CCS Case: Tension Pneumothorax

Case: Tension Pneumothorax

Clinical Setup

• Presentation: 28-year-old male after motorcycle crash: severe dyspnea, SpO2 84%, BP 82/50, HR 132, JVD, tracheal deviation away from left side, absent left breath sounds, hyperresonance.
• Location: Emergency Department (Trauma Bay).

Optimal Order Pathway

1. Immediate Orders (Minute 0–1):
   • Pulse oximetry, continuous cardiac monitoring, BP q5–15min.
   • 2 large-bore IVs, Normal saline wide open; high-flow O2.
   • Immediate needle decompression: large-bore needle into 2nd intercostal space midclavicular line (or 4th–5th ICS anterior axillary line) on affected side — DO NOT wait for imaging.
2. Focused Exam (Minute 1–2):
   • Primary trauma survey (ABCDE), chest wall (flail, open wounds, subcutaneous emphysema), repeat vitals post-decompression.
3. Diagnostics (Minute 2–5):
   • Portable CXR AFTER decompression (confirm lung re-expansion, check tube placement later).
   • CBC, type and crossmatch, ABG, FAST exam, trauma CT per protocol once stable.
4. Therapeutics (Minute 5–15):
   • Definitive: tube thoracostomy (chest tube) on affected side immediately after needle decompression.
   • Trauma surgery consult; continue fluid resuscitation and transfuse per massive-transfusion protocol if hemorrhagic shock coexists.
   • Analgesia; tetanus update; antibiotics if open chest wound.
5. Disposition (Minute 15–20):
   • Admit to trauma surgery/ICU depending on associated injuries.
   • Monitor chest tube output and air leak; repeat CXR after tube placement.
6. Final 2 Minutes:
   • Counsel on recovery timeline, smoking cessation (pneumothorax recurrence), seatbelt/helmet safety.
   • Schedule trauma surgery follow-up; arrange chest tube removal planning and PT referral.