Tension Pneumothorax and Hemothorax (article) Jun 15,2017

Medical ( Airway and Respirations )

Tension Pneumothorax and Hemothorax

Patrick O’Neil, PA


Tension Pneumothorax is one of the preventable causes of death that we see on the battlefield.  Right up there is its little brother, Hemothorax.  Previous wars saw much higher incidences of these deaths than the current wars in Iraq and Afghanistan, and all the other hot spots that we currently find ourselves in.  This reduction has been because we have body armor that protects the chest cavity and because every combatant is trained in how to treat a tension pneumothorax.  Unfortunately, the civilian world still sees a bunch of these injuries.

 What Causes a Tension Pneumothorax or Hemothorax?

A Tension Pneumothorax and Hemothorax are normally caused by some form of trauma. This can be in the form of penetrating trauma (bullet, knife, etc.), blunt trauma, blast injury, or even a hard cough.  In basic terms, think of the chest cavity as a rigid container that is holding three balloons.  The lungs will represent two large balloons with a third smaller balloon that represents the heart.  If we have air or blood that is continually leaking from the organs into the chest cavity, the pressure in that cavity is going to increase.  With every breath coming into the lungs, more air escapes from the injured balloon, and the chest cavity pressure increases.  With increasing pressure, the lung that sustained the injury can collapse.  If the pressures continue to increase, the opposite lung and heart can also be affected and collapse.  Obviously, this is a situation where the patient can no longer sustain life and will pass away.




Signs and Symptoms

1.  Chest Pain/Tightness

2.  Shortness of Breath with “air hunger”

3.  Difficulty Breathing with a noticeable decrease in expansion of the chest

4.  A conscious patient may want to sit up and refuse to lie on their back

5.  Rapid breathing

6.  Rapid Heart Rate

7.  Bulging veins in the neck (Jugular Vein Distention)

8.  Deviation of the trachea (wind pipe) to one side

9.  Breath sounds will be diminished on the affected side, if you listen to the lungs

10.  If you tap your finger over the chest cavity, it may sound like a drum


The treatment goal is to remove the air/blood that is causing the over pressurization within the cavity. 

We do this through several methods:

► A chest seal with a one-way valve can be placed over the opening in the chest.  This will allow the air to escape as the person breathes, but not allow unwanted external air to enter through the wound.  It will not inflate the collapsed lung, but it will possibly prevent the condition from worsening.

► A Needle Thoracentesis can be performed where a 14 gauge, 3-1/4 inch needle is placed just above the second rib in the anterior chest.  Placement will allow excess air to escape, but should only be performed by those individuals that have been trained in how to perform this invasive procedure.  This method will also not inflate the lung.

► The gold standard to treat a Tension Pneumothorax/Hemothorax is a chest tube hooked up to low pressure suction.  This will evacuate the unwanted air and blood from the chest cavity.  It also has the very important advantage of being able to inflate the collapsed lung.

 When to seek medical attention?

The big question here is, “How long can you hold your breath?”  It is obvious if you have suffered some form of chest trauma, and you have a hole in your chest, you might want to go to a hospital.  These are what I call a “no brainer” type situation.  That being said, these injuries can occur from non-trauma, such as a weakness on the surface of the lung and can be ruptured by a hard cough.  If I am at home and notice for any reason that I am having progressively worsening Shortness of Breath or a more difficult time breathing……..I am dialing 911.  I’m not going to try and drive myself as I may lose consciousness.  Even if I pass out in my home, as long as I have called 911, they know where to find me!     

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