Tension pneumothorax - Revision history

Danbot: Strip excess bold text - keep only critical safety emphasis

2026-03-22T09:23:05Z

Strip excess bold text - keep only critical safety emphasis

← Revisión anterior		Revisión del 09:23 22 mar 2026
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	*Air enters on inspiration but cannot escape on expiration		*Air enters on inspiration but cannot escape on expiration
	*Causes mediastinal shift, decreased venous return, and cardiovascular collapse		*Causes mediastinal shift, decreased venous return, and cardiovascular collapse
	*A ~~'''~~clinical diagnosis~~'''~~ — treatment should NOT be delayed for imaging<ref name="roberts">Roberts DJ, et al. Clinical presentation of patients with tension pneumothorax. ''Ann Surg''. 2015;261(6):1068-1078. PMID 25563886.</ref>		*A clinical diagnosis — treatment should NOT be delayed for imaging<ref name="roberts">Roberts DJ, et al. Clinical presentation of patients with tension pneumothorax. ''Ann Surg''. 2015;261(6):1068-1078. PMID 25563886.</ref>
	*Most common in [[Trauma\|trauma]], positive pressure ventilation, and after procedures (central line, thoracentesis)		*Most common in [[Trauma\|trauma]], positive pressure ventilation, and after procedures (central line, thoracentesis)

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	==Clinical Features==		==Clinical Features==
	*~~'''~~Hypotension~~'''~~ and ~~'''~~tachycardia~~'''~~ (most sensitive findings)		*Hypotension and tachycardia (most sensitive findings)
	*Respiratory distress, [[tachypnea]], [[Hypoxia\|hypoxia]]		*Respiratory distress, [[tachypnea]], [[Hypoxia\|hypoxia]]
	*Decreased or absent breath sounds on affected side		*Decreased or absent breath sounds on affected side
	*~~'''~~Tracheal deviation~~'''~~ away from affected side (late finding, unreliable in acute setting)		*Tracheal deviation away from affected side (late finding, unreliable in acute setting)
	*Jugular venous distension (may be absent with concurrent hypovolemia)		*Jugular venous distension (may be absent with concurrent hypovolemia)
	*Hyperresonance to percussion on affected side		*Hyperresonance to percussion on affected side
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	==Management==		==Management==
	===Immediate Decompression===		===Immediate Decompression===
	*~~'''~~Needle decompression~~'''~~ (temporizing measure):		*Needle decompression (temporizing measure):
	**~~'''~~14-16 gauge angiocatheter~~'''~~		**14-16 gauge angiocatheter
	**Site: ~~'''~~5th intercostal space, anterior axillary line~~'''~~ (preferred) or 2nd ICS midclavicular line<ref name="inaba">Inaba K, et al. Radiographic evaluation of alternative sites for needle decompression of tension pneumothorax. ''Arch Surg''. 2012;147(9):813-818. PMID 22987168.</ref>		**Site: 5th intercostal space, anterior axillary line (preferred) or 2nd ICS midclavicular line<ref name="inaba">Inaba K, et al. Radiographic evaluation of alternative sites for needle decompression of tension pneumothorax. ''Arch Surg''. 2012;147(9):813-818. PMID 22987168.</ref>
	**Insert over the top of the rib (avoid neurovascular bundle on inferior rib margin)		**Insert over the top of the rib (avoid neurovascular bundle on inferior rib margin)
	**Rush of air confirms diagnosis		**Rush of air confirms diagnosis
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	===Definitive Treatment===		===Definitive Treatment===
	*~~'''~~[[Chest tube\|Tube thoracostomy]]~~'''~~ (28-36 Fr)		*[[Chest tube\|Tube thoracostomy]] (28-36 Fr)
	**Required after needle decompression		**Required after needle decompression
	**5th ICS, anterior to mid-axillary line		**5th ICS, anterior to mid-axillary line
	**Connect to underwater seal / Pleurovac		**Connect to underwater seal / Pleurovac
	*In cardiac arrest: ~~'''~~bilateral finger thoracostomies~~'''~~		*In cardiac arrest: bilateral finger thoracostomies

	===Cardiac Arrest===		===Cardiac Arrest===
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	==Disposition==		==Disposition==
	*~~'''~~Admit~~'''~~ all patients with tension pneumothorax		*Admit all patients with tension pneumothorax
	*ICU admission if hemodynamic instability, mechanical ventilation, or ongoing air leak		*ICU admission if hemodynamic instability, mechanical ventilation, or ongoing air leak
	*Trauma surgery or thoracic surgery consultation		*Trauma surgery or thoracic surgery consultation

Danbot: Major expansion: clinical diagnosis emphasis, needle decompression technique, POCUS, cardiac arrest management, references

2026-03-21T18:31:47Z

Major expansion: clinical diagnosis emphasis, needle decompression technique, POCUS, cardiac arrest management, references

← Revisión anterior		Revisión del 18:31 21 mar 2026
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	==Background==		==Background==
	*~~Pneumothorax~~ with ~~ongoing air leak creating~~ a one-way valve mechanism ~~→ progressive accumulation of air under pressure in the pleural space~~		*Progressive accumulation of air in the pleural space with a one-way valve mechanism
	*Causes mediastinal shift, ~~compression of contralateral lung~~, and ~~impaired venous return → [[obstructive shock]] → cardiac arrest~~		*Air enters on inspiration but cannot escape on expiration
	*'''~~Death occurs from impaired venous return and hypoxia~~''' — ~~this is a clinical diagnosis treated immediately without waiting~~ for imaging		*Causes mediastinal shift, decreased venous return, and cardiovascular collapse
	*~~Causes: penetrating or blunt~~ [[~~thoracic~~ trauma]], ~~mechanical~~ ventilation (~~barotrauma),~~ central line ~~placement~~, [[pneumothorax (~~main~~)\|~~spontaneous pneumothorax~~]] ~~with valve mechanism~~		*A '''clinical diagnosis''' — treatment should NOT be delayed for imaging<ref name="roberts">Roberts DJ, et al. Clinical presentation of patients with tension pneumothorax. ''Ann Surg''. 2015;261(6):1068-1078. PMID 25563886.</ref>
			*Most common in [[Trauma\|trauma]], positive pressure ventilation, and after procedures (central line, thoracentesis)

			==Etiology==
			*[[Traumatic pneumothorax]] (penetrating or blunt)
			*Positive pressure ventilation (mechanical ventilation, NIPPV, BVM)
			*Iatrogenic (central venous catheterization, [[Thoracentesis\|thoracentesis]], nerve blocks)
			*Spontaneous (especially in tall, thin males; underlying [[COPD]], [[Asthma\|asthma]])

	==Clinical Features==		==Clinical Features==
	*~~Unilateral diminished or absent breath sounds~~		*'''Hypotension''' and '''tachycardia''' (most sensitive findings)
	*[[Hypotension~~]] or hemodynamic instability (obstructive shock — impaired RV filling)~~		*Respiratory distress, [[tachypnea]], [[Hypoxia\|hypoxia]]
	*Distended neck veins (may not occur if patient is hypovolemic)		*Decreased or absent breath sounds on affected side
	*Contralateral tracheal deviation ('''~~late finding~~''' ~~— do not wait for this~~)		*'''Tracheal deviation''' away from affected side (late finding, unreliable in acute setting)
	*~~[[Tachycardia]]~~, [[tachypnea]], [[hypoxia]]		*Jugular venous distension (may be absent with concurrent hypovolemia)
	*[[~~Cardiac arrest~~]] ([[~~PEA~~]] ~~or asystole~~) ~~— always consider tension pneumothorax in traumatic arrest~~		*Hyperresonance to percussion on affected side
			*Subcutaneous emphysema
			*[[PEA]] arrest or sudden cardiovascular collapse
			*Consider in intubated patients with '''acute deterioration''' ([[DOPE]] mnemonic)

	==Differential Diagnosis==		==Differential Diagnosis==
	~~{{Pneumothorax types}}~~		*[[Simple pneumothorax]]
	~~{{Thoracic trauma DDX}}~~		*[[Hemothorax]]
			*[[Cardiac tamponade]]
			*[[Massive pulmonary embolism]]
			*Right mainstem intubation
			*Auto-PEEP / air trapping
			*[[Myocardial infarction]]

	==Evaluation==		==Evaluation==
	~~[[File:PMC2892654 CRM2010-213818.004.png\|thumb\|Left sided tension pneumothorax with mediastinal shift]]~~		*'''Clinical diagnosis''' — do NOT delay treatment for CXR or CT
	'''~~This is a clinical~~ diagnosis — do NOT delay treatment for ~~imaging~~'''		*Point-of-care [[Ultrasound\|ultrasound (POCUS)]]: absent lung sliding on affected side (high sensitivity)<ref name="licht">Lichtenstein DA, et al. Relevance of lung ultrasound in the diagnosis of acute respiratory failure: the BLUE protocol. ''Chest''. 2008;134(1):117-125. PMID 18403664.</ref>
	*[[CXR]] (if time permits ~~and patient is stable~~): mediastinal shift~~, unilateral hyperlucency~~, deep sulcus sign		*CXR (if time permits): hyperlucency, absent lung markings, mediastinal shift, deep sulcus sign (supine)
	*~~[[Ultrasound~~: ~~Lungs\|Lung ultrasound]]: absent lung sliding on affected side (rapid bedside confirmation)~~		*CT chest: definitive but rarely indicated acutely
	~~{{Lung ultrasound pneumothorax}}~~

	==Management==		==Management==
	===Immediate Decompression===		===Immediate Decompression===
	*'''Needle ~~thoracostomy~~''' (~~decompression) —~~ temporizing measure:		*'''Needle decompression''' (temporizing measure):
	**14-gauge angiocatheter~~, 2nd intercostal space midclavicular line (traditional)~~		**'''14-16 gauge angiocatheter'''
	**~~Evidence suggests 4th-~~5th intercostal space at anterior axillary line ~~has lower failure rate~~ (~~less chest wall thickness~~)		**Site: '''5th intercostal space, anterior axillary line''' (preferred) or 2nd ICS midclavicular line<ref name="inaba">Inaba K, et al. Radiographic evaluation of alternative sites for needle decompression of tension pneumothorax. ''Arch Surg''. 2012;147(9):813-818. PMID 22987168.</ref>
	**Failure rate with standard needle ~~is up to 50% in obese or muscular patients~~		**Insert over the top of the rib (avoid neurovascular bundle on inferior rib margin)
	*'''~~Finger thoracostomy~~'~~'' — more reliable than needle decompression~~:		**Rush of air confirms diagnosis
	**~~4th-5th intercostal space, anterior axillary line~~		**May fail due to chest wall thickness — consider longer catheter (8 cm) or finger thoracostomy
	**~~Make incision through skin and intercostal muscles, bluntly enter pleural space with finger~~
	**~~Preferred in cardiac arrest or when needle decompression fails~~
	*'''Always followed by [[chest ~~tube]] placement'''~~ (~~needle/~~finger ~~alone is not definitive)~~

	===~~Chest Tube~~===		===Definitive Treatment===
	*~~Adult:~~ 28-36 Fr		*'''[[Chest tube\|Tube thoracostomy]]''' (28-36 Fr)
	*~~Pediatric~~: ~~Estimated as 4 × ETT size~~ (~~ETT = 4 + age/4~~)		**Required after needle decompression
	~~{{Chest tube size table}}~~		**5th ICS, anterior to mid-axillary line
			**Connect to underwater seal / Pleurovac
			*In cardiac arrest: '''bilateral finger thoracostomies'''

			===Cardiac Arrest===
			*Tension pneumothorax is a reversible cause of [[PEA]] arrest (the ''T'' in H's and T's)
			*Bilateral needle or finger thoracostomy during CPR
			*If ROSC not achieved after decompression, consider other causes

	==Disposition==		==Disposition==
	*Admit all patients ~~after chest tube placement~~		*'''Admit''' all patients with tension pneumothorax
	*ICU if ~~hemodynamically unstable or on~~ mechanical ventilation		*ICU admission if hemodynamic instability, mechanical ventilation, or ongoing air leak
	~~{{Flying instructions after pneumothorax}}~~		*Trauma surgery or thoracic surgery consultation

	~~==Complications==~~
	*[[Reexpansion pulmonary edema]] (rare but serious)
	*~~Tube malposition~~ or ~~dislodgement~~

	==See Also==		==See Also==
	*[[~~Pneumothorax (main)]]~~		*[[Spontaneous pneumothorax]]
	*[[Needle thoracostomy]]
	*[[Finger thoracostomy]]
	*[[Chest tube]]		*[[Chest tube]]
	*[[~~Adult pulseless arrest#Asystole and PEA~~ (~~Non-Shockable~~)~~\|Traumatic arrest~~]]		*[[Hemothorax]]
			*[[Thoracic trauma]]
			*[[Deterioration After Intubation (DOPE)]]

	==References==		==References==

Danbot: Expand with concise EM-focused content: clinical diagnosis emphasis, finger thoracostomy, needle failure rates

2026-03-21T01:22:39Z

Expand with concise EM-focused content: clinical diagnosis emphasis, finger thoracostomy, needle failure rates

← Revisión anterior		Revisión del 01:22 21 mar 2026
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	==Background==		==Background==
	*Death occurs from ~~hypoxic respiratory arrest~~ (~~V-Q mismatch~~), ~~not circulatory arrest~~		*Pneumothorax with ongoing air leak creating a one-way valve mechanism → progressive accumulation of air under pressure in the pleural space
			*Causes mediastinal shift, compression of contralateral lung, and impaired venous return → [[obstructive shock]] → cardiac arrest
			*'''Death occurs from impaired venous return and hypoxia''' — this is a clinical diagnosis treated immediately without waiting for imaging
			*Causes: penetrating or blunt [[thoracic trauma]], mechanical ventilation (barotrauma), central line placement, [[pneumothorax (main)\|spontaneous pneumothorax]] with valve mechanism

	==Clinical Features==		==Clinical Features==
	*Unilateral diminished or absent breath sounds		*Unilateral diminished or absent breath sounds
	*[[Hypotension]] or ~~evidence of hypoperfusion~~		*[[Hypotension]] or hemodynamic instability (obstructive shock — impaired RV filling)
	*Distended neck veins		*Distended neck veins (may not occur if patient is hypovolemic)
	**May not occur if patient is hypovolemic		*Contralateral tracheal deviation ('''late finding''' — do not wait for this)
	*Contralateral ~~Tracheal~~ deviation (late ~~sign~~)		*[[Tachycardia]], [[tachypnea]], [[hypoxia]]
	*~~Type of obstructive shock since prevents venous return to the right side of the heart~~		*[[Cardiac arrest]] ([[PEA]] or asystole) — always consider tension pneumothorax in traumatic arrest

	==Differential Diagnosis==		==Differential Diagnosis==
	{{Pneumothorax types}}		{{Pneumothorax types}}
	{{Thoracic trauma DDX}}		{{Thoracic trauma DDX}}
	~~{{SOB DDX}}~~

	==Evaluation==		==Evaluation==
	[[File:PMC2892654 CRM2010-213818.004.png\|thumb\|Left sided tension pneumothorax with mediastinal shift]]		[[File:PMC2892654 CRM2010-213818.004.png\|thumb\|Left sided tension pneumothorax with mediastinal shift]]
	'''~~Ideally~~ a clinical diagnosis ~~treated emergently (without~~ delay for ~~studies)~~'''		'''This is a clinical diagnosis — do NOT delay treatment for imaging'''
	*[[CXR]]		*[[CXR]] (if time permits and patient is stable): mediastinal shift, unilateral hyperlucency, deep sulcus sign
	*[[Ultrasound: Lungs\|Lung ultrasound]]		*[[Ultrasound: Lungs\|Lung ultrasound]]: absent lung sliding on affected side (rapid bedside confirmation)

	{{Lung ultrasound pneumothorax}}		{{Lung ultrasound pneumothorax}}

	==Management==		==Management==
	*~~Immediate [[needle~~ thoracostomy]]		===Immediate Decompression===
	**~~14ga IV in~~ midclavicular line ~~just above the rib at the second intercostal space~~		*'''Needle thoracostomy''' (decompression) — temporizing measure:
	**Evidence suggests ~~lowest~~ failure rate of needle decompression ~~is at the~~ 4th/5th ~~rib~~ space ~~along the~~ anterior axillary line ~~<ref>Laan DV et al. Chest Wall Thickness~~ and ~~Decompression Failure: A systematic Review and Meta-Analysis Coparing Anatomic Locations~~ in ~~Needle Thoracostomy. Injury 2015 [Epub Ahead of Print]. PMID: 26724173</ref>~~		**14-gauge angiocatheter, 2nd intercostal space midclavicular line (traditional)
	*Always followed by [[~~Chest Tube~~]] placement		**Evidence suggests 4th-5th intercostal space at anterior axillary line has lower failure rate (less chest wall thickness)
	'''~~Pediatric Chest Tube~~'''		**Failure rate with standard needle is up to 50% in obese or muscular patients
	Estimated as 4ETT		*'''Finger thoracostomy''' — more reliable than needle decompression:
	**ETT=(~~4+age~~/4)		**4th-5th intercostal space, anterior axillary line
			**Make incision through skin and intercostal muscles, bluntly enter pleural space with finger
			**Preferred in cardiac arrest or when needle decompression fails
			*'''Always followed by [[chest tube]] placement''' (needle/finger alone is not definitive)

			===Chest Tube===
			*Adult: 28-36 Fr
			*Pediatric: Estimated as 4 × ETT size (ETT = 4 + age/4)
	{{Chest tube size table}}		{{Chest tube size table}}

	==Disposition==		==Disposition==
	*Admit		*Admit all patients after chest tube placement
			*ICU if hemodynamically unstable or on mechanical ventilation
	{{Flying instructions after pneumothorax}}		{{Flying instructions after pneumothorax}}

	==Complications==		==Complications==
	*[[Reexpansion pulmonary edema]]		*[[Reexpansion pulmonary edema]] (rare but serious)
			*Tube malposition or dislodgement

	==See Also==		==See Also==
	*[[Pneumothorax (main)]]		*[[Pneumothorax (main)]]
	*[[Needle thoracostomy]]		*[[Needle thoracostomy]]
	*[[Finger ~~Thoracostomy~~]]		*[[Finger thoracostomy]]
			*[[Chest tube]]
	*[[Adult pulseless arrest#Asystole and PEA (Non-Shockable)\|Traumatic arrest]]		*[[Adult pulseless arrest#Asystole and PEA (Non-Shockable)\|Traumatic arrest]]

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	[[Category:Pulmonary]]		[[Category:Pulmonary]]
	[[Category:Trauma]]		[[Category:Trauma]]
			[[Category:Critical Care]]

Rossdonaldson1: /* See Also */

2021-08-24T16:19:54Z

Elcatracho: /* Management */

2020-11-25T22:35:22Z

Management

← Revisión anterior		Revisión del 22:35 25 nov 2020
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	*Immediate [[needle thoracostomy]]		*Immediate [[needle thoracostomy]]
	**14ga IV in midclavicular line just above the rib at the second intercostal space		**14ga IV in midclavicular line just above the rib at the second intercostal space
	*Evidence suggests lowest failure rate of needle decompression is at the 4th/5th rib space along the anterior axillary line <ref>Laan DV et al. Chest Wall Thickness and Decompression Failure: A systematic Review and Meta-Analysis Coparing Anatomic Locations in Needle Thoracostomy. Injury 2015 [Epub Ahead of Print]. PMID: 26724173</ref>Always followed by [[Chest Tube]] placement		**Evidence suggests lowest failure rate of needle decompression is at the 4th/5th rib space along the anterior axillary line <ref>Laan DV et al. Chest Wall Thickness and Decompression Failure: A systematic Review and Meta-Analysis Coparing Anatomic Locations in Needle Thoracostomy. Injury 2015 [Epub Ahead of Print]. PMID: 26724173</ref>
			*Always followed by [[Chest Tube]] placement
	'''Pediatric Chest Tube'''		'''Pediatric Chest Tube'''
	Estimated as 4ETT		Estimated as 4ETT

Elcatracho: /* Management */

2020-11-25T22:35:01Z

Management

← Revisión anterior		Revisión del 22:35 25 nov 2020
Línea 26:		Línea 26:
	*Immediate [[needle thoracostomy]]		*Immediate [[needle thoracostomy]]
	**14ga IV in midclavicular line just above the rib at the second intercostal space		**14ga IV in midclavicular line just above the rib at the second intercostal space
	*Always followed by [[Chest Tube]] placement		*Evidence suggests lowest failure rate of needle decompression is at the 4th/5th rib space along the anterior axillary line <ref>Laan DV et al. Chest Wall Thickness and Decompression Failure: A systematic Review and Meta-Analysis Coparing Anatomic Locations in Needle Thoracostomy. Injury 2015 [Epub Ahead of Print]. PMID: 26724173</ref>Always followed by [[Chest Tube]] placement

	'''Pediatric Chest Tube'''		'''Pediatric Chest Tube'''
	Estimated as 4ETT		Estimated as 4ETT

Rossdonaldson1: /* Evaluation */

2019-07-20T12:56:05Z

Evaluation

← Revisión anterior		Revisión del 12:56 20 jul 2019
Línea 20:		Línea 20:
	*[[CXR]]		*[[CXR]]
	*[[Ultrasound: Lungs\|Lung ultrasound]]		*[[Ultrasound: Lungs\|Lung ultrasound]]

			{{Lung ultrasound pneumothorax}}

	==Management==		==Management==

Rossdonaldson1: /* Disposition */

2019-07-18T19:16:11Z

Disposition

← Revisión anterior		Revisión del 19:16 18 jul 2019
Línea 36:		Línea 36:

	{{Flying instructions after pneumothorax}}		{{Flying instructions after pneumothorax}}

			==Complications==
			*[[Reexpansion pulmonary edema]]

	==See Also==		==See Also==

Chungirv: /* See Also */

2017-08-07T18:03:42Z

Ravillaa at 15:58, 31 July 2017

2017-07-31T15:58:32Z

← Revisión anterior		Revisión del 15:58 31 jul 2017
Línea 25:		Línea 25:
	**14ga IV in midclavicular line just above the rib at the second intercostal space		**14ga IV in midclavicular line just above the rib at the second intercostal space
	*Always followed by [[Chest Tube]] placement		*Always followed by [[Chest Tube]] placement

			'''Pediatric Chest Tube'''
			Estimated as 4ETT
			**ETT=(4+age/4)

	{{Chest tube size table}}		{{Chest tube size table}}

← Revisión anterior		Revisión del 16:19 24 ago 2021
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	==See Also==		==See Also==
	*[[Pneumothorax (main)]]		*[[Pneumothorax (main)]]
	*[[~~needle~~ thoracostomy]]		*[[Needle thoracostomy]]
	*[[Finger Thoracostomy]]		*[[Finger Thoracostomy]]
	*[[Adult pulseless arrest#Asystole and PEA (Non-Shockable)\|Traumatic arrest]]		*[[Adult pulseless arrest#Asystole and PEA (Non-Shockable)\|Traumatic arrest]]

← Revisión anterior		Revisión del 18:03 7 ago 2017
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	==See Also==		==See Also==
	*[[Pneumothorax (main)]]		*[[Pneumothorax (main)]]
			*[[needle thoracostomy]]
			*[[Finger Thoracostomy]]
			*[[Adult pulseless arrest#Asystole and PEA (Non-Shockable)\|Traumatic arrest]]

	==References==		==References==