ACLS Hs & Ts – Tension Pneumothorax
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Article at a Glance
- Tension pneumothorax is one of the Hs and Ts and a reversible cause of cardiac arrest.
- It is caused by a hole in the lung, often due to PPV that allows air to escape into the thorax, compressing the vena cava and restricting blood return to the heart.
- The provider must know the signs and symptoms.
- Treatment is decompression of the pneumothorax using a needle into the chest, allowing air to escape.
- Within 15 seconds, the lung should expand, pulses should return, and the patient should improve.
Tension pneumothorax is a condition when air is trapped in the pleural cavity. A penetrating chest injury can cause tension pneumothorax. Essentially, air is leaving the lung and collecting in the pleural space. Air is trapped in the pleural space during tension pneumothorax. A hole in a lung sometimes creates a one-way valve. As air leaves the lung, it can collect in the pleural cavity but cannot return to the lung. Pressure and tension build up. The tension pushes on all the lung structures towards the middle of the body. This is a problem because the vena cava lies in the middle of the body, returning blood to the heart. Air pressure pushes on the lungs and other organs. The vena cava is circled in yellow. Remember, the pressure in the vena cava is very low. Right before the vena cava hits the heart, the blood pressure is around 5 mmHg. Keep in mind, there’s no delineation between systolic or diastolic at this point. The pressure pushing on the vena cava may completely compress it, obstructing the blood returning to the heart. Fatalities from tension pneumothorax occur when the pressure builds up, compresses the vena cava, and blocks the blood returning to the heart.Definition and Physiology
Related Video – What is Pneumothorax?
Treatment
To treat tension pneumothorax, you have to decompress the chest. Create an opening to let the pressure escape and relieve the vena cava. Use a large 3-inch, 12-gauge needle.
Attempt for the second intercostal space, over the third rib. First, start midclavicular at the clavicle. Go down to the first rib. You can’t feel the first rib if you push down, as the first one you can appreciate is the second rib. From this rib, go down and find the third rib. Place the needle right over the top of that third rib at the midclavicular. Hopefully, the opening from the needle decompresses the chest.
The insertion site for pleural decompression is midclavicular above the third rib.
If the environment isn’t too noisy, you may hear the sound of air rushing out of the chest.
You’ll know the procedure was effective if the patient’s pulse quickly returns, usually within 10 or 15 seconds. You should expect to get a pulse back within 30 seconds at most. If not, the procedure was ineffective.
At this stage, insert another needle half a centimeter to the right or left, but still over the third rib. Repeat as necessary. It’s not uncommon to see patients come in with three or four needles on both sides to achieve decompression.
Physicians may need to insert several needles into the patient.
Make sure you are going over the top of the rib and not into the rib. Looking at the X-ray below, you can see where the needle was caught on a rib. When you insert the needle over the rib, there should be no resistance. You shouldn’t hit bone. Make sure to go over the top of the rib as the bottom contains nerves and blood vessels.
In this X-ray, the needle is kinked at the bone. Aim for the intercostal space, not the bone.
Read: Reversible Causes of Cardiac Arrest: Hs and Ts
Physicians aim above the rib to treat tension pneumothorax, avoiding blood vessels and nerves.
To find plural decompression landmarks, another avenue is to start at the sternomanubrial joint where the sternum meets the manubrium. Start here and navigate laterally to the midclavicular area. You should be right over the top of the third rib.
Another technique for locating the insertion site is to start at the sternomanubrial joint, which is marked by a white circle.
Who Does It Affect?
During spontaneous pneumothorax, otherwise known as simple pneumothorax, air comes out of the lung into the pleural space but is allowed back into the lung, so it never builds up any tension. These patients tend to be tall, thin, high school-aged, and male.
Most decompressions have one commonality: positive pressure ventilation. If your patient is intubated, they are at risk of developing tension pneumothorax.
Related Video – Tips for Bagging
For instance, a patient of mine in a helicopter developed a spontaneous tension pneumothorax right before we departed. All of a sudden, the high pressure alarm went off on the ventilator. I took the patient off the ventilator and went to bag him, but I couldn’t didn’t get any air into him. I listened to one side and determined the patient had absent lung sounds.
We proceeded with immediate plural decompression. I had a needle in my pocket, so I pulled it out, decompressed the patient, and after a few breaths, the patient became more compliant.
Signs and Symptoms
The following are some signs and symptoms of tension pneumothorax:
- Profound dyspnea: difficulty breathing
- Tachypnea: rapid breathing
- Hypotension
- Tracheal deviation: this is rare
The trachea’s position shifts when a tracheal deviation is present.
Summary
Tension pneumothorax occurs when air is present in the pleural cavity which builds up pressure and compresses the vena cava, blocking blood returning to the heart. Physicians treat it by decompressing the chest with a 3 inch, 12 gauge needle inserted above the third rib to relieve pressure. The symptoms of tension pneumothorax are dyspnea, tachypnea, hypotension, jugular vein distension, and tracheal deviation.
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