If possible percuss the patient's
chest (not always practical or feasible in the prehospital environment)
An Important Note on Interpretation of Clinical
tension pneumothorax is made on your assessment findings. The accuracy
of your assessment skills cannot be underemphasized here. DO NOT allow
yourself to become overly focused on the absence or presence of one or
more classic sign/symptom i.e.; a deviated trachea, distended neck
veins. If you discount something you are seeing or not seeing and do
not definitely treat the patient they may deteriorate rapidly into
Pertinent Assessment Findings
- Shortness of breath/dyspnea/air hunger
- Chest pain
- Open wounds/ecchymosis/abrasions/contusions/SQ air
- Tachycardia/Falling oxygen saturations
- Hyperessonance on the affected side
- Diminished/absent breath sounds on the affected side
- Altered mental status
- Deviated trachea to the contralateral side
- Distended neck veins (may or may not be present)
Conditions that may mimic Pneumothorax/Tension Pneumothorax
- Pulmonary Contusion-diminished breath sounds, dyspnea, hypoxia
- Multiple Rib Fractures- diminished breath sounds, dyspnea, chest pain
- Post Pnuemonectomy-diminished breath sounds
Your assessment needs to be rapid, but thorough and conducted with a high
index of suspicion. The intubated/ventilated patient
As with everything in emergency medicine we begin and end with the ABC's.
Securing the patients ABC's is paramount. Approach all patients with the
same assessment/treatment strategy. All patients with suspected or actual
pneumothoraces should be given 100% oxygen via non-rebreather mask. The
following patients should be considered candidates for intubation:
- GCS <8/Inability to protect their airway
- Hypoxia, respiratory distress, dyspnea, hypoventilation
- Multisystem instability (hemodynamically unstable/hypoxic/altered
During your assessment/treatment phase of airway/breathing a suspected
tension pneumothorax would be addressed (more on this later). After securing
the airway and breathing, initiate (2) large bore IV's and continue on with
the standard trauma treatment algorithm.
Treatment is supportive in nature with emphasis on reassessment for
deterioration. Monitor the patient's oxygenation status closely.
Treatment is straightforward and should be supportive. Observe the wound
closely. Look for bubbles and feel for subcutaneous emphysema (SQ air)
around the wound. The wound should be covered with a dressing that is
occlusive and non-porous. The dressing should be taped on three sides thus
allowing air to escape from the pleural cavity but not reenter. There are
many different "field expedient" ways to manufacture such a dressing using
plastic wrapping, tape, etc. However, a few commercial devices such as the
Asherman Chest Seal are available on the market. They are prepackaged and
ready to go. The Asherman device works particularly well. It is used in both
military and civilian applications with good results.
Making the diagnosis is much harder than the treatment. The treatment
hinges on getting the air that is under tension out of the pleural cavity.
This is best accomplished via tube thoracostomy (chest tube) but a needle
thoracostomy is faster and more expedient.
The goal of needle throacostomy is to introduce a needle into the pleural
cavity thus relieving the trapped air. The needle will temporarily halt the
rising intrathoracic pressure and stop the impingement on the pulmonary and
Emergency Needle Decompression
Suspicion of a
tension pneumothorax accompanied with alterations in ventilation or
perfusion mandates immediate needle decompression.
Indications for Chest Needle Decompression/Needle Thoracostomy
Diminished/Absent breath Sounds with any of the following:
- Significant dyspnea/shortness of breath
- Falling/Low oxygen saturations <90%
- Altered mental status
- Signs/Symptoms of shock (tachycardia, hypotension)
Chest Needle Decompression/The Procedure
- Gather Equipment-A large (14 gauge or larger) angiocath works
well. It is imperative that you use at least a 2-2 ¼" needle. For the
procedure to be effective you must be able to puncture into the pleural
cavity. Some patients may have a thick (2-3cm) chest wall. You must use a
needle with an adequate length. There are several commercial devices on
the market that are specifically designed for needle thoracostomy. Most
include a flutter valve or one-way valve device on them. These valves act
to allow air to escape but not reenter the pleural cavity. A finger cut
from a latex glove or a condom works also. Using a flutter valve on the
needle is not as imperative as using a long enough needle. The likelihood
of enough air reentering via the needle to really effect the patient is
- Identify Landmarks-You may use the 2nd intracostal (ICS) space
at the midclavicular line or the 5th-6th ICS at the midaxillary line to
perform the procedure. Take care to note the proper site and landmarks.
The 5th ICS is roughly the nipple line. Pick your site and clean the area
with alcohol or betadine.
- Insertion-Insert the needle on the superior aspect of the rib.
Remember that a nerve, vein and artery run on the inferior aspect. You may
puncture the skin holding the needle perpendicularly. If you hit a rib
"tunnel" slightly to puncture over the superior aspect. As the needle
enters the pleural space you should hear a hiss or rush of air as the air
under tension is released. Secure the needle or device to the chest wall
and if available attach a flutter valve. Anticipate placement of a chest
tube as soon as qualified personnel and equipment are available.
- Follow-up-Continue to monitor the patient for dyspnea, or
return/worsening of symptoms. If the patient deteriorates further consider
repeating the procedure at another site. The in situ needle or device
could have clotted off.
Simplex pneumothorax is relatively common in trauma patients however,
tension pneumothorax is even less common but much more deadly. Being able to
quickly recognize the clinical picture and having an aggressive patient care
protocol in place for managing tension pneumothorax is of the utmost
importance. Rarely are there such deleterious conditions in the trauma
patient that can be definitively treated and reversed.
Comments or feedback about this article? We'd like to
hear what you have to say. You can contact us by
1. American College of Surgeons, ATLS Student Manual, 7th Edition
2. Bjerke, H. Scott, Tension Pneumothorax, EMedicine Journal Jan 2002
3. Sheehy, Sue, Emergency Nursing: Principles and Practice, 4th edition 1998
About the Author: Kevin High has been a RN for 16 years and an EMT
for 13 years. He has an extensive background in EMS, Emergency Nursing, and
Air Medical Transport. Kevin's EMS background includes working as an ALS
provider for two 911 agencies in Tennessee and also as an adjunct faculty
member for local EMS education programs. Kevin has been a flight nurse at
Vanderbilt LifeFlight for nine years. Kevin lectures and teaches on a local,
state and national level and he has authored over 10 articles that have
appeared in journals such as Journal of Emergency Nursing, EMS Magazine, Air
Med, Air Medical Journal, and Emergency Medicine.