In tension pneumothorax, air enters the pleural space with each breath and cannot escape, so pressure collapses the lung and pushes on the heart and great veins. Blood return to the heart falls and the patient can go into shock and arrest within minutes, so treatment comes before imaging.
Key symptoms
- Sudden severe shortness of breath
- Sharp chest pain on one side
- Anxiety, restlessness and sweating
- Confusion or collapse as shock develops
What you find on exam
- Absent breath sounds and hyperresonance on the affected side
- Fast heart rate, low blood pressure and low oxygen saturation
- Distended neck veins; tracheal shift away is a late sign
- Rising airway pressures in a ventilated patient
Tests
- Clinical diagnosis; do not wait for an X-ray
- Bedside ultrasound: no lung sliding
- Chest X-ray after decompression to check that the lung re-expands
Treatment basics
- High-flow oxygen
- Needle decompression at the 4th or 5th intercostal space, anterior axillary line, or the 2nd space, midclavicular line
- Finger thoracostomy by trained clinicians
- Chest tube placement after decompression
- Watch for recurrence and a blocked or kinked needle
Red flags
- Falling systolic blood pressure or loss of pulse
- Oxygen saturation dropping despite oxygen
- Worsening after starting positive-pressure ventilation
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Sources: NCCPA PANCE Content Blueprint; NREMT psychomotor skill sheets (EMT and Paramedic); NASEMSO National Model EMS Clinical Guidelines. Written by Making Synapses. Making Synapses is not affiliated with these organizations.