1. Rapid Clinical Assessment
- ABCDE Approach
- Monitoring and Oxygenation:
- Put on high flow mask
- Maintain SpO₂ > 95%.
- Place the patient on a cardiac monitor.
- Establish intravenous (IV) access.
2. Identification of Tension Pneumothorax
Clinical Presentation
i. Respiratory Distress
-
Severe shortness of breath
-
Tachypnea (rapid breathing)
-
Hypoxia (low oxygen saturation)
ii. Asymmetrical Chest Movement
-
Reduced or absent chest expansion on the affected side
-
The chest wall may appear hyperinflated on one side
iii.Tracheal Deviation
-
The trachea shifts away from the side of the pneumothorax (contralateral deviation)
-
Best assessed at the suprasternal notch
-
The affected side produces a hollow or tympanic sound due to trapped air
-
Percussion over the ipsilateral side reveals increased resonance
-
Diminished or absent breath sounds on the affected side upon auscultation
-
May also note decreased vocal fremitus on palpation
-
Jugular venous distension due to impaired venous return to the heart
-
Not always present, especially in hypovolemic patients
eFAST Findings:
- Absence of Sliding Sign
- Presence of Stratosphere/Barcode Sign
- Presence of Lung Point
- Absence of Lung Pulse
3. Immediate Intervention
Goal: Relieve intrathoracic pressure to allow lung re-expansion and restore venous return to the heart.
Preferred Method: Finger Thoracostomy
- Identify the fifth intercostal space at the anterior or mid-axillary line (the "safe triangle").
Procedure:
i. Use aseptic technique and wear personal protective equipment.
ii. Position the patient supine or with the head elevated if possible.
iii. Make a 2–3 cm horizontal incision over the rib below the intended intercostal space.
iv. Blunt Dissection: Use a curved hemostat to dissect through subcutaneous tissue and muscle layers.
v. Advance over the superior border of the rib to avoid the neurovascular bundle.
vi. Puncture the parietal pleura and insert a gloved finger into the pleural space.
vii. Feel for the release of air (hiss) and lung re-expansion.
Advantages
i. Definitive Decompression:
- Creates a larger aperture for air evacuation.
ii. Direct Confirmation:
- Allows tactile feedback upon entering the pleural space
iii. Overcome the Limitation:
- inadequate catheter length in patients with a thick chest wall.
4. Post-Decompression
- Monitor the patient's respiratory and hemodynamic status.
- Prepare for chest tube (intercostal drain) insertion for definitive management.