Episode 25: Tension pneumothorax 2

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Where can you undertake decompression of a pneumothorax?

Be particularly careful when using the 2nd intercostal space mid-clavicular line that you are sufficiently lateral. For example, here are the locations identified as ‘2nd ICS mid clavicular line’ amongst 25 EM physicians in a 2005 EMJ paper.


From http://emj.bmj.com/content/22/11/788

The Three Kings: George Clooney’s recommended approach to decompression of a tension pneumothorax. Note – again please do not use this location!

Devices used for decompression:


Dressings available for covering an open pneumothorax +/- thoracostomy in a spontaneously breathing patient:



  • Ball, C. G., Wyrzykowski, A. D., Kirkpatrick, A. W., Dente, C. J., Nicholas, J. M., Salomone, J. P., et al. (2010). Thoracic needle decompression for tension pneumothorax: clinical correlation with catheter length. Canadian Journal of Surgery Journal Canadien De Chirurgie53(3), 184–188.
  • Barton, E. D., Epperson, M., Hoyt, D. B., Fortlage, D., & Rosen, P. (1995). Prehospital needle aspiration and tube thoracostomy in trauma victims: a six-year experience with aeromedical crews. The Journal of Emergency Medicine13(2), 155–163.
  • Beckett, A., Savage, E., Pannell, D., Acharya, S., Kirkpatrick, A., & Tien, H. C. (2011). Needle Decompression for Tension Pneumothorax in Tactical Combat Casualty Care: Do Catheters Placed in the Midaxillary Line Kink More Often Than Those in the Midclavicular Line? The Journal of Trauma71, S408–S412. http://doi.org/10.1097/TA.0b013e318232e558
  • Cullinane, D., Morris, J., Bass, J., & Rutherford, E. (2001). Needle thoracostomy may not be indicated in the trauma patient. Injury32, 749–752.
  • Ferrie, E. P., Collum, N., & McGovern, S. (2005). The right place in the right space? Awareness of site for needle thoracocentesis. Emergency Medicine Journal22(11), 788–789. http://doi.org/10.1136/emj.2004.015107
  • Fitzgerald, M., Mackenzie, C. F., Marasco, S., Hoyle, R., & Kossmann, T. (2008). Pleural decompression and drainage during trauma reception and resuscitation. Injury39(1), 9–20. http://doi.org/10.1016/j.injury.2007.07.021
  • Givens, M. L., Ayotte, K., & Manifold, C. (2004). Needle thoracostomy: implications of computed tomography chest wall thickness. Academic Emergency Medicine : Official Journal of the Society for Academic Emergency Medicine11(2), 211–213. http://doi.org/10.1197/j.aem.2003.09.015
  • Harcke, H. T., Mabry, R. L., & Mazuchowski, E. L. (2013). Needle thoracentesis decompression: observations from postmortem computed tomography and autopsy. Journal of Special Operations Medicine : a Peer Reviewed Journal for SOF Medical Professionals13(4), 53–58.
  • Inaba, K., Branco, B. C., Eckstein, M., Shatz, D. V., Martin, M. J., Green, D. J., et al. (2011). Optimal positioning for emergent needle thoracostomy: a cadaver-based study. The Journal of Trauma71(5), 1099–103– discussion 1103. http://doi.org/10.1097/TA.0b013e31822d9618
  • Inaba, K., Ives, C., McClure, K., Branco, B. C., Eckstein, M., Shatz, D., et al. (2012). Radiologic evaluation of alternative sites for needle decompression of tension pneumothorax. Archives of Surgery (Chicago, Ill : 1960)147(9), 813–818. http://doi.org/10.1001/archsurg.2012.751
  • Jadder, U., & McAuley, D. (2005). Transthoracic ultrasonography to diagnose pneumothorax in trauma. BestBETS.org, 1–3.
  • Jones, R., & Hollingsworth, J. (2002). Tension pneumothoraces not responding to needle thoracocentesis. Emergency Medicine Journal19, 176–177.
  • MD, A. R. M., MD, M. E. R., MD, C. S. C., & MD, J. L. M. (2015). Ultrasound determination of chest wall thickness: implications for needle thoracostomy. The American Journal of Emergency Medicine, 1–5. http://doi.org/10.1016/j.ajem.2010.06.030
  • MD, B. B., & MD, J.-M. T. (2012). Initial Management and Resuscitation of Severe Chest Trauma. Emergency Medicine Clinics of NA30(2), 377–400. http://doi.org/10.1016/j.emc.2011.10.010
  • MD, E. J. C., MD, C. H. C., BS, R. M., PHD, C. L. A., RDMS, C. A. K. M. M., RDMS, S. S. M., & RDMS, J. C. F. M. (2013). Ultrasound in Emergency Medicine. The Journal of Emergency Medicine44(1), 142–149. http://doi.org/10.1016/j.jemermed.2012.02.032
  • Netto, F. A. C. S., Shulman, H., Rizoli, S. B., Tremblay, L. N., Brenneman, F., & Tien, H. (2008). Are needle decompressions for tension pneumothoraces being performed appropriately for appropriate indications? The American Journal of Emergency Medicine26(5), 597–602. http://doi.org/10.1016/j.ajem.2007.08.016
  • Rathinam, S., Grobler, S., Bleetman, A., Kink, T., & Steyn, R. (2014). Evolved design makes ThoraQuik safe and user friendly in the management of pneumothorax and pleural effusion. Emergency Medicine Journal31(1), 59–64. http://doi.org/10.1136/emermed-2012-201821
  • Rathinam, S., Quinn, D. W., Bleetman, A., Wall, P., & Steyn, R. S. (2011). Evaluation of ThoraQuik: a new device for the treatment of pneumothorax and pleural effusion. Emergency Medicine Journal28(9), 750–753. http://doi.org/10.1136/emj.2009.082297
  • Sanchez, L. D., Straszewski, S., Saghir, A., Khan, A., Horn, E., Fischer, C., et al. (2011). Anterior versus lateral needle decompression of tension pneumothorax: comparison by computed tomography chest wall measurement. Academic Emergency Medicine : Official Journal of the Society for Academic Emergency Medicine18(10), 1022–1026. http://doi.org/10.1111/j.1553-2712.2011.01159.x
  • Wax, D. B., & Leibowitz, A. B. (2007). Radiologic assessment of potential sites for needle decompression of a tension pneumothorax. Anesthesia and Analgesia105(5), 1385–8– table of contents. http://doi.org/10.1213/01.ane.0000282827.86345.ff
  • Yamagiwa, T., Morita, S., Yamamoto, R., Seki, T., Sugimoto, K., & Inokuchi, S. (2012). Determination of the appropriate catheter length for needle thoracostomy by using computed tomography scans of trauma patients in Japan. Injury43(1), 42–45. http://doi.org/10.1016/j.injury.2010.11.022
  • Zengerink, I., Brink, P. R., Laupland, K. B., Raber, E. L., Zygun, D., & Kortbeek, J. B. (2008). Needle thoracostomy in the treatment of a tension pneumothorax in trauma patients: what size needle? The Journal of Trauma64(1), 111–114.  http://doi.org/10.1097/01.ta.0000239241.59283.03

Episode 24: Tension pneumothorax 1


Firstly, go and read Simon and Tim Harris’ great 2005 paper on the subject which we reference repeatedly in the podcast. It is available free open access here.

A pneumothorax exists when air accumulates in the potential space between the visceral and parietal pleura:

Pneumothorax during respiratory cycle

From: www.wisdomjobs.com

A tension pneumothorax exists when the air in the pleural cavity is under high pressure resulting in compression of the surrounding structures.

Simon mentions Rutherford’s diagram in the podcast. This is taken from a 1968 paper examining the progressive pathophysiology of a tension pneumothorax. The graph shows the changes in intrapleural pressure (on the ipsilateral and contralateral sides) in spontaneously breathing goats who had air injected into one side of their chest. We can’t find the full article free/open access anywhere I’m afraid. But this is the reference: THE PATHOPHYSIOLOGY OF PROGRESSIVE, TENSION PNEUMOTHORAX. Rutherford RB, Hurt HH, Brickman RD, Tubb JM. Journal of Trauma and Acute Care Surgery, March 1968,8(2):212-227

Diagram from Rutherford's 1968 paper on tension pneumothorax

The imaging findings of tension pneumothorax might look like this:

More plain film images are available in this article on the Radiopaedia website.

And you can see what a CT scan of a patient with tension pneumothorax looks like in this vimeo shared on the Life in the Fast Lane website.

If you want to know about ultrasound findings of pneumothorax, check out this great R.E.B.E.L.EM post.


Leigh-Smith S, Harris T. Tension pneumothorax—time for a re-think? EMJ. 2005; 22:8-16.  doi.org/10.1136/emj.2003.010421

Roberts DJ, Leigh-Smith S et al. Clinical Presentation of patients with a Tension Pneumothorax – a systematic review. Annals of Surgery. 2015; 261: 1068-78. doi: 10.1097/SLA.0000000000001073