Emergency decompression of a tension pneumothorax using:
This procedure can be life saving but it can have complications so we need to select the right situation to perfrome it.
The presence of tension pneumothorax is not always an "all or nothing" thing - symptoms usually start fairly mildly and progress. That rate of progression can be rapid or considerably slower. The progression of symptoms might be our biggest clue.
Clear thought re pros and cons is important before we decompress a chest. How much do we suspect a tension? How sick is the patient? Can we perform an USS? Can we wait to try to be clearer about the diagnosis? .....all weighed against...if we think this is a tension and if we think it is markedly affecting the patient (extreme dyspnoea/tachypnoea, reduced ventilation (hyperexpanded, reduced breath sounds), hypotension, deteriorating in front of us) then we we need to act now.
In the absence of haemodynamic or significant respiratory compromise and without clear signs of a tension pneumothorax, we can pause, observe and attempt to clarify the diagnosis with USS, CXR or clinical findings...but watch for that progression.
Traumatic cardiac arrest where tension pneumothorax is a possibility.
Significant doubt about the diagnosis and patient not in extremis.
14 or 16G IV cannula - longer is better -
20ml syringe (not essential)
Optional - Heimlich valve or improvised Heimlich valve
Select site (ease, speed, chance of success)
5th intercostal space in the anterior or mid axillary line (possibly higher chance of success than the traditional site, below)
2nd intercostal space in the mid-clavicular line (the second rib joins the sternum at the Angle of Louis) - failure rate up to 50%
Open or 'finger' thoracostomy is a useful alternative that guarantees the chest cavity is decompressed and can provide diagnostic information.
NB Do not insert your finger if there is a rib fracture next to the insertion site - the bone will cut through your glove and into you.
Cannula too short and thus not reaching the pleural space.
Possible creation of a small pneumothorax from the cannula.
Obstruction of the cannula by tissue leading to failed decompression.
Failure to follow up this procedure with formal chest tube insertion.
If needle thoracostomy fails: