Tension Pneumothorax & Thoracic Trauma
Emergency thoracic trauma algorithms: landmarking and executing needle decompression, finger thoracostomy in ventilated patients, chest tube placement, and emergency department resuscitative thoracotomy criteria.
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Tension pneumothorax is a clinical diagnosis; obtaining a chest radiograph in an unstable patient is malpractice. Decompress immediately. The updated ATLS guideline prefers the 5th intercostal space anterior axillary line over the traditional 2nd ICS midclavicular line in adults due to chest wall thickness. In a trauma cardiac arrest from penetrating chest trauma, emergency resuscitative thoracotomy (clamshell) is indicated if signs of life were present within 15 minutes of ED arrival.
1. Tension Pneumothorax Diagnosis & Decompression Landmarking
Tension pneumothorax produces progressive respiratory failure and obstructive shock due to one-way valve pleural air accumulation causing mediastinal shift and inferior vena cava kinking.
| Technique | Landmark Location | Equipment / Gauge | Clinical Pear/Trap |
|---|---|---|---|
| Needle Thoracostomy (Adults) | 5th Intercostal Space, Anterior Axillary Line | 14G catheter, >= 8 cm length | Standard 5 cm needles fail in up to 50% of adult patients due to chest wall depth |
| Needle Thoracostomy (Pediatrics) | 2nd Intercostal Space, Midclavicular Line | 18–20G catheter, over top of 3rd rib | Always insert needle directly over the rib below to avoid the subcostal neurovascular bundle |
| Finger Thoracostomy | 5th ICS anterior-axillary line | Scalpel, curved Kelly clamp, finger | Standard of care in intubated trauma patients; finger confirms pleural entry with rush of air/blood |
| Chest Tube Placement | 5th ICS slightly anterior to mid-axillary line | 28–32 Fr tube aimed posterior/apical | Secure with 0-silk suture; connect to -20 cmH2O water seal suction |
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