Tension Pneumothorax

Tension pneumothorax (Fig. 19.1) may occur either from blunt or penetrating trauma and can be identified by tracheal deviation, unilateral loss of breath sounds, distended neck veins or respiratory distress. If the patient is immediately decompensating from a tension pneumothorax and has no breath sounds on this side of the injury, a large bore needle should be inserted into the second intercostal space in the midclavicular line. If this results in a massive hiss of air, one can conclude that the tension pneumothorax was the cause of the problem. It should be noted that the needle should not be placed too medial, (i.e. parasternal) lest the internal mammary artery be injured.

Should a chest tube be placed for all patients with pneumothorax after blunt or penetrating trauma? The answer is an unequivocal yes. This is because these pneumothoraces frequently enlarge when the patient is stabilized, and if the patient goes to the operating room and undergoes intubation and positive pressure breathing, then the pneumothorax will surely increase and cause compression of the mediastinum with tamponade. The tube is placed laterally and directed posteriorly so as to drain any blood that may accumulate. Although some may advocate that for pneumothorax the tube should be placed anteriorly, generally for trauma it is placed laterally or posteriorly. If there is a tiny amount of effusion or blood present on the initial chest x-ray, there may be justification for not placing a chest tube and watching it expectantly, if there is no evidence of pneumothorax.

Fig 19.1. Left tension pneumothorax in a boy with blunt tracheobronchial disruption. Mediastinal shift is clearly evident. A right sided pneumothorax is present as well and is decompressed with a chest tube.

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