🚨 Tension Pneumothorax

A life-threatening condition where air enters the pleural space but cannot escape, leading to progressive accumulation of air and increased intrathoracic pressure. This compresses the lung, shifts the mediastinum, and impairs venous return, causing cardiovascular collapse. It requires immediate recognition and decompression.

Sudden onset of severe pleuritic chest pain and dyspnoea, often following trauma or in ventilated patients. Clinical signs include tracheal deviation away from the affected side, absent breath sounds on the affected side, hyper-resonance to percussion, and distended neck veins. Hypotension and tachycardia are late, ominous signs.

Rapidly assess airway and breathing, noting respiratory rate, oxygen saturation, and tracheal position. Check circulation for heart rate, blood pressure, and capillary refill time; assess for distended neck veins. Disability assessment (GCS) and exposure to look for chest wall trauma.

Rapidly deteriorating oxygen saturation, increasing respiratory distress, progressive hypotension, increasing tachycardia, or new onset of tracheal deviation. Any sign of cardiovascular collapse warrants immediate intervention.

Clinical diagnosis is paramount; do not delay treatment for investigations. If stable enough, a Chest X-ray (CXR) can confirm diagnosis. ABG may show hypoxia and respiratory acidosis. ECG may show non-specific changes or signs of right heart strain.

Immediate needle decompression (thoracocentesis) is life-saving, inserting a large-bore cannula into the 2nd intercostal space, mid-clavicular line, or 5th intercostal space, mid-axillary line. Administer high-flow oxygen. Following decompression, a chest drain should be inserted definitively. Monitor vital signs closely.

Any suspicion of tension pneumothorax requires immediate senior input and intervention. Failure to improve after needle decompression, or recurrent tension, necessitates urgent surgical review. ICU referral may be needed for ongoing respiratory support.

Tension pneumothorax is a clinical diagnosis; 'don't wait for the X-ray'. Needle decompression is a temporising measure, always followed by chest drain insertion. Remember the classic triad: tracheal deviation, absent breath sounds, and hyper-resonance. It's a common trauma scenario.