Step	Action	Key Points	Exam Pearls
1️⃣ Recognise	Clinical diagnosis	Sudden dyspnoea, absent breath sounds, hyper-resonance, raised JVP, hypotension, tracheal deviation (late sign)	Do NOT wait for chest X-ray
2️⃣ Call for Help	Activate emergency response	Senior support + resus team	Time-critical emergency
3️⃣ ABCDE	Start immediate resuscitation	Airway assessment, 15L O₂ via non-rebreather mask, monitoring (SpO₂, BP, ECG)	Treat simultaneously while diagnosing
4️⃣ Needle Decompression	Immediate decompression	2nd ICS mid-clavicular line OR 4th/5th ICS anterior axillary line	Listen for “hiss” of escaping air
5️⃣ Chest Drain	Definitive management	Insert in safe triangle	Do not delay for imaging
6️⃣ Reassess	Monitor response	Check vitals, breath sounds, oxygenation, ensure drain functioning	Consider alternative diagnosis if no improvement

🫁 Overview

Life-threatening form of pneumothorax.
Requires urgent needle decompression.
“Hiss” of escaping air supports diagnosis.
If no tension present → minimal harm; remove needle and reassess.

⚙️ Pathophysiology

Air enters pleural space but cannot escape (one-way valve mechanism).
Progressive pressure rise compresses lung and mediastinum.
If intrathoracic pressure exceeds venous filling pressure → obstructive shock.

🧾 Causes

💥 Trauma

Penetrating (stab wounds, rib fractures)
Blunt trauma (e.g. RTA)

⚕️ Iatrogenic

Central line insertion
Lung biopsy / bronchoscopy
Percutaneous tracheostomy
Positive pressure ventilation (barotrauma)
CPR, intercostal nerve block, thoracocentesis

🌊 Environmental

Diving
Flying

🌀 Atraumatic

Primary (young, tall, thin)
Secondary (COPD, fibrosis, malignancy)

👩‍⚕️ Clinical Features

Sudden dyspnoea and pleuritic chest pain.
Tachycardia ❤️‍🔥
Respiratory distress, anxiety.
Reduced/absent breath sounds on affected side.
Hyper-resonant percussion note.
Tracheal deviation away from affected side (late).
Raised JVP.
Hypotension → pre-arrest sign.
Subcutaneous emphysema may be present.

📸 Imaging (If Stable)

Do NOT delay treatment for imaging.

Visible visceral pleural line.
Absent lung markings peripherally.
Collapsed ipsilateral lung.
Mediastinal shift away.
Flattened hemidiaphragm.
Subcutaneous emphysema.

Ultrasound: ~94% sensitive, 100% specific Absent lung sliding + “lung point” sign.

🛠️ Management

⚡ Immediate ABCDE

Sit upright.
15 L/min O₂ via non-rebreather mask.

💉 Emergency Needle Decompression

2nd ICS, mid-clavicular line (classical).
OR 4th/5th ICS anterior axillary line (preferred in many UK centres).
Leave cannula in situ.

🩺 Definitive Treatment

Chest drain in safe triangle.
Do not wait for CXR.
Monitor for recurrence or drain blockage.

🧠 Cases - Tension Pneumothorax

Case 1 - Trauma 🚑: High-speed RTA. Agitated, RR 36, absent left breath sounds, trachea deviated right, JVP raised, SpO₂ 78%. Immediate needle decompression → chest drain.
Case 2 - Iatrogenic 💉: COPD patient collapses during CVC insertion. Hypotension, distended neck veins, absent breath sounds. Rapid decompression is life-saving.
Case 3 - Cardiac Arrest 🫀: Ventilated ITU patient develops PEA. High airway pressures, unilateral absent breath sounds. Immediate bilateral decompression during ALS.

🩺 Exam Tip: Tension pneumothorax = obstructive shock. Treat first. Confirm later. Needle decompression saves life. Chest drain is definitive.

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Tension Pneumothorax

🚨 Immediate Actions - Tension Pneumothorax