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Tension pneumothorax and the “forbidden CXR”
  1. R McRoberts1,
  2. M McKechnie1,
  3. S Leigh-Smith2
  1. 1Emergency Department, The Royal Infirmary, Edinburgh, UK
  2. 2Defence Medical Services, Gosport, UK
  1. Correspondence to:
 Mr S Leigh-Smith
 c/o, Institute of Naval Medicine, Monckton House, Alverstoke, Gosport PO12 2DL, UK;


A case is presented of unilateral tension pneumothorax associated with flail chest and pulmonary contusions in a spontaneously ventilating patient after a fall. The tension element was not suspected until chest x ray was available, nor was immediate needle thoracocentesis performed. No morbidity resulted as a consequence. This case highlights the difficulty in deciding whether or not tension pneumothorax is the predominant cause of respiratory distress in a patient with multiple chest injuries. It provides further evidence challenging some of the doctrine on how to treat suspected tension pneumothorax.

  • CT, computed tomography
  • CXR, chest x ray
  • pneumothorax
  • tension

Statistics from

A 47 year old male fell six metres onto grass from a second floor apartment. Following ambulance transport he arrived in the emergency deaprtment resuscitation room 40 minutes later.

He complained of severe right sided pleuritic chest pain and dyspnoea, worse when supine. For this reason he was transferred in a semi-erect position. He admitted heavy consumption of alcohol that day and a past history of epilepsy treated with phenytoin.

Examination revealed: speaking in sentences although with obvious respiratory distress, respiratory rate of 28, arterial oxygen saturation 99% on 15 litres oxygen with reservoir bag, central trachea, no venous distension in the neck, right sided decreased breath sounds, right sided hyperresonance, no external marks on chest, warm well perfused peripheries, heart rate 117 beats per minute, blood pressure 134/82 mmHg, Glasgow coma score 15, and moving all four limbs.

The initial clinical impression was right sided simple pneumothorax and chest x ray (CXR) was immediately done. This showed a large right pneumothorax, marked contralateral shift of the mediastinum, hyperinflation, obvious flattening of the right hemidiaphragm (suggesting some degree of tension),1 and pulmonary contusion (fig 1).

Figure 1

 Initial chest x ray.

The patient’s condition did not warrant immediate needle thoracocentesis and so a decision was made to proceed straight to tube thoracostomy. This was performed in the fifth intercostal space, mid-axillary line, 30 minutes after arrival in the resuscitation room. It produced a marked expulsion of air under pressure which drained continuously during inhalation and exhalation demonstrating tension pneumothorax. A 32 French gauge intercostal drain was then inserted. Following this a repeat CXR demonstrated partial lung re-inflation and midline mediastinum with multiple right sided rib fractures, right clavicular fracture, and resolution of the hyperinflation (fig 2).

Figure 2

 Post tube thoracostomy chest x ray.

In view of worsening ventilatory status, continuing chest pain, and flail chest he underwent rapid sequence induction of anaesthesia and mechanical ventilation. A computed tomography (CT) of the chest revealed a small residual haemopneumothorax, extensive right sided pulmonary contusion, clavicular fracture, and multiple rib fractures.

Also diagnosed on CT were left pubic rami fractures, right petrous temporal bone fractures, right sided facial fractures, and a contusion of the right liver lobe.

He was extubated within 24 hours and returned home on day 8.


Other than respiratory distress there was little to suggest tension before this patient’s CXR. No hyperinflation was present2 tracheal deviation/neck vein distension is rare, and hypotension is a pre-terminal sign3—none of which he had despite marked mediastinal deviation on CXR and a potentially significant time delay between injury and thoracostomy. This supports evidence that mediastinal deviation may be more marked in the presence of pulmonary contusions4 and has poor correlation with the clinical picture.5

In patients with multiple thoracic injuries it can be difficult to make a definitive diagnosis as to the primary cause of respiratory distress. In our view the early CXR was appropriately ordered and contributed to the patient’s care, as it confirmed the diagnosis of tension pneumothorax. The indications for needle thoracocentesis are controversial and widely debated in some fora.6,7 Despite omitting needle thoracocentesis this patient did not deteriorate in the 70 minutes between injury and chest decompression with tube thoracostomy.


The evidence base on the presenting symptoms and signs of tension pneumothorax in a spontaneously ventilating patient grows. This case further demonstrates that classical signs may be absent.3 It also shows that development of a tension pneumothorax in such a patient does not invariably mean that cardiorespiratory collapse is imminent.

A recent review article recommends reconsideration of the symptoms and signs used to diagnose tension pneumothorax.3

It also suggests that if the patient’s clinical condition is stable and there are no signs of pre-terminal decompensation then immediate needle thoracocentesis may not be indicated but CXR should be performed without delay. This patient’s clinical presentation and progress lends support to these suggestions.



  • Funding: none.

  • Competing interests: none declared

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