Tension pneumothorax — Rapid | Doctor's Passport Education

Synopsis

Recognise tension physiology clinically and perform immediate chest decompression through the safest available trained route, followed by definitive drainage and treatment of the cause.

Tension pneumothorax is pleural air under pressure causing severe respiratory compromise and/or obstructive shock; it is physiology, not simply mediastinal shift on an image.
Suspect it after chest trauma, positive-pressure ventilation/NIV, pleural/lung procedure or spontaneous pneumothorax with abrupt hypoxia, hypotension or peri-arrest deterioration.
Look for unilateral reduced/absent breath sounds and expansion, hyperresonance, rapidly increasing airway pressures, falling tidal volumes, distended neck veins or surgical emphysema; tracheal deviation is late and unreliable.

Key red flags

Spontaneously breathing patient

Acute pleuritic pain and severe dyspnoea progressing to unilateral absent breath sounds, hypoxaemia, tachycardia and hypotension; agitation may precede reduced consciousness.

Investigation priorities

Immediate clinical ABCDE assessmentFirst step

Establish severe respiratory compromise or obstructive shock and choose emergency decompression.

Management branches

UnstableDecompress before imaging

Suspected tension pneumothorax with haemodynamic instability or severe respiratory compromise.

Call resuscitation/trauma and airway help, give high-concentration oxygen, monitor and expose the chest; if on NIV/ventilation, temporarily release positive pressure as clinically safe while immediate decompression is prepared.
Use open thoracostomy in hospital when an appropriately trained operator is immediately available; enter at the 4th/5th intercostal space just anterior to the mid-axillary line using the approved sterile trauma technique.

Stable imaging findingPneumothorax without tension physiology

Pneumothorax is suspected or imaged but the patient has no severe respiratory compromise or haemodynamic instability.

Key medicines

Medical oxygenHigh-concentration oxygen via reservoir mask at 15 L/min in severe compromise/peri-arrest; use 100% oxygen during ALS, then titrate after stabilisation to 94–98% or 88–92% if hypercapnia risk.

Lidocaine 1%If the conscious patient's physiology allows seconds for anaesthesia, infiltrate the lateral thoracostomy/drain tract; total lidocaine without adrenaline should not exceed 3 mg/kg (1% = 10 mg/mL), using less in frailty/liver disease.

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