Decompressing a tension pneumothorax

When dealing with a tension pneumothorax causing hemodynamic instability, it's crucial that you rapidly decompress the pneumothorax before setting up for a chest tube placement. In this step-by-step video, from our Emergency Procedures Masterclass course, you'll learn how to perform both a needle compression and a finger compression, as well as what to do if things go wrong!

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[00:00:00] When dealing with a tension pneumothorax causing hemodynamic instability, time is of the essence, so it's important to rapidly decompress the tension pneumothorax and buy some time to set up for a chest tube. Let's start with a needle decompression. A large bore catheter, over a needle at least 16 gauge, can be placed either in the fifth anterior axillary line or the second midclavicular line. The needle should be placed over the rib until it enters the pleural cavity.

[00:00:30] The needle is then removed, leaving the catheter in and if there's air under tension, you'll hear the hiss of the air escaping, kind of like when you're letting out air out of a tire. It sounds like a tsss. Because the catheter is thin and has a small bore, it can easily kink and occlude so a needle decompression is always followed by a chest tube placement. Now, let's talk about finger decompression. In the case of a traumatic arrest, where someone was either stabbed or was in a

[00:01:00] car accident or fell from height and they lose their pulses in front of you, a rapid technique called finger decompression can provide both therapeutic and diagnostic results. The procedure essentially involves performing a rapid chest tube without the tube. Here's what you have to do. First, make a 3 to 4 cm incision deep to the muscle at the fourth or fifth rib at the midaxillary line. Then puncture the pleura with a curved clamp, this is called the Kelly clamp. Then open the

[00:01:30] clamp and allow all that trapped air, from the pneumothorax, to escape. You might get sprayed with some blood in this setting. If there's no air, that's escaping, then place your finger into the hole and make sure that you are in the right place in the pleural cavity. This is why we call this procedure a finger decompression. If a lot of air escapes, you've just diagnosed and also treated a tension pneumothorax. But if a lot of blood escapes, you've diagnosed a significant hemothorax.

[00:02:00] And finally, if only a little bit of blood comes out, you should consider the possibility of a traumatic cardiac tamponade. Now that you know how to rapidly decompress a tension pneumothorax, it's time to quickly put in a chest tube.