What is the initial management for a suspected tension pneumothorax, specifically regarding the use of finger thoracostomy (FT)?

Management of Suspected Tension Pneumothorax

For suspected tension pneumothorax, immediate needle decompression with a cannula of adequate length (at least 4.5 cm, preferably 7 cm) should be performed at either the second intercostal space in the mid-clavicular line or the fifth intercostal space in the mid-axillary line, followed by tube thoracostomy. 1

Recognition and Diagnosis

• Tension pneumothorax occurs when intrapleural pressure exceeds atmospheric pressure throughout the respiratory cycle, creating a one-way valve effect that traps air in the pleural space 2, 1
• Clinical presentation includes rapid labored respiration, cyanosis, sweating, tachycardia, progressive respiratory distress, and hypoxemia 2, 1
• Particularly suspect tension pneumothorax in patients on mechanical ventilation or non-invasive ventilation who suddenly deteriorate or develop pulseless electrical activity (PEA) 1, 3
• The diagnosis is primarily clinical - do not delay treatment while waiting for radiographic confirmation 1

Emergency Management Algorithm

Step 1: Immediate Decompression

• Insert a cannula of adequate length (minimum 4.5 cm, preferably 7-8.25 cm) into the second intercostal space in the mid-clavicular line 2, 1
• Use a 14-gauge or 10-gauge needle/catheter unit (No. 14 puncture needle) 2, 4
• Insert the needle/catheter perpendicular to the chest wall and advance fully to the hub 1
• Hold the needle/catheter in place for 5-10 seconds before removing the needle to allow for full decompression 1, 4

Step 2: Confirm Successful Decompression

• Successful decompression is indicated by: hiss of escaping air, decrease in respiratory distress, increase in oxygen saturation, and/or improvement in signs of shock 1, 4
• Leave the decompression cannula in place until a functioning intercostal tube can be positioned 2, 1

Step 3: Definitive Management

• Place a chest tube (tube thoracostomy) after initial decompression 2
• Connect the chest tube to an underwater seal drainage system 1
• If needle decompression fails after two attempts and the patient remains in shock, consider finger thoracostomy (simple thoracostomy) if the provider has appropriate skills and authorization 4

Anatomical Considerations

• The 5th intercostal space along the mid-axillary line (5MAL) may be considered for right-sided tension pneumothorax 1
• For left-sided cases, the 2nd intercostal space along the mid-clavicular line (2MCL) is safer due to potential risk of cardiac injury with lateral approaches 1
• Chest wall thickness often exceeds 3 cm in 57% of patients, making standard shorter needles ineffective - use longer needles (7-8.25 cm) 2, 1

Special Considerations

• Patients on positive pressure ventilation who develop pneumothorax should always receive tube thoracostomy as positive pressure maintains the air leak 1, 3
• An undetected small pneumothorax without symptoms can progress to tension pneumothorax through positive pressure ventilation during general anesthesia 3
• In tactical combat casualty care, perform needle decompression on both sides of the chest for casualties with torso trauma who suffer traumatic cardiac arrest 4
• Simple thoracostomy (finger thoracostomy) may be faster and simpler to perform in pre-hospital trauma settings and avoids risks associated with chest drain insertion 5

Post-Procedure Care

• Obtain a chest radiograph to confirm tube position and lung re-expansion 1
• Provide adequate analgesia and monitor vital signs and respiratory status 1
• Assess for persistent air leak or complications 1
• For patients with chest tubes, flush with saline every 2 hours to ensure patency 2

Common Pitfalls to Avoid

• Delaying treatment while waiting for radiographic confirmation - tension pneumothorax is a clinical diagnosis requiring immediate intervention 1
• Using needles that are too short - chest wall thickness often exceeds 3 cm 2, 1
• Removing the decompression cannula before a functioning chest tube is in place 2, 1
• Performing more than two needle decompressions before proceeding to evaluate for other causes of shock (such as hemorrhage) 4