Recognizing Tension Pneumothorax: A Comprehensive Guide for Paramedics and Emergency Professionals
Abstract
Background: Tension pneumothorax is a life-threatening condition characterized by the progressive accumulation of air within the pleural space, leading to a positive pressure that displaces mediastinal structures, impairs venous return, and causes cardiovascular collapse. It represents a critical emergency across prehospital, emergency department, and intensive care settings, requiring immediate recognition and intervention to prevent mortality.
Aim: This comprehensive guide aims to educate paramedics and emergency professionals on the pathophysiology, rapid clinical identification, and emergent management of tension pneumothorax to improve patient outcomes.
Methods: The article synthesizes current medical knowledge on tension pneumothorax, detailing its etiology (traumatic, iatrogenic, and spontaneous), pathophysiology, and diagnostic approaches. Evaluation methods, including point-of-care ultrasound and chest X-ray for stable patients, are reviewed, with an emphasis on clinical diagnosis for unstable patients.
Results: The findings underscore that tension pneumothorax is a clinical diagnosis. Key signs include respiratory distress, hypotension, unilateral absent breath sounds, and tracheal deviation. Immediate needle decompression, typically in the anterior axillary line, is the critical first intervention, followed by definitive chest tube thoracostomy. Delays in decompression are directly linked to increased mortality.
Conclusion: Proficiency in the rapid recognition and immediate management of tension pneumothorax is a fundamental competency for frontline clinicians. Successful outcomes depend on a high index of suspicion, prompt needle decompression without awaiting imaging, and coordinated interprofessional care for definitive treatment and complication management.
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References
Rojas R, Wasserberger J, Balasubramaniam S. Unsuspected tension pneumothorax as a hidden cause of unsuccessful resuscitation. Ann Emerg Med. 1983 Jun;12(6):411-2.
ATLS Subcommittee; American College of Surgeons’ Committee on Trauma; International ATLS working group. Advanced trauma life support (ATLS®): the ninth edition. J Trauma Acute Care Surg. 2013 May;74(5):1363-6.
Roberts DJ, Leigh-Smith S, Faris PD, Ball CG, Robertson HL, Blackmore C, Dixon E, Kirkpatrick AW, Kortbeek JB, Stelfox HT. Clinical manifestations of tension pneumothorax: protocol for a systematic review and meta-analysis. Syst Rev. 2014 Jan 04;3:3.
Cameron PA, Flett K, Kaan E, Atkin C, Dziukas L. Helicopter retrieval of primary trauma patients by a paramedic helicopter service. Aust N Z J Surg. 1993 Oct;63(10):790-7.
Coats TJ, Wilson AW, Xeropotamous N. Pre-hospital management of patients with severe thoracic injury. Injury. 1995 Nov;26(9):581-5.
Eckstein M, Suyehara D. Needle thoracostomy in the prehospital setting. Prehosp Emerg Care. 1998 Apr-Jun;2(2):132-5.
Diaz R, Heller D. StatPearls [Internet]. StatPearls Publishing; Treasure Island (FL): Jul 31, 2023. Barotrauma and Mechanical Ventilation(Archived)
Melton LJ, Hepper NG, Offord KP. Incidence of spontaneous pneumothorax in Olmsted County, Minnesota: 1950 to 1974. Am Rev Respir Dis. 1979 Dec;120(6):1379-82.
Gupta D, Hansell A, Nichols T, Duong T, Ayres JG, Strachan D. Epidemiology of pneumothorax in England. Thorax. 2000 Aug;55(8):666-71.
Sharma A, Jindal P. Principles of diagnosis and management of traumatic pneumothorax. J Emerg Trauma Shock. 2008 Jan;1(1):34-41.
Toffel M, Pin M, Ludwig C. [Thoracic Surgical Aspects of Seriously Injured Patients]. Zentralbl Chir. 2020 Feb;145(1):108-120.
McPherson JJ, Feigin DS, Bellamy RF. Prevalence of tension pneumothorax in fatally wounded combat casualties. J Trauma. 2006 Mar;60(3):573-8.
Vinson DR, Ballard DW, Hance LG, Stevenson MD, Clague VA, Rauchwerger AS, Reed ME, Mark DG., Kaiser Permanente CREST Network Investigators. Pneumothorax is a rare complication of thoracic central venous catheterization in community EDs. Am J Emerg Med. 2015 Jan;33(1):60-6.
Tsotsolis N, Tsirgogianni K, Kioumis I, Pitsiou G, Baka S, Papaiwannou A, Karavergou A, Rapti A, Trakada G, Katsikogiannis N, Tsakiridis K, Karapantzos I, Karapantzou C, Barbetakis N, Zissimopoulos A, Kuhajda I, Andjelkovic D, Zarogoulidis K, Zarogoulidis P. Pneumothorax as a complication of central venous catheter insertion. Ann Transl Med. 2015 Mar;3(3):40.
El-Nawawy AA, Al-Halawany AS, Antonios MA, Newegy RG. Prevalence and risk factors of pneumothorax among patients admitted to a Pediatric Intensive Care Unit. Indian J Crit Care Med. 2016 Aug;20(8):453-8.
Roberts DJ, Leigh-Smith S, Faris PD, Blackmore C, Ball CG, Robertson HL, Dixon E, James MT, Kirkpatrick AW, Kortbeek JB, Stelfox HT. Clinical Presentation of Patients With Tension Pneumothorax: A Systematic Review. Ann Surg. 2015 Jun;261(6):1068-78.
Martin M, Satterly S, Inaba K, Blair K. Does needle thoracostomy provide adequate and effective decompression of tension pneumothorax? J Trauma Acute Care Surg. 2012 Dec;73(6):1412-7.
Barton ED, Rhee P, Hutton KC, Rosen P. The pathophysiology of tension pneumothorax in ventilated swine. J Emerg Med. 1997 Mar-Apr;15(2):147-53.
Nelson D, Porta C, Satterly S, Blair K, Johnson E, Inaba K, Martin M. Physiology and cardiovascular effect of severe tension pneumothorax in a porcine model. J Surg Res. 2013 Sep;184(1):450-7.
Light RW. Pleural diseases. Dis Mon. 1992 May;38(5):266-331.
Gordon R. The deep sulcus sign. Radiology. 1980 Jul;136(1):25-7.
DORNHORST AC, PIERCE JW. Pulmonary collapse and consolidation; the role of collapse in the production of lung field shadows and the significance of segments in inflammatory lung disease. J Fac Radiol. 1954 Apr;5(4):276-81.
Zhang M, Liu ZH, Yang JX, Gan JX, Xu SW, You XD, Jiang GY. Rapid detection of pneumothorax by ultrasonography in patients with multiple trauma. Crit Care. 2006;10(4):R112.
Soldati G, Iacconi P. The validity of the use of ultrasonography in the diagnosis of spontaneous and traumatic pneumothorax. J Trauma. 2001 Aug;51(2):423.
Shostak E, Brylka D, Krepp J, Pua B, Sanders A. Bedside sonography for detection of postprocedure pneumothorax. J Ultrasound Med. 2013 Jun;32(6):1003-9.
Zarogoulidis P, Kioumis I, Pitsiou G, Porpodis K, Lampaki S, Papaiwannou A, Katsikogiannis N, Zaric B, Branislav P, Secen N, Dryllis G, Machairiotis N, Rapti A, Zarogoulidis K. Pneumothorax: from definition to diagnosis and treatment. J Thorac Dis. 2014 Oct;6(Suppl 4):S372-6.
Arao K, Mase T, Nakai M, Sekiguchi H, Abe Y, Kuroudu N, Oobayashi O. Concomitant Spontaneous Tension Pneumothorax and Acute Myocardial Infarction. Intern Med. 2019 Apr 15;58(8):1131-1135.
Vallee P, Sullivan M, Richardson H, Bivins B, Tomlanovich M. Sequential treatment of a simple pneumothorax. Ann Emerg Med. 1988 Sep;17(9):936-42.
Henry M, Arnold T, Harvey J., Pleural Diseases Group, Standards of Care Committee, British Thoracic Society. BTS guidelines for the management of spontaneous pneumothorax. Thorax. 2003 May;58 Suppl 2(Suppl 2):ii39-52.
Dominguez KM, Ekeh AP, Tchorz KM, Woods RJ, Walusimbi MS, Saxe JM, McCarthy MC. Is routine tube thoracostomy necessary after prehospital needle decompression for tension pneumothorax? Am J Surg. 2013 Mar;205(3):329-32; discussion 332.
Terada T, Nishimura T, Uchida K, Hagawa N, Esaki M, Mizobata Y. How emergency physicians choose chest tube size for traumatic pneumothorax or hemothorax: a comparison between 28Fr and smaller tube. Nagoya J Med Sci. 2020 Feb;82(1):59-68.
Chen KC, Chen PH, Chen JS. New options for pneumothorax management. Expert Rev Respir Med. 2020 Jun;14(6):587-591.
Eguchi M, Abe T, Tedokon Y, Miyagi M, Kawamoto H, Nakasone Y. [Traumatic Intercostal Lung Hernia Repaired by Video-assisted Thoracoscopic Surgery;Report of a Case]. Kyobu Geka. 2019 Nov;72(12):1038-1041.
Johnson G. Traumatic pneumothorax: is a chest drain always necessary? J Accid Emerg Med. 1996 May;13(3):173-4.
Paydar S, Ghahramani Z, Ghoddusi Johari H, Khezri S, Ziaeian B, Ghayyoumi MA, Fallahi MJ, Niakan MH, Sabetian G, Abbasi HR, Bolandparvaz S. Tube Thoracostomy (Chest Tube) Removal in Traumatic Patients: What Do We Know? What Can We Do? Bull Emerg Trauma. 2015 Apr;3(2):37-40.
van den Brande P, Staelens I. Chemical pleurodesis in primary spontaneous pneumothorax. Thorac Cardiovasc Surg. 1989 Jun;37(3):180-2.
Huang TW, Lee SC, Cheng YL, Tzao C, Hsu HH, Chang H, Chen JC. Contralateral recurrence of primary spontaneous pneumothorax. Chest. 2007 Oct;132(4):1146-50.
British Thoracic Society Fitness to Dive Group, Subgroup of the British Thoracic Society Standards of Care Committee. British Thoracic Society guidelines on respiratory aspects of fitness for diving. Thorax. 2003 Jan;58(1):3-13.
Hsu CW, Sun SF, Lee DL, Chu KA, Lin HS. Clinical characteristics, hospital outcome and prognostic factors of patients with ventilator-related pneumothorax. Minerva Anestesiol. 2014 Jan;80(1):29-38.
Chen KY, Jerng JS, Liao WY, Ding LW, Kuo LC, Wang JY, Yang PC. Pneumothorax in the ICU: patient outcomes and prognostic factors. Chest. 2002 Aug;122(2):678-83.
Cooper JS, Hanson KC. StatPearls [Internet]. StatPearls Publishing; Treasure Island (FL): Dec 13, 2023. Decompression Sickness
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Copyright (c) 2025 Wael Abdullah Alharbi, Eid Salem Muaythif Alhazmi, Amjad Mudhayyif Alsufyani, Rashed Ali Alhutaylah, Ibrahim Jobran Moafa, Shadi Abdullah Hamzi
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