Makindo Medical Notes

🚨 Tension Pneumothorax (TPTX) is a clinical diagnosis – do not wait for radiology. Immediate needle thoracocentesis is lifesaving. When intrapleural pressure rises like a balloon 🎈, venous return is impaired → cardiac output collapses → death if untreated. 🪡 Pop the balloon with a needle and let the air out!

🫁 About

• Needs urgent decompression with a needle → “hiss of air” confirms diagnosis.
• If no tension present, little harm done: remove needle and proceed to CXR for other causes.

⚙️ Aetiology

• Air enters pleural space but cannot escape (valve effect).
• If intrathoracic pressure > diastolic filling pressure → cardiac output falls → shock and death.

🧾 Causes

• 💥 Trauma
  • Penetrating (stab wound, rib fracture)
  • Blunt trauma (e.g. RTA)
• ⚕️ Iatrogenic
  • Central line or pacing wire insertion
  • Lung biopsy, bronchoscopy
  • Percutaneous tracheostomy
  • Positive pressure ventilation (barotrauma)
  • CPR, intercostal nerve block, thoracentesis
• 🌊 Non-Iatrogenic
  • Diving, flying, rib fractures
• 🌀 Atraumatic
  • Primary (young, tall, thin, unknown cause)
  • Secondary (underlying lung disease e.g. COPD, fibrosis)

👩‍⚕️ Clinical Features

• Seen after chest trauma, procedures (e.g. CVC insertion), or on ventilation.
• Subcutaneous emphysema possible.
• Cardinal signs: tachycardia ❤️‍🔥, cyanosis, anxiety, rapid deterioration.
• Raised JVP, absent breath sounds on affected side, hyper-resonant chest.
• Hypotension = late and deadly sign ☠️.
• Obvious chest wound may be present.

📸 Imaging

Patients often too unstable for CXR, but classic findings include:

• Thin vertical line of visceral pleura.
• Loss of lung markings distal to line.
• Complete ipsilateral lung collapse.
• Mediastinal shift away from pneumothorax.
• Tracheal deviation to contralateral side.
• Flattened hemidiaphragm.
• Subcutaneous emphysema.

🔍 Ultrasound (94% sensitive, 100% specific): absent lung sliding, “lung point” seen.

🛠️ Management

• ⚡ Immediate ABCDE approach: Sit up, 15L/min O₂ via NRB mask.
• 💉 If in extremis: Immediate needle decompression
  • Classically: 2nd intercostal space, midclavicular line.
  • Alternative (preferred in many UK hospitals): 4th/5th ICS anterior axillary line (safe triangle).
  • Listen for hiss of escaping air, leave cannula in situ.
• 🩺 Chest drain insertion (definitive): placed in “safe triangle”. Do not wait for imaging.
• If no hiss after cannula → consider malposition or alternate diagnosis.
• Monitor for recurrence if drain blocks or dislodges.