01Approach to the Critical Patient/attcp60

Immediate recognition and decompression

›Clinical diagnosis triggers

›Respiratory distress with unilateral absent breath sounds

›Do not wait for imaging to act

›Clinical diagnosis demands immediate decompression before imaging

›Hemodynamic instability pattern

›Tachycardia as most common early finding

›Hypotension with obstructive shock physiology

›High-risk settings requiring immediate suspicion

›Mechanically ventilated patient with sudden desaturation

›Any intubated patient with acute hemodynamic collapse

›Post-procedural deterioration after central line or thoracentesis

›Immediate decompression sequence

›High-flow oxygen 100% FiO2 while preparing

›Non-rebreather mask in spontaneously breathing patients

›FiO2 1.0 on ventilator for intubated patients

›Needle decompression as bridge if definitive not immediately available

›2nd intercostal space midclavicular line traditional approach

›5th intercostal space midaxillary line alternative with higher success in obese patients

›10 to 14 gauge over-the-needle catheter

›Tube thoracostomy as definitive treatment

›4th to 6th intercostal space anterior to midaxillary line

›WSES-AAST 2025 guideline preferred approach

›Ventilated patient escalation

›Disconnect from ventilator immediately if tension physiology suspected

›Differentiates from auto-PEEP as cause

›Provides immediate relief if tension is cause

›Cardiac arrest from tension pneumothorax

02History/hx70

Mechanism and onset

›Traumatic etiologies

›Blunt chest trauma

›Rib fractures as risk indicator

›Pneumothorax in polytrauma approximately 20%

›Severe chest trauma up to 50% pneumothorax rate

›Penetrating injury

›Stab or gunshot wound to chest

›Ipsilateral progression to tension without wound seal

›Iatrogenic

›Central venous catheter placement

›Thoracentesis or lung biopsy

›Bronchoscopy

›Non-traumatic etiologies

›Barotrauma in mechanically ventilated patients

›High tidal volumes

›High PEEP settings

›Underlying lung disease amplifies risk

›Spontaneous pneumothorax progression

›Simple spontaneous pneumothorax converting to tension

›One-way valve mechanism at pleural breach

›Onset character

›Acute dyspnea and ipsilateral pleuritic chest pain

›Sudden and severe onset typical

Symptoms

›Cardinal symptoms

›Dyspnea

›Rapidly worsening especially in ventilated patients

03Physical Exam/exam56

Vitals

›Vital signs pattern in tension pneumothorax

›Tachycardia

›Most common and earliest finding

›Heart rate typically > 120 per minute in hemodynamic compromise

›Hypotension

›SBP < 90 mmHg

›Narrow pulse pressure

›Tachypnea

›Respiratory rate > 30 per minute

›Increased work of breathing

›Hypoxia

›SpO2 falling despite supplemental oxygen

›Hypoxia in approximately 50% of spontaneously breathing patients

›Hypoxia in approximately 92% of mechanically ventilated patients

Chest and respiratory exam

›Auscultation

›Absent or markedly decreased breath sounds on affected side

›Most reliable bedside finding

›Unilateral absence highly discriminating

›Normal or hyperactive breath sounds on contralateral side

›Percussion

›Hyperresonance on affected side

›Air-filled pleural space

›Differentiates from hemothorax dullness

›Inspection and palpation

›Asymmetric chest expansion

›Reduced excursion on affected side

04Differential Diagnosis/ddx48

Obstructive shock mimics

›Cardiac tamponade

›ICD-10 I31.9

›Beck's triad: hypotension, JVD, muffled heart sounds

›Bilateral breath sounds preserved

›POCUS: pericardial effusion with RV collapse

›Massive pulmonary embolism

›ICD-10 I26.09

›Acute dyspnea and hypotension

›Bilateral breath sounds typically present

›Risk factors: immobility, malignancy, prior VTE

›POCUS: RV dilation, D-sign, tricuspid regurgitation

›Auto-PEEP dynamic hyperinflation

›In mechanically ventilated patients only

›Mimics tension physiology without air in pleural space

›Trial of ventilator disconnection differentiates

Hemothorax and pleural mimics

›Massive hemothorax

›ICD-10 J94.2

›Dullness to percussion vs hyperresonance in tension

›Hypotension present but flat neck veins

›No JVD

›Simple pneumothorax

›ICD-10 J93.9

›Same presentation as tension without hemodynamic compromise

›No mediastinal shift

›Differentiating clue: hemodynamic stability

05Laboratory Tests/lt36

Point-of-care and immediate labs

›Arterial blood gas

›Hypoxemia: PaO2 < 60 mmHg

›Respiratory alkalosis early pattern

›Compensatory hyperventilation

›PaCO2 < 35 mmHg

›Respiratory and metabolic acidosis late pattern

›Shock physiology

›PaCO2 rising with fatigue

›Labs do not diagnose tension pneumothorax

›Clinical diagnosis only

›Do not delay treatment for lab results

›Lactate

›Elevated with obstructive shock and tissue hypoperfusion

›>= 2 mmol/l indicates organ hypoperfusion

›Serial lactate to assess resuscitation response

Standard trauma and resuscitation labs

›Complete blood count

›Bleeding assessment with concurrent hemothorax

›Baseline hematocrit for transfusion decision making

›Comprehensive metabolic panel

›Renal function for contrast planning if CT needed

›Electrolyte correction before and after resuscitation

›Coagulation studies

›PT INR and aPTT

›Relevant for procedural planning and trauma context

›Type and screen

›Standard trauma labs

06Diagnostic Tests/dt63

Scoring Systems

›Pneumothorax severity and management tools

›WSES-AAST severity grading 2025

›Guides surgical versus conservative approach

›Based on size, hemodynamic status, and ventilatory status

›British Thoracic Society pneumothorax size criteria

›Rim > 2 cm on CXR indicating large pneumothorax

›Guides drainage decisions for simple pneumothorax

›Tension physiology is a clinical not radiographic diagnosis

›Scoring systems do not apply to tension pneumothorax management

›Immediate decompression overrides any scoring tool

MRI

›MRI role in pneumothorax

›Not indicated for acute tension pneumothorax

›Availability constraints prohibit acute use

›Motion artifact from respiratory distress

›Limited non-acute applications

›Suspected underlying pleural malignancy

›Complex pleural disease characterization after stabilization

›Contraindications in acute setting

›Hemodynamically unstable patient

›Requirement for metal resuscitation equipment nearby

CT

›CT chest indications

›Gold standard for diagnosis and characterization

›Reserved for stable patients only

›Never delay decompression for CT

›Post-stabilization indications

07Disposition/dispo42

Admission criteria

›Mandatory hospital admission for all tension pneumothorax

›No outpatient management pathway exists

›All patients require admission after decompression

›Post-arrest patients require ICU admission

›ICU admission indications

›Hemodynamic instability or vasopressor requirement

›Cardiac arrest from tension pneumothorax

›Mechanically ventilated patients

›Persistent air leak

›Bilateral pneumothorax

Level of care determination

›ICU level criteria

›Post-cardiac arrest management

›Targeted temperature management consideration

›Neurological outcome assessment

›Vasopressor requirement

›Ongoing hemodynamic support

›Continuous monitoring

›Mechanical ventilation ongoing

›Ventilator weaning planning

›Air leak management

›Floor or step-down criteria

›Hemodynamic stability after decompression

›SBP >= 90 mmHg without vasopressors

›Heart rate < 100 per minute

›Functioning chest tube with confirmed lung re-expansion

›CXR confirming full expansion

08Treatment/t103

Immediate decompression

›Needle decompression technique

›2nd intercostal space midclavicular line approach

›10 to 14 gauge over-the-needle catheter

›Insert over superior rib edge to avoid neurovascular bundle

›Rush of air confirms pleural space entry

›5th intercostal space midaxillary line approach

›Alternative with potentially higher success in obese patients

›Preferred by some trauma protocols

›Colorimetric capnography adjunct

›CO2 detection at needle confirms pleural space entry

›Improves initial decompression success 82% vs 66% without adjunct

›American Journal of Emergency Medicine 2025 study

›Needle decompression limitations

›High failure rate due to chest wall thickness

›Catheter kinking and occlusion

›Bridge to definitive decompression only

Finger thoracostomy

›Simple finger thoracostomy technique

›4th or 5th intercostal space anterior midaxillary line

›Blunt dissection through chest wall

›Finger sweep confirms pleural space

›Success rate comparison

›92.1% success vs 76.3% for needle decompression in cadaveric studies

›Prehospital Emergency Care 2026 study

›Faster decompression times than needle

›Indications for preference over needle

›Prehospital setting

›Known needle decompression failure

›Obese patients with thick chest wall

Tube thoracostomy definitive treatment

›Chest tube placement

›4th to 6th intercostal space anterior to midaxillary line

›WSES-AAST 2025 preferred site

›Safe triangle bordered by pectoralis, latissimus, and horizontal nipple line

›Tube size selection

›Small bore 18 to 24 Fr for pneumothorax

›Large bore 28 to 32 Fr for hemothorax or combined injury

›Pleural catheter acceptable for uncomplicated pneumothorax

›Underwater seal drainage

›Connect to underwater seal after insertion

›Low-pressure suction may reduce hospital stay

›WSES-AAST 2025 guidance supports suction consideration

›Post-insertion management

›Confirm lung re-expansion with CXR

›Immediate post-placement CXR

›Tube position and expansion assessment

›Continuous monitoring

›Vitals response after decompression

›Chest tube output per hour

›Air leak assessment on water seal

›Chest tube removal criteria

›No air leak for 24 to 48 hours

›Full lung expansion confirmed on imaging

›No significant drainage

Resuscitation adjuncts

›Fluid resuscitation

›Isotonic crystalloid IV bolus 500 to 1000 mL while preparing decompression

›Temporary venous return augmentation

›Not a substitute for mechanical decompression

›Blood products in traumatic hemopneumothorax

›Packed red cells if hemoglobin low or active bleeding

›Massive transfusion protocol if chest tube output > 1500 mL

›Vasopressor therapy for refractory hypotension

›Norepinephrine

›0.1 to 0.5 mcg/kg/min IV infusion

›Titrate to MAP >= 65 mmHg

›Bridge only while preparing definitive decompression

›Epinephrine for peri-arrest or arrest

›1 mg IV per ACLS protocol for PEA arrest

›CPR should continue during decompression attempt

›Sedation and analgesia

›Emergent needle decompression generally requires no sedation

›Tube thoracostomy in conscious patients

›Ketamine 0.5 to 1 mg/kg IV for procedural sedation

›Fentanyl 1 to 2 mcg/kg IV for analgesia

›Positive-pressure ventilation caution

›PPV can rapidly convert simple pneumothorax to tension

›Maintain high suspicion in any patient on PPV with acute decompensation

Open pneumothorax management

›Initial wound management

›Three-sided occlusive dressing

›Prevents air entrainment while allowing escape

›Immediately applied to open chest wound

›Avoid completely occlusive seal before chest tube

›Risk of converting open to tension pneumothorax

›Definitive management

›Tube thoracostomy remote from wound

›Chest wall defect surgical repair

›Antibiotic prophylaxis for penetrating injuries

›Indicated for penetrating open pneumothorax

›Not indicated for blunt or spontaneous pneumothorax tube insertion

Post-decompression monitoring

›Clinical improvement endpoints

›Hemodynamic stabilization within minutes of successful decompression

›BP improvement

›Heart rate reduction

›SpO2 improvement

›If no improvement after decompression

›Consider contralateral pneumothorax

›Reassess for concurrent tamponade

›Ensure tube position confirmed

›Chest tube failure assessment

›Persistent air leak beyond 3 to 5 days

›Thoracic surgery consultation

›VATS consideration

›Failure to re-expand after 3 to 5 days

›CT to assess underlying parenchymal disease

›Surgical consultation

09Special Populations/sp82

Pregnancy

›Physiologic considerations in pregnancy

›Diaphragm elevation reduces lung reserve

›Earlier hypoxemia with any respiratory compromise

›Lower tolerance for tension physiology

›Hypotension impacts uteroplacental perfusion

›Maternal SpO2 target >= 95% to maintain fetal oxygenation

›Left lateral decubitus positioning to relieve aortocaval compression

›Increased respiratory rate baseline in pregnancy

›May mask early tachypnea as warning sign

›Procedural considerations in pregnancy

›Needle decompression and chest tube placement as in non-pregnant

›No modification to decompression technique

›Definitive decompression is mandatory regardless of gestational age

›Imaging

›CXR with abdominal shielding when required

›CT only when clinical benefit outweighs radiation risk

›Fetal monitoring

›Continuous fetal monitoring when viable gestation

›Obstetric team involvement for gestations > 23 to 24 weeks

›Sedation and analgesia in pregnancy

›Ketamine generally considered safe for procedural use

›Benzodiazepines with caution

›Fentanyl for analgesia is acceptable

Geriatric

›Physiologic vulnerabilities in older adults

›Reduced respiratory reserve

›Earlier decompensation with smaller pneumothorax

›Diminished cough reflex and secretion clearance

›Reduced cardiovascular reserve

›Less tachycardia response blunting hemodynamic alarm

›Beta-blocker use masks tachycardia

›Altered pharmacokinetics

›Reduced renal clearance for drug dosing

›Polypharmacy interactions with sedation agents

›Presentation differences in older adults

›Atypical presentation common

›Confusion or delirium as primary presenting symptom

›Falls as presenting event from syncope

›Comorbidities amplifying risk

›COPD: higher risk of barotrauma and spontaneous pneumothorax

›Osteoporosis: rib fractures from minor trauma

›Management modifications in older adults

›Lower threshold for ICU admission

›Limited physiologic reserve

›Frailty and limited home supports

›Sedation dose reduction

›Ketamine 0.25 to 0.5 mg/kg IV for procedural sedation

›Fentanyl 0.5 to 1 mcg/kg IV for analgesia

›Aggressive pain management after chest tube

›Adequate analgesia prevents respiratory splinting

›Non-steroidal anti-inflammatory use with caution given renal risk

Pediatrics

›Etiology differences in children

›Traumatic causes common in older children and adolescents

›Sports injuries

›Motor vehicle trauma

›Iatrogenic causes in neonates and ICU infants

›High-frequency ventilation barotrauma

›Central line complications

›Primary spontaneous pneumothorax in adolescents

›Similar tall thin male phenotype to adults

›Marfan syndrome screening in recurrent cases

›Physiologic differences in pediatric patients

›Mediastinal structures more mobile

›Faster hemodynamic compromise from mediastinal shift

›Earlier and more dramatic presentation

›Smaller chest wall

›Smaller needle decompression gauge for small children

›18 to 22 gauge in young children

›Higher respiratory rate baseline

›Age-appropriate tachypnea thresholds apply

›Infant RR > 60, child RR > 40 as concern thresholds

›Pediatric management

›Needle decompression at 2nd intercostal space midclavicular line

›18 to 22 gauge in young children

›14 to 16 gauge in older children and adolescents

›Tube thoracostomy size weight-based

›Neonate 10 to 14 Fr

›Infant 14 to 20 Fr

›Child 20 to 28 Fr

›Adolescent as per adult sizing

›Pediatric ACLS for PEA arrest from tension

›Bilateral chest decompression during pulseless arrest

›Weight-based epinephrine 0.01 mg/kg IV per pediatric ACLS

10Background/b91

Epidemiology

›Incidence and prevalence

›Tension pneumothorax accounts for 3 to 5% of all trauma deaths

›Leading cause of preventable death in trauma

›Third most common cause of preventable prehospital death

›Traumatic pneumothorax incidence in polytrauma approximately 20%

›Up to 50% in severe chest trauma

›WSES-AAST 2025 data

›Spontaneous pneumothorax incidence

›Primary: 7.4 per 100,000 males per year, 1.2 per 100,000 females per year

›Secondary: higher mortality due to underlying lung disease

›Population distribution

›Trauma cases: all ages with injury

›Primary spontaneous: tall thin males aged 20 to 40 years

›Secondary spontaneous: older adults with COPD and lung disease

›Iatrogenic: procedural complication across all ages

›Mechanically ventilated patient risk

›Hypotension 12.6 times more likely in ventilated vs spontaneously breathing patients

›Cardiac arrest 17.7 times more likely in ventilated patients

›70.4% develop hypotension or cardiac arrest within minutes

›Annals of Surgery 2015 systematic review

›Recurrence rates

›Primary spontaneous pneumothorax: 30 to 50% recurrence rate

›Risk highest in first year after initial episode

Pathophysiology

›One-way valve mechanism

›Air enters pleural space on inspiration

›Breach in lung parenchyma or chest wall

›Check-valve prevents air escape on expiration

›Progressive pleural air accumulation with each breath

›Ipsilateral lung compression and collapse

›Mediastinal shift to contralateral side

›Hemodynamic consequences

›Impaired venous return

›Mediastinal shift kinks superior and inferior vena cava

›Reduced right ventricular preload

›Right heart strain and failure

›Reduced right ventricular output

›Reduced left ventricular filling from decreased RV output

›Obstructive shock

›Profound hypotension from reduced cardiac output

›Tissue hypoperfusion and lactic acidosis

›Respiratory consequences

›Ipsilateral lung compression

›Atelectasis and loss of gas exchange

›Ventilation-perfusion mismatch

›Contralateral lung compression

›Mediastinal shift reduces contralateral expansion

›Hypoxemia from bilateral compromise

›Positive-pressure ventilation amplification

›Each breath forces more air into pleural space

›Dramatically accelerates tension physiology

›Classification of pneumothorax types

›Primary spontaneous

›No identifiable lung disease

›Apical subpleural blebs typical

›Secondary spontaneous

›Underlying lung disease

›Higher morbidity and mortality

›Traumatic

›Blunt or penetrating mechanism

›Iatrogenic

›Procedure related

Therapeutic Considerations

›Decompression method selection

›Needle decompression vs finger thoracostomy debate

›Finger thoracostomy 92.1% success vs needle 76.3% in cadaveric models

›Needle preferred when operator unfamiliar with thoracostomy

›Finger thoracostomy preferred in prehospital by trained providers

›Both are bridges to definitive tube thoracostomy

›Needle and finger thoracostomy are temporizing measures

›Tube thoracostomy must follow all bridge decompression methods

›Re-expansion pulmonary edema

›Rare complication after rapid lung re-expansion

›Unilateral pulmonary edema on CXR

›Supportive management with oxygen and PEEP

›Risk factors

›Large pneumothorax with prolonged lung collapse

›Young patients

›Recurrence prevention strategy

›Smoking cessation critical

›Reduces recurrence risk significantly

›Clinical Medicine 2025 review emphasis

›Surgical pleurodesis consideration

›Video-assisted thoracoscopic surgery with pleurodesis and bullectomy

›Indications: recurrent pneumothorax, persistent air leak, bilateral pneumothorax

›High-risk occupations: pilots, divers requiring definitive prevention

›Chemical pleurodesis

›Talc pleurodesis for patients not surgical candidates

›Secondary spontaneous pneumothorax in COPD patients

›Antibiotic considerations

›Not indicated for blunt or spontaneous pneumothorax chest tube

›Indicated for penetrating injuries and open pneumothorax

›Prophylaxis evidence limited for routine chest tube insertion

11Patient Discharge Instructions/pdi37

copy discharge instructions

›Tension pneumothorax recovery instructions

›All tension pneumothorax patients are admitted to hospital

›No patient with tension pneumothorax goes home from the emergency department

›These instructions apply after hospital discharge following treatment

›Activity restrictions

›Avoid heavy lifting or straining for 6 weeks

›No Valsalva maneuvers during recovery

›Gradual return to normal activity as cleared by specialist

›Air travel and diving restrictions

›No air travel until confirmed resolution on imaging

›Typically 2 to 6 weeks after confirmed resolution

›Confirm with treating physician or specialist before flying

›No scuba diving permanently or until cleared by specialist

›Pressure changes dramatically increase recurrence risk

›Specialist clearance required before return to diving

›No commercial air travel until chest tube removed and full expansion confirmed

›Medications and wound care

›Take prescribed pain medications as directed

›Chest tube site wound care instructions as provided

›Keep wound dry and clean until healed

›Complete any prescribed antibiotic course if given for penetrating injury

›Warning signs requiring immediate return to emergency department

›Sudden worsening shortness of breath

›Chest pain that is new or worsening

›Lightheadedness or fainting

›Bluish discoloration of lips or fingertips

›Racing heart or palpitations

12References/r39

Guidelines and key sources

›Primary guidelines

›WSES-AAST Thoracic Trauma Guidelines 2025

›Coccolini F et al. World Journal of Emergency Surgery 2025

›Comprehensive trauma pneumothorax management protocol

›British Thoracic Society Pleural Disease Guideline

›Spontaneous pneumothorax classification and management

›Conservative vs interventional approach criteria

›AHA ACC Chest Pain Guideline 2021

›Gulati M et al. Journal of the American College of Cardiology 2021

›Differential diagnosis framework for chest pain presentations

Key trials and systematic reviews

›Systematic reviews

›Roberts DJ et al. Annals of Surgery 2015

›Clinical Presentation of Patients With Tension Pneumothorax systematic review

›Spontaneously breathing vs ventilated patient data

›Cardiac arrest 17.7 times more likely in ventilated patients

›Chan KK et al. Cochrane Database of Systematic Reviews 2020

›Chest Ultrasonography vs Supine CXR for Pneumothorax in Trauma

›Ultrasound superiority in trauma pneumothorax detection

›Anderson D et al. JAMA Surgery 2022

›Comprehensive Review of Chest Tube Management

›Recent evidence

›Ausman JA et al. Prehospital Emergency Care 2026

›Needle decompression vs finger thoracostomy in cadaveric models

›Finger thoracostomy 92.1% vs needle 76.3% success rate

›Dubroc Z et al. American Journal of Emergency Medicine 2025

›Colorimetric capnography adjunct during needle decompression

Evidence & Review

Evidence & Review