Diferencia entre revisiones de «Tension pneumothorax»

(Major expansion: clinical diagnosis emphasis, needle decompression technique, POCUS, cardiac arrest management, references)
(Strip excess bold text - keep only critical safety emphasis)
 
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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

Revisión actual - 09:23 22 mar 2026

Background

  • Progressive accumulation of air in the pleural space with a one-way valve mechanism
  • Air enters on inspiration but cannot escape on expiration
  • Causes mediastinal shift, decreased venous return, and cardiovascular collapse
  • A clinical diagnosis — treatment should NOT be delayed for imaging[1]
  • Most common in 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, nerve blocks)
  • Spontaneous (especially in tall, thin males; underlying COPD, asthma)

Clinical Features

  • Hypotension and tachycardia (most sensitive findings)
  • Respiratory distress, tachypnea, hypoxia
  • Decreased or absent breath sounds on affected side
  • Tracheal deviation away from affected side (late finding, unreliable in acute setting)
  • Jugular venous distension (may be absent with concurrent hypovolemia)
  • 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

Evaluation

  • Clinical diagnosis — do NOT delay treatment for CXR or CT
  • Point-of-care ultrasound (POCUS): absent lung sliding on affected side (high sensitivity)[2]
  • CXR (if time permits): hyperlucency, absent lung markings, mediastinal shift, deep sulcus sign (supine)
  • CT chest: definitive but rarely indicated acutely

Management

Immediate Decompression

  • Needle decompression (temporizing measure):
    • 14-16 gauge angiocatheter
    • Site: 5th intercostal space, anterior axillary line (preferred) or 2nd ICS midclavicular line[3]
    • Insert over the top of the rib (avoid neurovascular bundle on inferior rib margin)
    • Rush of air confirms diagnosis
    • May fail due to chest wall thickness — consider longer catheter (8 cm) or finger thoracostomy

Definitive Treatment

  • Tube thoracostomy (28-36 Fr)
    • Required after needle decompression
    • 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

  • Admit all patients with tension pneumothorax
  • ICU admission if hemodynamic instability, mechanical ventilation, or ongoing air leak
  • Trauma surgery or thoracic surgery consultation

See Also

References

  1. ↑ Roberts DJ, et al. Clinical presentation of patients with tension pneumothorax. Ann Surg. 2015;261(6):1068-1078. PMID 25563886.
  2. ↑ 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.
  3. ↑ Inaba K, et al. Radiographic evaluation of alternative sites for needle decompression of tension pneumothorax. Arch Surg. 2012;147(9):813-818. PMID 22987168.
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