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4. In spontaneously breathing patients, tension pneumotho- 13. If a needle is removed from the thorax, the site of NDC
rax is thought to be rare and manifest with respiratory should be clearly marked with the letters NDC, as well as
compromise and tachycardia; hemodynamic changes can be documented on a casualty card.
occur but are less common. 14. A wound that openly communicates with the pleural
5. In positive pressure ventilated patients, the incidence of space will release any accumulated intrapleural air. Only
tension pneumothorax may be higher, develop rapidly, vented chest seals should be used on these wounds and
have a circulatory impact and lead promptly to cardiac the vented seal should be burped as the first course of
arrest, if left untreated. action if tension pneumothorax is suspected and then at
6. Differences and similarities in presentations of a develop- regular intervals. Patients should not be placed in a posi-
ing tension pneumothorax. tion that interferes with the venting of the chest seal.
15. Training for this procedure should include: realistic rate of
TABLE 5 Common Presentations of a Developing Tension incidence; thoracic anatomy and accurate location of land-
Pneumothorax 5 marks; areas of high risk; important underlying structures;
Spontaneously breathing Positive pressure ventilated and the consequences of subsequent damage; techniques to
Delayed onset (usually) Rapid onset and progression limit the depth of needle insertion; recognition of accurate
(usually) diagnosis and misdiagnosis; marking of decompression site.
Chest pain Hypotension 16. Every effort should be made to standardize the naming
Increasing respiratory distress Increasing ventilatory pressure convention and definitions. The data capture should dif-
Increasing respiratory rate Subcutaneous emphysema ferentiate between positive pressure ventilated—tension
Increasing tachycardia Increasing tachycardia pneumothorax and spontaneously breathing—tension
pneumothorax, and where possible include confirmation
Decreasing SpO 2 Decreasing SpO 2 of positive or negative diagnosis. Confirmation of diag-
Decreasing lung sounds and Decreasing lung sounds and nosis can be aided by viewing bubbles in a partially filled
resonance on affected side resonance on affected side syringe. Improved data capture and documentation will
Ultrasound evidence Ultrasound evidence assist and guide future recommendations.
Late: decreasing respiratory rate, Late: Cardiac arrest
hypotension, decreasing level of
consciousness, respiratory arrest Author Contributions
followed by cardiac arrest PT, GS, JJ and MB conceived the study concept. PT and MB
SpO = oxygen saturation. wrote the first draft, and all authors read, contributed to, and
2
approved the final manuscript.
7. NDC of a tension pneumothorax is the accepted emer-
gency lifesaving intervention. In a positive pressure ven- Disclosures
tilated patient, a finger thoracostomy may prove more None.
effective. The definitive treatment remains the placement
of a formal tube thoracostomy with application of nega- Disclaimer
tive pressure or one-way valve mechanism. The view(s) expressed herein are those of the author(s) and do
8. NDC carries the risk of iatrogenic harm, including: not reflect the official policy or position of any of the institu-
a. Injury to the heart or blood vessels, resulting in cardiac tions the authors are affiliated with.
tamponade or intrathoracic hemorrhage
b. Traumatic puncture of the lung, resulting in the poten- Funding
tial for pneumothorax if one did not previously exist The authors have indicated they have no financial relation-
c. Damage to solid organs of the abdomen ships relevant to this article to disclose.
d. Infection
9. Iatrogenic risk should be offset by including training not References
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11. In a spontaneously breathing patient, the likelihood of a 5. Leigh-Smith S, Harris T. Tension pneumothorax—time for a re-think?
tension pneumothorax developing is greater and the time Emerg Med J. 2005;22(1):8–16. doi:10.1136/emj.2003.010421
to severe physiological impact shorter; thus, the threshold 6. Ball CG, Ranson K, Dente CJ, et al. Clinical predictors of occult
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12. When performing an NDC, the provider should be cogni- prospective observational study. Injury. 2009;40(1):44–47. doi: 10.
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