Tension Pneumothorax

Question 1

CWI- Indications

Answer 1

Suspected tension pneumothorax including in traumatic cardiac arrest

Question 2

CWI- Contraindications

Answer 2

The Air Release System (ARS) may not be appropriate for paediatric/small patients (use 14G or 16G decompression needle depending on patient’s size

Question 3

CWI- Clinical Precautions

Answer 3

• Tension pneumothorax decompression is a low volume/high risk skill performed in high pressure circumstances and requires regular practice to maintain familiarity with locating the appropriate physical landmarks and familiarity with equipment.
• If both sides of the chest are being decompressed, the patients right side should be decompressed first to minimise the risk of the needle puncturing the heart.
• Once inserted, if air escapes, or air and blood bubbles through the cannula, or no air/blood detected, leave inset. If copious blood flows out, remove the cannula and cover the insertion site with an occlusive dressing.
• There is a risk of body fluid being expelled under pressure when the procedure is initially done, or if CPR is subsequently performed.
• This procedure is monitored through the Limited Occurrence process.

Question 4

CWI- Equipment required

Answer 4

• Chlorhexidine/alcohol swab
• ARS needle (or approx sized cannula
• Sharps container
• Sterile gauze
• Adhesive tape

Question 5

CWI- Health, Safety and Welfare

Answer 5

• Apply standard precautions
• Modify as informed by the dynamic risk assessment
• It is recommended that paramedics wear gloves, safety glasses and a P2 mask at a minimum

Question 6

CWI- Prepare Equipment

Answer 6

Remove lid from Air Release System protective canister

Question 7

CWI- Locate and prepare site

Answer 7

• 2nd intercostal space, mid clavicular line on the affected site
• Thoroughly clean the insertion site with swab, ideally 10 seconds side to side or up down motion, repeated with second swab then allowed to dry
• Ensure easy access to sharps container

Question 8

CWI- Insertion of ARS/cannula

Answer 8

• Remove device from canister
• Insert needle at 90 degree angle to chest wall in lower part of 2nd intercostal space (just above rib below) angling towards the body of the vertebrae, holding cannula hub for support until a “give” is felt
• Progress needle into chest. Stop if a rush of air is heard, otherwise advance to the hilt.
• Withdraw needle from cannula and discard
• Leave cannula in place to decompress pneumothorax

Question 9

CWI- Post decompression

Answer 9

• Fold a piece of sterile gauze over the back of cannula and secure it with adhesive tape around the hub
• The ARS can be replaced by a pneumocath kit when appropriate. It should be left in place and open until this can be achieved or until arrival at hospital, with the patient monitored for possible recurrence of the tension pneumothorax

Question 10

CWI- Problem solving

Answer 10

• If the physical decompression has proved positive but air flow or physiological parameters decline suggesting the patient is re-tensioning:
• flush the cannula with 5-19ml of saline
• if that is ineffective then perform a second decompression in close proximity to the original cannula on the lateral side
• reassess for a positive response

Question 11

Define pneumothorax

Answer 11

The presence of air or gas in the pleural cavity (i.e. the potential space between the visceral and parietal pleura of the lung) which can impair oxygenation and/or ventilation

Question 12

Define Tension pneumothorax

Answer 12

A pneumothorax causing a progressive rise in intrapleural pressure to levels that become positive throughout the respiratory cycle and collapses the lung, shifts the mediastinum, and impairs venous return to the heart. Air continues to get into the pleural space but cannot exit.

Question 13

Define haemothorax

Answer 13

Occurs following a blunt or penetrating trauma when blood builds in the pleural space. Impaired gas exchange. Potentially large and incompressible haemorrhage. Chest cavity is large significant blood loss into an open space.

Question 14

Soft signs of pneumothorax

Answer 14

• Distended jugular veins
• Tracheal deviation (uncommon and very late sign)
• Surgical emphysema
• Asymmetry of chest
• Absent or hyper-resonant chest sounds on affected side
• Cyanosis
• Ventilating- stiff bag- resistance when ventilating
• Increased tidal C02

Question 15

Hard signs of pneumothorax

Answer 15

• increased respiratory distress
• decreasing perfusion
• decreasing conscious state