Tension Pneumothorax

One-way air leak into pleural space → mediastinal shift → ↓venous return → cardiovascular collapse. Suspect with central line attempt, brachial plexus block, trauma, or sudden ↑PIP under PPV.

Recognition

•Hypoxia + hypotension + ↑PIP
•Tracheal deviation away (late sign)
•Absent unilateral breath sounds, hyperresonance
•Distended neck veins, JVD
•Hemodynamic improvement with disconnection from PPV

Steps

1
Recognize the trio: hypoxia, hypotension, ↑PIP
2
Disconnect from PPV + 100% FiO₂
Disconnection is both diagnostic and immediate decompression.
3
Needle decompression — 2nd ICS midclavicular line (adult)
Pediatric: 4th–5th ICS midaxillary preferred per ATLS 10th.
4
Hemodynamic support — fluid + pressor as needed
5
Definitive: chest tube 32–36 Fr, 5th ICS midaxillary line
6
Confirm placement + post-procedure CXR

Drugs + doses

Drug	Dose	Note
Phenylephrine	100–200 mcg IV bolus while preparing decompression
Norepinephrine	0.05–1 mcg/kg/min infusion

Pitfalls

!Don't wait for CXR if suspected; clinical diagnosis.
!Adult-length needle (3–5 cm) often inadequate for obese chest wall — use longer.
!Bilateral chest tubes if patient has had bilateral procedures + sudden collapse.

Sources

ATLS 10th Edition
WSES Guidelines 2017

Anatomy reference

Sourced reference images. 4 matches for "lung pleura thorax respiratory".

Wikimedia · Public domain

Servier · CC BY 3.0

Servier · CC BY 3.0

Wikimedia · CC BY 4.0

Browse the full image library →

Education only — not a substitute for facility protocols, MOC certification, or clinical judgment. Always follow your institutional crisis algorithm and confirm doses against current package inserts.