Tension Pneumothorax (TPTX): Chest Trauma Part I

A special thank you to Myles Francis of Archangel Dynamics for allowing me to publish his Tactical Medicine posts here on Vigilant Wolf. Myles is a friend and past guest of Ever Vigilant podcast (episode 59).

In order to fully understand the next few posts, we need to understand the physiology behind TPTX. As always, this post is provided for educational / information purposes only. Follow your local protocols, we are not responsible for what you choose to do with this information.

A Pneumothorax is a condition where air gets trapped between a lung and the chest wall. In penetrating trauma, a defect in the chest wall results in a buildup of air inside the chest on the affected side. In Closed/Blunt trauma, a lung can burst or be otherwise injured, causing an air leak into the chest. Closed chest injury can also occur from excessive BVM ventilation or an improperly programmed ventilator (Remember, the P in the DOPE nemonic is for Pneumothorax). If left untreated, this can progress to a TPTX.

TPTX is an immediately life threatening condition. Many things occur as air pressure increases. The lung on the affected side of the chest will collapse, causing severe respiratory distress and a decrease in oxygenation & ventilation. Eventually, the heart will be compressed, as well as Superior Vena Cava (the large vessel that returns blood to the heart), decreasing preload. When combined, or when working independently, these cause a decrease in Cardiac Output, resulting in obstructive shock, which will lead to death if untreated.

TPTX is a leading cause of death in trauma, and should be considered in any Traumatic Arrest with associated chest trauma. In a tactical setting, management is deferred until the Tactical Field Care Phase, under R: Respiration. In a non tactical setting, this should be addressed during your primary survey / life threats assessment, after first ruling out controllable hemorrhage. TPTX is a common cause of post intubation arrest in trauma patients, so do this before you RSI.

Signs / Symptoms of Tension Pneumothorax:

  • 1. In a tactical setting, severe or progressive respiratory distress and / or Tachypnea with associated chest trauma should be considered a TPTX and treated accordingly. Any traumatic arrest in a tactical setting without obviously mortal wounds should also be considered as a possible TPTX.

  • 2. Respiratory Distress. This is the most commonly observed sign, and is often described as “Air Hunger.” Imagine your worst CHF Patient ever - panicked, unable to be consoled, and franticly gasping for air.

  • 3. Hypoxia is common.

  • 4. Chest discomfort / Pain.

  • 5. Uneven chest rise & fall and / or uneven breath sounds. Breath sounds will be diminished on the affected side of the chest. Place your hands on the patient's chest as they breathe.

  • 6. Signs of shock: Tachycardia, Hypotension, pale skin, diaphoresis (a result of the heart compensating for its decreasing cardiac output).

  • 7. “Late Signs” (Often seen in the peri-arrest or arrest stage): Tracheal deviation (the trachea and chest contents shifts to the unaffected side of the chest as a result if uneven intrathoracic pressure) and jugular vein distention (venous pooling, a sign of poor preload and a shock state). In the Traumatic Arrest patient, a narrow complex tachycardia as an underlying rhythm of PEA may be seen on the cardiac monitor.

  • 8. A special note. In severe injury, BOTH sides of the chest can be affected, as can the Mediastinum (called a Pneumomediastinum). Always assess both sides of the chest and the back of the body (to rule out a pass through injury in penetrating chest trauma).

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