Emergency Medicine · Year 3 · from Emergency Medicine

Case 3: Tension Pneumothorax

Patient Demographics

  • Age: 22 years
  • Sex: Male
  • Occupation: College athlete

Chief Complaint

"Sudden chest pain and I can't breathe."

History of Present Illness

A 22-year-old tall, thin male basketball player develops sudden onset of right-sided chest pain and severe dyspnea during practice. The pain is sharp, pleuritic, and he feels like he "can't get enough air." No trauma occurred. He has never had this before. He is a non-smoker.

Initial Assessment

ESI Level: 1 - Critical, rapidly deteriorating

Vital Signs (initial):

  • Heart rate: 124 bpm
  • Blood pressure: 102/68 mmHg
  • Respiratory rate: 36 breaths/min
  • SpO2: 84% on room air

Vital Signs (5 minutes later):

  • Heart rate: 140 bpm
  • Blood pressure: 74/50 mmHg
  • Respiratory rate: 40 breaths/min
  • SpO2: 78%
  • Patient becoming confused

Physical Examination

Pulmonary:

  • Severe respiratory distress
  • Absent breath sounds on right
  • Hyperresonance to percussion on right
  • Trachea deviating to left (late sign)

Cardiovascular:

  • Tachycardic
  • Distended neck veins (JVD)
  • Weak peripheral pulses

Clinical Diagnosis

TENSION PNEUMOTHORAX

Classic findings present:

  • Absent breath sounds (affected side)
  • Hyperresonance (affected side)
  • Hypotension (obstructive shock)
  • JVD (impaired venous return)
  • Tracheal deviation (late sign - toward unaffected side)

This is a CLINICAL diagnosis - do NOT delay for imaging

Management

Immediate Needle Decompression:

  • 14-gauge angiocatheter
  • Location: 2nd intercostal space, midclavicular line, RIGHT side
  • Above the rib (avoid neurovascular bundle)
  • Rush of air heard - immediate improvement

Post-Decompression Vitals:

  • BP: 98/62 mmHg
  • HR: 110 bpm
  • SpO2: 92% on high-flow O2
  • Mental status improved

Tube Thoracostomy (Chest Tube):

  • Location: 5th intercostal space, anterior axillary line (triangle of safety)
  • 28 French chest tube inserted
  • Connected to water seal/suction at -20 cm H2O
  • Large air leak noted initially

Imaging

Chest X-ray (post-chest tube):

  • Chest tube in good position
  • Lung re-expanded
  • Small residual apical pneumothorax
  • No effusion

Hospital Course

  • Air leak resolved by day 2
  • Chest tube removed day 3
  • Follow-up CXR: Complete resolution
  • Discharged day 4

Discussion with Patient

Primary Spontaneous Pneumothorax:

  • Common in tall, thin young males
  • Often due to rupture of apical blebs
  • Recurrence risk: 30% within 5 years
  • Smoking would significantly increase risk

Activity Restrictions:

  • No flying for 2 weeks after resolution
  • No scuba diving (permanent consideration)
  • Sports: Can resume after 2-3 weeks if asymptomatic

Return Precautions:

  • Sudden chest pain or dyspnea = return immediately
  • May need surgical pleurodesis if recurrent

Teaching Points

  1. Tension pneumothorax is a CLINICAL diagnosis: Don't wait for CXR
  2. Needle decompression is temporizing: Must be followed by chest tube
  3. Remember the anatomy: 2nd ICS midclavicular OR 4th-5th ICS anterior axillary
  4. Absent breath sounds + hemodynamic instability = decompress immediately
  5. Primary spontaneous pneumothorax: Think tall, thin, young males
  6. Bedside ultrasound: Absent lung sliding can rapidly confirm pneumothorax

Clinical Image

Image Description: Chest radiograph demonstrating a large right-sided tension pneumothorax with complete lung collapse, mediastinal shift to the left, and depression of the right hemidiaphragm.

Attribution: Image from Wikimedia Commons, Chest X-ray showing tension pneumothorax. Licensed under CC BY-SA 3.0. Source: https://commons.wikimedia.org/wiki/File:Tension_pneumothorax_chest_X-ray.jpg

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