This article was originally posted Jan. 17, 2011. It has been updated to include additional information and resources as well as a video.
Tension pneumothorax is a life-threatening condition that requires rapid recognition and treatment in the prehospital setting. Treatment may include thoracic decompression, often called needle thoracostomy or needle decompression. EMS providers must understand when needle decompression is indicated and how to accurately locate the correct needle decompression site to relieve pressure and restore ventilation. This is particularly true for combat and tactical team medics who are working in tactical environments and may often encounter thoracic trauma.
Any open chest wound has a high probability of developing a tension pneumothorax. EMS providers need to be keenly aware of the signs, symptoms and treatment of a tension pneumothorax. Prompt identification of and intervention for tension pneuomothorax are critical to prevent patient deterioration and death.
|More: The basics of thoracic trauma: It’s all about airflow and pressure
Tension pneumothorax: Injury overview
A pneumothorax means air in the chest cavity. This occurs when air, either from the lungs or outside the body, enters the pleural space that is normally occupied by the lung. It is called a closed pneumothorax when the chest wall is intact. With an intact chest wall, a pneumothorax can be caused by several things, but the most frequently encountered cause is from trauma resulting in a rib fracture that punctures a lung, releasing air into the pleural space. The signs and symptoms for a closed pneumothorax are:
- Chest pain
- Tachypnea
- Dyspnea
Normally, a closed pneumothorax is not a life-threatening condition unless it progresses into a tension pneumothorax.
An open pneumothorax occurs when there is an opening in the chest wall, which can be the result of penetrating trauma such as a gunshot wound or stabbing. This opening allows air to move from the outside of the body, through the opening in the chest wall, and directly into the pleural space. The larger the hole, or holes, in the chest wall, the greater the amount of air that can enter the pleural space.
Remember, the opening can also be on the patient’s back in the case of an entry or exit wound. The provider needs to check both the front, back, and sides of the patient for penetrating trauma. Additionally, if the patient is wearing body armor, it is important to check for atypical entry and exit sites that may occur from deflections due to the armor. The signs and symptoms are similar to a closed pneumothorax with the addition of sucking or gurgling sounds that may occur over the opening.
Tension pneumothorax symptoms
A tension pneumothorax occurs when the patient cannot compensate, and several events begin to occur that can lead to death. As air fills the pleural space on inspiration through the opening with an open pneumothorax, the wound can act as a one-way valve and not allow the air to exit. This leads to a cascading effect on the patient.
As more air enters the pleural space, the pressure in the space increases and begins to collapse the lung on the injured side. As the injured lung collapses, there is less air that can be exchanged for perfusion in the lung. Once the lung has collapsed, pressure begins to compress the heart, shifting the mediastinum toward the uninjured lung. This triad of a collapsing lung, shift in the mediastinum, and rebreathing is the beginning of a rapid deterioration of a patient’s ability to maintain oxygenation.
As this continues, the compression of the vena cava reduces cardiac blood flow to the heart and decreasing cardiac output. This leads to difficulty breathing and tachycardia. A noticeable shift in the trachea will be evident. This entire process leads to a life-threatening condition known as a “tension pneumothorax.” The patient in this condition will die if treatment is not provided.
How to treat a tension pneumothorax
For an open pneumothorax, treatment requires sealing the open wound with an occlusive dressing. This is often taught by using Vaseline gauze and securing the gauze to the patient’s chest with tape. However, this can be a difficult process in the field depending on the size of the wound, the patient’s condition, and the area the dressing is applied.
Often the area is hairy, bloody and dirty, which can be factors in keeping the occlusive dressing intact. There are dressings that are manufactured specifically for chest wounds. These dressings have an aggressive and very sticky adhesive, which ensures a secure seal to the chest. Some of these dressings are available in larger sizes to fit a greater amount of surface area and others have a one-valve, with the idea that trapped air can vent from the pleural space. Commercial dressings for open chest trauma have been used with great success by both military and tactical medics, and should be part of a medic’s standard supply.
With an open chest wound that is covered, the patient may often still deteriorate and have a tension pneumothorax. This happens when air is leaking from a damaged lung continuing to fill the pleural space with air that cannot escape. When the patient’s condition is deteriorating, some paramedic programs teach that it may be possible to lift the dressing from the wound allowing trapped air to escape, or even gently spread the wound to help air escape. The wound is then resealed after such a procedure.
What is needle decompression?
If this does not relieve the trapped air, the next step is a thoracic decompression, often called needle thoracostomy or needle decompression. This involves using a needle catheter to release the trapped air in the pleural space. If the patient has either a closed or open tension pneumothorax, then the need for a needle decompression is required to save the patient.
A needle decompression involves inserting a large bore needle in the second intercostal space, at the midclavicular line. This reduces intrathoracic pressure, allowing the lung to re-expand and restoring adequate ventilation and circulation.
Where should the needle be inserted for proper needle decompression?
The preferred needle decompression site is the second intercostal space at the midclavicular line on the affected side. Correct site selection is essential to avoid injury to underlying structures and ensure effective decompression.
How do you know if needle decompression is helpful?
Signs that needle decompression is effective include improved breath sounds, decreased respiratory distress, improved oxygen saturation, and stabilization of vital signs. Providers may also hear a rush of air when the needle is inserted, confirming release of trapped pressure.
What equipment does a paramedic need for needle decompression?
It is important to have the proper equipment on hand to successfully perform a needle decompression.
A 14-gauge needle is recommended — 8-cm needles are more successful than 5-cm but may increase risk of injury to underlying structures. Longer needles may be required in patients with significant chest wall thickness.
If using a needle catheter with a flash chamber, you should ensure that the chamber is removed. There are specially manufactured needles designed just for a tension pneumothorax. These are prepackaged 3.25-inch 14 gauge needles that do not have flash chambers. The removal of the chamber ensures that in a high-stress situation, the provider will not have to remember to remove it. It has been reported that often the provider will forget to remove the flash chamber, and this will cause the procedure to fail.
How to perform a needle decompression for a tension pneumothorax
A needle decompression should only be performed if the patient has a tension pneumothorax. When inserting the needle, it should be inserted at a 90-degree angle to the chest wall. This is a critical point as this will position the needle straight into the pleural space. If any other angle is used, there may be a chance of hitting other structures in the area such as major blood vessels or even the heart.
The following are steps to perform a chest decompression. However, you should follow your own protocols.
- Ensure patient is oxygenated if possible
- Select proper site; affected side at the second intercostal space and along the mid-clavicular line. Note: Draw an imaginary line from the nipple up to the clavicle. The needle should not be closer to the middle of the chest than this line
- Clean site with alcohol or povidone solution
- Prepare needle; if it has a leur-lock or flash chamber, it will need to be removed
- Insert the needle into the second intercostal space at a 90-degree angle to the chest, just over the third rib. Note: There are blood vessels running along the bottom of the ribs. Ensure the needle is closer to the top margin of the lower rib in the intercostal space. This will prevent these vessels from being damaged
- Listen for a rush of exiting air from the needle
- Remove the needle and leave the catheter in place, properly disposing of the needle
- Secure the catheter in place with tape. Some suggest covering the end of the catheter, but this will depend on the situation
- Ensure the tension has been relieved and the patient’s condition improves. If there is no improvement, the procedure will need to be repeated with another needle placed adjacent to the first needle
- Monitor, then reassess the patient
A tension pneumothorax is a life-threatening situation. It may present with either a closed or open chest injury. The medical provider needs to be keenly aware that there is a high probability of a tension pneumothorax if the patient has an open trauma to the chest wall. Good assessment skills, proper equipment, and the training to effectively relieve a tension pneumothorax are vital to save patients from this critical condition.
References
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- Britten S, Palmer SH. Chest wall thickness may limit adequate drainage of tension pneumothorax by needle thoracentesis. J Accid Emerg Med. 1996; 13:426–7.
- Bellamy RF: “The causes of death in conventional land warfare: Implications for combat casualty care research.” Military Medicine.149(2):55–62, 1984.
- Eckstein M, Suyehara D. Needle thoracostomy in the prehospital setting. Prehosp Emerg Care. 1998; 2:132–5
- Holcomb JB, McMullin NR, Pearse L: “Causes of death in U.S. Special Operations Forces in the global war on terrorism 2001–2004.” Annals of Surgery. 245(6):986–991, 2007.
- Ludwig J, Kienzle GD. Pneumothorax in a large autopsy population. Am J Clin Path. 1978;24 –26.
- McPherson JJ , Feigin DS, and Bellamy RF. Prevalence of Tension Pneumothorax in Fatally Wounded Combat Casualties. J Trauma. 2006;60:573–578.
- Memorandum. Department of the Army, Office of the Surgeon General. Management of Soldiers with Tension Pneumothorax. 2006.
- Wound Data and Munitions Effectiveness Team (WDMET) study prepared by the Army Material Command, stored at the National Naval Medical Center, Bethesda MD, Access controlled by the Uniformed Services University of the Health Sciences, Bethesda, MD.
