Anatomy Msk · Year 1 · from Anatomy Msk
Case 3: Tension Pneumothorax
Clinical Image
Source: Wikimedia Commons - Tension Pneumothorax - CC BY-SA 3.0
Case Presentation
A 28-year-old man is brought by EMS from the scene of a motorcycle crash. EMS reports he was hypotensive at the scene with blood pressure 70/40 mmHg and respiratory distress. On arrival, he is agitated and diaphoretic with severe respiratory distress. Vital signs: HR 135, BP 75/50, RR 38, SpO2 78% on non-rebreather mask. Examination reveals distended neck veins (JVD), tracheal deviation to the left, absent breath sounds on the right, and hyperresonance to percussion on the right chest. The left chest has normal breath sounds. Given the clinical picture of tension pneumothorax, immediate needle decompression is performed at the right second intercostal space in the midclavicular line with a 14-gauge angiocatheter. A rush of air is heard, and within seconds his blood pressure improves to 105/70 and oxygen saturation rises to 92%. A right tube thoracostomy is then placed with continuous air leak and 200 mL of blood output. Post-procedure chest X-ray shows improved lung expansion with the chest tube in good position. He is taken to the operating room for exploratory thoracotomy which reveals a lacerated intercostal artery requiring ligation.
Key Learning Points
- Tension pneumothorax is a clinical diagnosis requiring immediate intervention - do not wait for chest X-ray
- Air enters the pleural space through a one-way valve mechanism, causing progressive hemodynamic compromise
- Increased intrathoracic pressure causes lung collapse, mediastinal shift, kinking of great vessels, and decreased venous return
- Classic findings: hypotension, JVD, tracheal deviation, absent breath sounds, hyperresonance on the affected side
- Needle decompression at 2nd intercostal space, midclavicular line is life-saving, followed by tube thoracostomy