What is A patient after road traffic accident presented with tension pneumothorax. What is the first line of management? and explain in detail?
Ans. a. Insert wide bore needle in 2nd intercostal space (Ref: Sabiston 19/e p1599; Schwartz 9/e p138; Bailey 25/e p342)First line of management in tension pneumothorax: Insert wide bore needle in 2nd intercostal space.'Treatment of tension pneumothorax consists of immediate decompression by rapid insertion of a large-bore needle into the 2nd intercostal space in the mid-clavicular lineQ of the affected hemithorax.'This case is a classical description of tension pneumothorax of right hemithorax with decreased breath sounds and shock. Since patient is shouting it means her airway is clear. Immediate decompression with large bore needle in mid clavicular line in 2nd intercostal space is the urgent treatment for this patient followed by insertion of IV line and fluid administration.Tension PneumothoraxA tension pneumothorax develops when a 'one-way valve' air leak occurs either from the lung or through the chest wallQ.Air is forced into thoracic cavity without any means of escape, completely collapsing the affected lungQ.Mediastinum is displaced to the opposite side, decreasing venous return and compressing the opposite lungQ.Common Causes of Tension Pneumothorax* Penetrating chest traumaQ* Blunt chest traumaQ (with parenchymal injury & air leak that did not spontaneously close)* Iatrogenic lung punctures (e.g. due to subclavian central venepuncture)* Mechanical positive pressure ventilationQClinical Features:Clinical presentation is dramatic.The patient is panicky with tachypnoea. dyspnoea and distended neck veins (similar to pericardial tamponade)Q.Clinical examination can reveal tracheal deviation (a late finding - not necessary' to clinically confirm diagnosis), hyperresonance and absent breath sounds over the affected hemithoraxQ.Diagnosis:Tension pneumothorax is a clinical diagnosis and treatment should not he delayedQ by waiting for radiological confirmation.Treatment:Treatment consists of immediate decompression by rapid insertion of a large-bore needle into the 2nd intercostal space in the mid-clavicular lineQ of the affected hemithorax.This is immediately followed by insertion of a chest tube through the 5th intercostal space in the anterior axillary lineQ.If the tension in the pleural space is not relieved, the patient is likely to die from inadequate cardiac output or marked hypoxemiaQ.