Tension pneumothorax

Published 03/08/2022

Tension pneumothorax

Set-up: 

 

Lines/access: 

RIJ CVC, 2 peripheral cannulae 

Infusions: 

Sedatives, metaraminol (must be attached to peripheral cannulae – nothing attached to CVC) 

1L crystalloid (hanging with giving set but not attached to patient) 

Airway: 

ETT 

Ventilator: 

V-SIMV 500/8 FiO2 0.60 Rate 14 breaths/minute 

Other: 

Cardiac arrest trolley 

Clinical Setting

I:       You are the ICU registrar and are called to assess bed 2 

S:      Nurse reports difficulty in getting reliable arterial line trace 

B:      70-year-old ventilated patient with new fever, radial arterial line in situ, metaraminol running – trouble with trace 

A:     Unable to aspirate 

R:      Called for help 

Potential Clinical Course

  • Initially A ETT, B Sp02 80% on FiO2 0.6, TV 250ml, ETCO2 4.5kPa (climbing), RR 14 (controlled), auscultation clear on left, quiet on right, trachea deviated to left, C HR 115, BP 98/52 (falling), CRT >3sec, D sedated 
  • BP continues to fall, cardiac arrest 
  • Initial rhythm sinus tachycardia (PEA) 
  • Exclude relevant reversible causes. Patient has a right-sided tension pneumothorax: continue for a further cycle if not identified and treated 
  • Decompressive thoracostomy 
  • ROSC 
  • Asks for equipment for a chest drain 
  • Post resuscitation care 

Information for Faculty

  • Initial settings: SpO2 97% on FiO2 0.5 
  • ETCO2 4.5kPa 
  • RR 14 
  • Clear auscultation left lung field, quiet at right apex 
  • HR 88bpm SR 
  • BP 114/67 

 

  • Initial deterioration: SpO2 94% on FiO2 0.5 
  • ETCO2 4.5kPa 
  • RR 14 
  • Clear auscultation left lung field, quiet on right lung field 
  • HR 98bpm SR 
  • BP 105/52 

 

  • Progress to: SpO2 70% if FiO2 not increased. If increased then 85% 
  • ETCO2 3.0kPa 
  • RR (depending upon candidate’s ventilator settings) 
  • HR 146bpm SR 
  • BP 76/34 

 

  • Cardiac arrest: PEA  
  • SpO2 unrecordable 
  • ETCO2 4 
  • RR depends on patient ventilator settings/manual bagging 
  • BP dependent on chest compressions 

 

(Post needle thoracostomy) 

 

  • ROSC: SpO2 90% increasing to 94% 
  • ETCO2 3.0kPa rising to 4.2kPa 
  • HR 118bpm ST 
  • BP 145/88 

 

 

Scenario ends when candidate requests equipment for formal chest drain. 

Faculty Roles

Bedside Nurse 1:  

  • You are a senior critical care nurse 
  • You have received a 70 year old lady from the ED, already intubated and ventilated due to a community acquired pneumonia and worsening hypoxia. 
  • You are concerned that the arterial line isn’t working in a ventilated patient on metaraminol  
  • Do not volunteer the information that the patient has recently had a central line placed – however, if they ask you to give anything down the central line ask if they have ordered a CXR to check the position. If they have not worked out that the patient has a tension pneumothorax once they have a cardiac arrest, ask if it’s okay to use the central line without an x-ray 

 

Bedside Nurse 2: 

  • You are a new starter 
  • You have basic nursing skills but no specific ICU/airway skills 
  • You have no idea what is going on, and seem pretty disinterested unless the candidate declares a tension pneumothorax/emergency 

 

HiLLO: 5, 6 

Tension pneumothorax
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