Know Your Guidelines – Life-Threatening Tension Pneumothorax

Andrea Eberly, MD, MS, FAAEMEmergency Medicine, Guideline Knowledge Check, Medical News

Emergency Medicine Guidelines Knowledge Check Pneumonia

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Today’s Guideline Knowledge Check question comes from the desk of Med-Challenger Emergency Medicine Editor-in-Chief, Andrea Eberly, MD, FAAEM.

Based on the 2018 Advanced Trauma Life Support (ATLS) Resuscitation Guidelines…

Has the recommended site for adult needle decompression of a life-threatening tension pneumothorax changed since the last (2012) ATLS guidelines?

Yes or No?

Try this review question and find out if you're following the most current guideline.

Guideline Review Question

A 36-year old female bicyclist weighing about 160 lbs. is brought in by EMS after being hit by a car. She is combative and has multiple obvious injuries. En route she received a 1 L intravenous fluid bolus with warmed crystalloid. Her vital signs upon arrival at the emergency department are P127, BP 97/68, RR 32, pulse oximeter on 100% oxygen 90%. She is intubated, after which she develops rapid hemodynamic collapse and is difficult to ventilate. Breath sounds appear absent on the right side and, after adjustment of the endotracheal tube without change in the patient’s status, there is strong suspicion of a right-sided tension pneumothorax.

According to the 2018 Advanced Trauma Life Support guidelines, how is this situation best handled?

Answer Options:

Immediate needle decompression at right 2nd intercostal space at midclavicular line, followed by chest tube thoracostomy at right 5th intercostal space, just anterior to midaxillary line

Immediately pull back endotracheal tube and selectively intubate left bronchus, set up for emergent right chest tube thoracostomy

Immediate needle decompression at the right 4th or 5th intercostal space just anterior to the midaxillary line, possibly followed by finger thoracostomy, while setting up for tube thoracostomy at the same site

Emergent bedside ultrasound to confirm tension pneumothorax and exclude abdominal herniation into chest while simultaneously setting up for immediate tube thoracostomy

Answer Explanation & References:

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About the Author:

Andrea Eberly, MD, FAAEM graduated from the David Geffen Medical School of Los Angeles (UCLA) and completed her residency in Emergency Medicine at the University Medical Center, Tucson, Arizona. After working as an attending physician in Tucson, she followed a recruiting call to the island of Guam, where she served in various roles, including as the director of the emergency department, the EMS Medical Director of Guam, and the Director of the 911 Call System. She has maintained her emergency medicine board certification through three cycles of American Board of Emergency Medicine Board Exams (last in 2014), all three with the help of Med-Challenger.

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