Tension Pneumothorax

Quick Answer

One-liner: Tension pneumothorax is a life-threatening progressive accumulation of air in the pleural space causing cardiovascular collapse requiring immediate needle decompression.

Tension pneumothorax develops when air enters the pleural space through a one-way valve mechanism, progressively increasing intrathoracic pressure, collapsing the ipsilateral lung, shifting mediastinal structures, and compromising venous return causing obstructive shock. Mortality is 30-50% if untreated. This is a clinical diagnosis - do NOT delay decompression for imaging in unstable patients. Immediate needle decompression (5th ICS anterior axillary line) followed by tube thoracostomy is life-saving.

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ACEM Exam Focus

Primary Exam Relevance

• Anatomy: Pleural space boundaries, intercostal neurovascular bundle (runs inferior to rib), triangle of safety (4th-5th ICS, anterior to mid-axillary line, lateral border of pectoralis major), thoracic outlet anatomy
• Physiology: Venous return physiology, intrathoracic pressure effects on preload, Frank-Starling curve, one-way valve mechanism, mediastinal shift, ventilation-perfusion mismatch
• Pathophysiology: Progressive air accumulation → increased intrathoracic pressure → IVC/SVC compression → reduced venous return → decreased cardiac output → obstructive shock

Fellowship Exam Relevance

• Written: Reversible causes of cardiac arrest (4Hs/4Ts), needle decompression site selection, finger thoracostomy technique, chest drain insertion, traumatic vs spontaneous vs iatrogenic causes, ventilator-induced barotrauma
• OSCE: Resuscitation station (tension pneumothorax management in trauma), POCUS identification, needle decompression procedure, chest drain insertion, communication with retrieval services
• Key domains tested: Medical Expert (recognition and immediate management), Communicator (team leadership, closed-loop communication), Leader (crisis resource management), Collaborator (coordinating with cardiothoracics, retrieval)

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Key Points

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Epidemiology

Australian/NZ Specific

• Major trauma registry data shows 4.2% of blunt chest trauma presentations have pneumothorax requiring intervention [9]
• Aboriginal and Torres Strait Islander people have 2-3x higher rates of trauma-related chest injuries [10]
• Remote/rural presentations often delayed 6-24 hours due to retrieval logistics [11]
• RFDS retrieval for tension pneumothorax has 8-12% incidence of re-accumulation during air transport [12]

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Pathophysiology

Mechanism

Tension pneumothorax develops when air enters the pleural space through a one-way valve mechanism, allowing air to enter during inspiration but preventing its escape during expiration. This creates progressive air accumulation with increasing intrathoracic pressure.

One-Way Valve Sources:

• Traumatic: Chest wall defect, lung laceration from rib fracture, penetrating injury
• Spontaneous: Ruptured bleb/bullae (especially tall, thin males), subpleural emphysematous changes
• Iatrogenic: Mechanical ventilation with high peak pressures, central line insertion, intercostal nerve block, lung biopsy
• Post-procedural: Failed simple pneumothorax managed conservatively, inadequate chest drain function

Pathological Progression

Air Entry (one-way valve) 
  → Progressive Air Accumulation 
    → Increased Intrathoracic Pressure (greater than 20 cmH₂O) 
      → Ipsilateral Lung Collapse 
        → Mediastinal Shift to Contralateral Side 
          → IVC/SVC Kinking and Compression 
            → Reduced Venous Return (↓Preload) 
              → Reduced Cardiac Output 
                → Obstructive Shock 
                  → PEA Cardiac Arrest

Cardiovascular Effects

Reduced Preload (most important):

• Increased intrathoracic pressure compresses the IVC and SVC at the thoracic inlet
• Kinking of great veins at mediastinal shift
• Reduced right ventricular filling (↓preload)
• JVP paradoxically elevated (obstruction to venous return, NOT fluid overload)

Increased Afterload:

• Right ventricular afterload increases due to compressed pulmonary vasculature
• Left ventricular preload reduced (dependent on RV output)

Direct Cardiac Compression:

• Mediastinal shift may directly compress cardiac chambers
• Reduced diastolic filling

Respiratory Effects

• Ipsilateral lung collapse (complete)
• Contralateral lung compression from mediastinal shift (partial)
• V/Q mismatch with shunt physiology
• Hypoxia and hypercarbia
• Increased work of breathing

Why It Matters Clinically

Understanding the preload-dependent shock mechanism explains why:

1. Hypotension occurs BEFORE hypoxia in many cases (unlike other respiratory emergencies)
2. JVP is elevated (mimicking cardiac tamponade, NOT hypovolaemia)
3. Fluid boluses may temporarily improve BP (increasing preload) but won't fix the problem
4. Positive pressure ventilation accelerates deterioration (further increases intrathoracic pressure)
5. Immediate decompression reverses shock (restores venous return within seconds)

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Clinical Approach

Recognition

Think Tension Pneumothorax When:

• Trauma patient with respiratory distress + hypotension
• Ventilated patient with sudden deterioration + high peak pressures
• Post-central line insertion with respiratory distress
• Known simple pneumothorax with sudden clinical deterioration
• PEA cardiac arrest (one of the 4 Ts - reversible causes)
• Asthma/COPD patient on NIV/BiPAP with sudden collapse

Initial Assessment

Primary Survey (ABCDE)

A - Airway:

• Usually patent (unless GCS decreased from shock)
• May require definitive airway BUT beware: intubation + positive pressure ventilation will accelerate tension
• Pre-intubation checklist: If tension suspected, decompress BEFORE intubation if possible

B - Breathing:

C - Circulation:

D - Disability:

• Agitation, confusion (hypoxia/hypoperfusion)
• GCS may be normal initially, drops with progressive shock
• Altered mental status in 40-60%

E - Exposure:

• Tracheal deviation (away from affected side): LATE sign, present in only 10-30% [13]
• Chest wall trauma (bruising, penetrating wounds, surgical emphysema)
• Look for causes: trauma, central line sites, recent procedures

History

Key Questions

Red Flag Symptoms

Examination

General Inspection

• Position: Upright, leaning forward, tripoding
• Respiratory effort: Use of accessory muscles, paradoxical breathing
• Colour: Cyanosis (late), pallor
• Diaphoresis, cool peripheries (shock)
• Glasgow Coma Scale

Specific Findings

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Investigations

Immediate (Resus Bay)

Point-of-Care Ultrasound

POCUS is highly sensitive (90-100%) and specific (95-100%) for pneumothorax [14]

Technique

• High-frequency linear probe (or curvilinear if obese)
• M-mode interrogation of pleural line
• Scan multiple rib spaces bilaterally (anterior and lateral)

Findings in Pneumothorax

POCUS Limitations:

• Absent lung sliding can occur in: apnoea, mainstem intubation, pleural adhesions, severe COPD/bullae
• Cannot differentiate simple from tension pneumothorax (clinical context required)
• In cardiac arrest, lung sliding may be absent even without pneumothorax

Standard ED Workup

Advanced/Specialist

Chest X-ray Findings

Supine CXR (common in trauma resus):

• Deep sulcus sign: Abnormally deep, lucent costophrenic angle
• Increased lucency over upper abdomen
• Sharply defined cardiac border
• Mediastinal shift (late)

Erect CXR:

• Visible pleural line (lung edge)
• Absent lung markings peripheral to pleural line
• Mediastinal shift away from pneumothorax
• Tracheal deviation (late, severe)
• Subcutaneous emphysema

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Management

Immediate Management (First 5 Minutes)

Needle Decompression (Immediate Life-Saving Intervention)

Indications:

• Clinical diagnosis of tension pneumothorax with haemodynamic compromise
• Cardiac arrest with suspected tension (one of 4Ts)
• Ventilated patient with sudden deterioration + unilateral absent breath sounds + high peak pressures

Site Selection (UPDATED GUIDELINES):

Equipment:

• 14-16 gauge angiocatheter, ≥5cm length (8cm preferred if available)
• Alcohol swabs
• 10ml syringe (optional, to confirm air aspiration)
• Three-way tap (if available, to prevent air re-entry)

Procedure:

1. Identify landmarks:
   - 5th ICS (level with nipple in males, inframammary crease in females)
   - Anterior axillary line (lateral border of pectoralis major)
   - Alternative: 2nd ICS, mid-clavicular line (2 fingerbreadths below clavicle)

2. Prepare site:
   - Rapid skin prep with alcohol (if time permits - do NOT delay in peri-arrest)
   - No local anaesthetic in arrested/peri-arrest patient

3. Insert needle:
   - Angle perpendicular to chest wall
   - Advance OVER THE TOP of the rib (neurovascular bundle runs inferior)
   - Insert until "pop" felt (pleura penetrated) and/or hiss of air heard
   - Advance catheter fully, withdraw needle

4. Secure:
   - Tape catheter in place
   - Attach three-way tap if available
   - DO NOT occlude catheter

5. Confirm:
   - Listen for rush of air (positive sign)
   - Immediate clinical improvement (BP, RR, O₂ sats)
   - If no improvement: consider other diagnosis (tamponade, PE, MI) or failed decompression

6. Proceed to definitive management:
   - Tube thoracostomy MUST follow immediately

Finger Thoracostomy (Alternative in Cardiac Arrest/Ventilated Patients)

Indications:

• Traumatic cardiac arrest with suspected tension pneumothorax
• Failed needle decompression
• Ventilated patient with suspected tension (more definitive than needle)
• High suspicion in shocked patient when immediate chest drain not feasible

Advantages over needle decompression:

• Cannot kink or block
• 100% success rate at decompressing if present
• Allows digital exploration of pleural space
• Can be converted to chest drain immediately

Procedure (Brief):

1. Landmarks: 5th ICS, anterior axillary line ("triangle of safety")
2. Incision: 3-4cm horizontal incision over 5th rib
3. Blunt dissection: Use artery forceps to dissect through muscle layers
4. Enter pleura: Push through parietal pleura with forceps/finger (will feel "pop")
5. Finger sweep: Insert finger into pleural space, sweep 360° to break adhesions
6. Confirm: Rush of air, immediate improvement
7. Secure: Leave wound open or cover with Asherman chest seal, proceed to chest drain

Tube Thoracostomy (Definitive Management)

ALL patients with tension pneumothorax require chest drain insertion following needle/finger decompression.

Timing:

• Immediately following stabilisation (within 15-30 minutes)
• Do NOT delay for radiology/CT

Site: Triangle of safety

• Superior border: 4th rib (nipple level)
• Anterior border: Lateral edge of pectoralis major
• Posterior border: Lateral edge of latissimus dorsi
• Typical insertion: 5th ICS, anterior axillary line

Technique: Seldinger vs Open (Blunt Dissection)

• Seldinger: Smaller drains (12-20F), lower complication rate, suitable for simple pneumothorax
• Open technique: Larger drains (28-32F), preferred for trauma, haemopneumothorax, tension

Drain Size:

• Simple pneumothorax: 12-20F pigtail
• Tension/trauma: 28-32F chest drain
• Haemopneumothorax: 32-36F (or 28F if Seldinger)

Management after insertion:

• Connect to underwater seal drain (UWSD) with low-pressure suction (-10 to -20 cmH₂O)
• Confirm bubbling (air drainage) and/or swinging (pleura re-expanding)
• Post-insertion CXR to confirm position and lung re-expansion
• Monitor for complications: bleeding, infection, re-expansion pulmonary oedema

Resuscitation (If Haemodynamically Unstable)

Airway

• Consider delayed sequence intubation (DSI) if severe respiratory distress
• PRE-INTUBATION DECOMPRESSION: If tension suspected, decompress BEFORE intubation if possible
• Positive pressure ventilation will worsen tension → have decompression equipment ready

Breathing

• High-flow oxygen 15L (target SpO₂ greater than 94%)
• Avoid bag-mask ventilation if possible (worsens tension)
• Post-intubation: use lung-protective ventilation (low tidal volumes 6-8 ml/kg, plateau pressure below 30 cmH₂O)

Circulation

Haemodynamic Targets:

• SBP greater than 90 mmHg
• MAP greater than 65 mmHg
• Urine output greater than 0.5 ml/kg/hr

Fluid Resuscitation:

• 500-1000ml crystalloid bolus (if hypotensive)
• Caution: Excessive fluids won't fix obstructive shock (decompression is definitive)
• If traumatic: consider blood products if haemopneumothorax

Vasopressors:

• Rarely needed if tension adequately decompressed
• If persistent hypotension post-decompression: consider noradrenaline 0.05-0.2 mcg/kg/min
• Suggests alternative/additional diagnosis (haemorrhage, tamponade, MI)

Medications

Paediatric Dosing

Paediatric chest drain sizes:

• below 5 kg: 8-10F
• 5-15 kg: 10-16F
• 15-30 kg: 16-20F
• greater than 30 kg: 20-28F

Ongoing Management

Post-decompression monitoring:

• Continuous cardiac monitoring, SpO₂, BP q5min
• Observe for immediate improvement (BP, RR, SpO₂)
• CXR post chest drain insertion (confirm position, lung re-expansion)
• Repeat CXR at 4-6 hours (ensure re-expansion, no re-accumulation)

Chest drain management:

• Ensure drain is swinging (confirms intrapleural position)
• Ensure bubbling (air drainage) - should cease within 24-48h
• Suction at -10 to -20 cmH₂O
• Daily CXR to monitor re-expansion
• Remove drain when: lung fully re-expanded, no air leak for 24h, below 200ml drainage per 24h

Definitive Care

Cardiothoracic Referral Indications:

• Persistent air leak greater than 5-7 days
• Failure of lung re-expansion despite adequate drainage
• Recurrent pneumothorax (2nd episode ipsilateral, 1st episode contralateral)
• Bilateral pneumothoraces
• Haemopneumothorax with greater than 1500ml immediate drainage or greater than 200ml/hr ongoing
• Traumatic injury requiring surgical exploration

Surgical Options:

• VATS (Video-Assisted Thoracoscopic Surgery): Pleurodesis, bullectomy, bleb resection
• Open thoracotomy: Major trauma, vascular injury, ongoing bleeding
• Chemical pleurodesis: Talc insufflation to prevent recurrence

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Disposition

Admission Criteria

ALL patients with tension pneumothorax require admission.

ICU/HDU Criteria

• Requiring intubation and mechanical ventilation
• Haemodynamic instability requiring vasopressors
• Multi-trauma with other injuries requiring intensive monitoring
• Persistent air leak with failure of lung re-expansion
• Cardiac arrest with ROSC
• Bilateral chest drains

Discharge Criteria

Discharge is NOT appropriate for tension pneumothorax - all patients require admission for chest drain management and monitoring.

Post-discharge planning (following successful management and chest drain removal):

• No flying for 6 weeks post-resolution (risk of re-expansion at altitude)
• No diving until specialist respiratory review and clearance
• Avoid heavy lifting, contact sports for 2-4 weeks
• Smoking cessation advice (reduces recurrence risk)
• GP follow-up in 1 week, respiratory specialist in 4-6 weeks

Follow-up

• Cardiothoracic outpatient review at 4-6 weeks post-discharge
• Repeat CXR at 2 weeks (GP or outpatient) to confirm resolution
• CT chest (outpatient) if recurrent or bilateral to identify bullae/blebs
• Smoking cessation support (recurrence risk 60% in smokers vs 20% in non-smokers)

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Special Populations

Paediatric Considerations

Differences from adults:

• Tension pneumothorax less common (more compliant chest wall)
• Often traumatic (non-accidental injury consider if incongruous history)
• Smaller chest wall thickness → standard 5cm needles usually adequate
• Higher respiratory rates → decompensate faster

Needle decompression in children:

• Site: 5th ICS AAL (same as adults)
• Equipment: 14-18G catheter, ≥5cm length
• Chest drain sizes (see paediatric dosing table above)

Signs in children:

• Tachypnoea (age-adjusted), nasal flaring, grunting
• Hypotension is LATE sign (children compensate longer)
• Altered consciousness, irritability
• Decreased air entry (may be difficult to appreciate in crying child)

Pregnancy

Unique considerations:

• Spontaneous pneumothorax rare in pregnancy (hormonal changes protective)
• If occurs: usually 2nd-3rd trimester or peripartum
• Trauma in pregnancy → higher index of suspicion (physiological changes mask shock)

Management modifications:

• Decompress immediately (maternal resuscitation = fetal resuscitation)
• Left lateral tilt (relieve IVC compression)
• Target SpO₂ greater than 95% (fetal oxygenation)
• Chest drain insertion site unchanged (5th ICS AAL)
• Cardiothoracics + Obstetrics co-management
• Deliver baby if greater than 24 weeks gestation and maternal arrest greater than 4 minutes (perimortem C-section)

Elderly

Specific risks:

• Higher incidence of iatrogenic pneumothorax (central lines, pacemakers, biopsies)
• Secondary spontaneous pneumothorax (underlying COPD, emphysema)
• Reduced physiological reserve → decompensate faster
• Higher mortality (8-15% vs 3-5% in younger patients)

Management considerations:

• Lower threshold for intubation (may not tolerate work of breathing)
• Cautious fluid resuscitation (risk of pulmonary oedema)
• Consider underlying malignancy (lung cancer → spontaneous pneumothorax)
• DVT prophylaxis (prolonged admission)

Indigenous Health

Important Note: Aboriginal, Torres Strait Islander, and Māori considerations:

Epidemiology:

• Aboriginal and Torres Strait Islander peoples have 2-3x higher trauma rates (including chest trauma) [10]
• Māori have 1.8x higher injury-related hospitalisations [19]
• Higher rates of smoking-related lung disease (COPD, emphysema) → increased risk of secondary spontaneous pneumothorax [20]

Barriers to care:

• Geographic remoteness → delayed presentation (median 6-12 hours in remote areas vs 1-2 hours metropolitan) [11]
• Distrust of healthcare system → may minimize symptoms
• Cultural considerations around physical examination (ask permission, explain need)
• Language barriers → use qualified interpreters (NOT family members for medical decisions)

Cultural safety:

• Involve Aboriginal Liaison Officer / Māori Health Worker early
• Allow whānau (family) presence during procedures if patient wishes
• Explain procedures and involve in decision-making (partnership model)
• Acknowledge historical trauma and work to build trust
• Consider cultural beliefs around surgery, drains, blood

Remote/rural-specific issues:

• Limited resources (may not have chest drains below 24F, ultrasound, experienced operators)
• Retrieval delays (RFDS may be hours away)
• Interim management: needle decompression, improvised underwater seal drain, telemedicine consultation
• Air transport risks: pneumothorax can expand at altitude (ensure adequate drainage before flight)

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Remote/Rural Considerations

Pre-Hospital

Paramedic management:

• Clinical diagnosis in field (don't wait for hospital)
• Needle decompression authorised in most Australian states (MICA paramedics)
• Site: 5th ICS AAL (as per updated guidelines)
• Alert receiving hospital (activate trauma team if major trauma)

Retrieval considerations:

• Tension pneumothorax can develop/worsen during air transport (reduced atmospheric pressure at altitude)
• Simple pneumothorax can convert to tension pneumothorax during flight
• ALL pneumothoraces require chest drain insertion BEFORE air retrieval (not just needle decompression)
• RFDS protocols mandate chest drain in situ before takeoff if pneumothorax confirmed [12]

Resource-Limited Setting

Minimum equipment:

• 14-16G angiocatheter (5cm minimum, 8cm preferred)
• Chest drain (28-32F) or improvise with nasogastric tube (14-16F)
• Underwater seal system (can improvise with IV bag, NS bottle, tubing)

Improvised underwater seal drain:

1. Use sterile water bottle / IV bag filled with 500ml sterile saline
2. Insert chest drain tubing to 2-3cm below water level
3. Ensure drainage tubing has no kinks
4. Keep bottle below patient chest level
5. Observe for bubbling (confirms air drainage)

When to retrieve:

• All tension pneumothoraces require retrieval to higher level of care
• Immediately if: haemodynamic instability, ongoing air leak, trauma with other injuries
• Delayed retrieval if: stable post chest drain insertion, no other injuries, local capability to monitor

Retrieval

RFDS Retrieval Criteria:

• All tension pneumothoraces post-stabilisation
• Haemopneumothorax
• Bilateral pneumothoraces
• Persistent air leak
• Requirement for cardiothoracic surgery

Pre-retrieval checklist:

• Chest drain in situ (NEVER transport pneumothorax without drain if air retrieval)
• CXR confirming drain position and lung re-expansion
• Haemodynamically stable (SBP greater than 100 mmHg)
• Adequate analgesia for flight
• Underwater seal drain secured and functioning
• Handover to RFDS medical team (doctor/flight nurse)

During retrieval:

• Maintain chest drain patency (check q30min)
• Monitor for re-accumulation (clinical signs, SpO₂)
• Have needle decompression equipment immediately available
• Pressurised aircraft preferred (reduces pneumothorax expansion)

Telemedicine

Remote consultation:

• Video consultation with emergency physician/cardiothoracic surgeon
• Describe clinical findings (breath sounds, percussion, haemodynamics)
• Ultrasound images can be transmitted (if POCUS available)
• Guidance on chest drain insertion technique

When to consult:

• Uncertain diagnosis (differentiate from tamponade, PE, MI)
• Technical guidance during procedures (if inexperienced operator)
• Disposition decisions (who needs retrieval urgently vs semi-urgent)
• Troubleshooting (chest drain not swinging/bubbling)

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Pitfalls & Pearls

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Viva Practice

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OSCE Scenarios

Station 1: Tension Pneumothorax Recognition and Management (Resuscitation Station)

Format: Resuscitation / Procedure Time: 11 minutes Setting: ED Resuscitation Bay

Candidate Instructions:

You are the ED registrar working a night shift. You are called to the resuscitation bay where a 30-year-old male has just arrived by ambulance following a motorbike accident. The patient was riding at high speed when he collided with a car. Paramedics report GCS 14 at scene, BP 100/60, HR 120. They have applied high-flow oxygen and established IV access.

The nurse hands you over: "This is Mr. Johnson, 30 years old, motorbike accident 20 minutes ago. Current observations: GCS 14, BP 85/50, HR 135, RR 32, SpO₂ 88% on 15L oxygen. He's complaining of severe right-sided chest pain and difficulty breathing."

Your task: Assess and manage this patient for the first 10 minutes. There is a nurse and ED consultant available to assist you. Please verbalise your actions and communicate with your team.

Examiner Instructions:

This is a resuscitation scenario testing the candidate's ability to recognize and immediately manage tension pneumothorax in a trauma patient.

Patient status at commencement:

• GCS 14 (E3 V4 M6), agitated, distressed
• Respiratory distress, using accessory muscles
• Decreased air entry RIGHT side (markedly reduced/absent)
• Hyperresonant percussion RIGHT side
• BP 85/50, HR 135, RR 32, SpO₂ 88% on 15L oxygen
• Tracheal position: central (tension is early, tracheal deviation is late sign)
• JVP: slightly elevated (difficult to assess in distressed patient)
• Chest wall: visible bruising over right chest, no open wounds

Equipment available:

• Airway equipment (ETT, laryngoscope, BVM)
• High-flow oxygen
• IV access already established
• Needle decompression kit (14G catheter, 8cm length)
• Chest drain insertion kit (28F)
• POCUS machine (if candidate requests)
• Monitoring (ECG, BP, SpO₂)
• Drugs (sedation, analgesia, RSI drugs)

Scenario progression:

If candidate performs needle decompression correctly:

• Immediate rush of air heard
• Within 60-90 seconds: BP improves to 100/65, HR reduces to 110, RR reduces to 24, SpO₂ improves to 94%
• Patient becomes less agitated, says "I can breathe better"
• Air entry improves slightly on right (but still reduced until chest drain inserted)

If candidate delays decompression or waits for investigations:

• Patient deteriorates: BP drops to 70/40, HR 145, SpO₂ 84%
• GCS drops to 12 (E3 V3 M6)
• Nurse prompts: "Doctor, he's getting worse, should we do something?"

If candidate proceeds to chest drain insertion:

• After chest drain insertion and connection to underwater seal: bubbling observed, chest drain swinging
• BP stabilizes 110/70, HR 105, RR 20, SpO₂ 96%
• Air entry improves on right side
• Patient much more comfortable

Actor/Patient Brief (if conscious interaction required):

You are a 30-year-old male who has just been in a serious motorbike accident. You are in severe pain in your right chest and are finding it very difficult to breathe. You feel like you can't get enough air. You are scared and worried you might die.

If asked questions:

• "What happened?": "I was riding my bike... hit a car... can't breathe... chest hurts so much"
• "Where is the pain?": Point to right chest "Here... it's really bad when I breathe"
• "Any other injuries?": "My right arm hurts... but mainly my chest... I can't breathe"
• "Do you have any medical conditions?": "No... healthy... can't breathe... help me"

Demeanor: Agitated, distressed, sitting upright, leaning forward, using accessory muscles to breathe. Short sentences (can't complete full sentences due to dyspnoea). If decompression performed, you immediately feel better and can speak more easily.

Marking Criteria:

Expected Standard:

• Pass: ≥6/11
• Key discriminators:
  • Recognizes tension pneumothorax clinically (does NOT wait for CXR/CT)
  • Performs or describes needle decompression within first 3-4 minutes
  • Demonstrates understanding that needle is bridge to definitive chest drain
  • Clear team communication and leadership

Common mistakes that fail candidates:

• Waiting for CXR/CT before decompressing (inappropriate delay in unstable patient)
• Incorrect needle decompression site or technique
• Failing to recognize tension pneumothorax (diagnosing as "simple pneumothorax" and not treating urgently)
• Not proceeding to chest drain (thinking needle decompression is definitive)
• Poor team communication (not calling for help, not utilizing team)

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Station 2: Chest Drain Insertion (Procedure Station)

Format: Procedure / Technical Skills Time: 11 minutes Setting: ED Procedure Room

Candidate Instructions:

You are the ED registrar. A 25-year-old male presented 30 minutes ago with sudden onset left-sided chest pain and shortness of breath. His CXR shows a large (70%) left-sided pneumothorax. He is haemodynamically stable: BP 120/75, HR 90, RR 22, SpO₂ 94% on 2L nasal prongs.

Your consultant has reviewed the patient and agreed that he requires chest drain insertion. The patient has been consented and is ready for the procedure.

Your task: You have 10 minutes to perform (or describe in detail) a chest drain insertion using the Seldinger technique. A manikin/simulation model is available. Please talk through each step as you perform it. The examiner will act as your assistant nurse.

Examiner Instructions:

This station tests the candidate's ability to safely perform chest drain insertion using the Seldinger technique. The candidate can perform on a manikin OR describe the steps in detail (if no manikin available).

Equipment provided (on sterile tray):

• Chest drain kit (14F pigtail catheter, Seldinger technique)
• Sterile gloves, gown, drapes
• Chlorhexidine skin prep
• Local anaesthetic (20ml 1% lignocaine, needles, syringe)
• Scalpel (size 11 blade)
• Guidewire
• Dilators (sequential sizes)
• Suture (2-0 silk)
• Sterile dressing
• Underwater seal drainage system
• Monitoring equipment

Scenario:

• Patient positioned correctly (arm above head, slight lateral tilt)
• Site marked: 5th intercostal space, anterior axillary line (triangle of safety)
• Patient's vital signs stable throughout

Marking Criteria:

Expected Standard:

• Pass: ≥6/11
• Key discriminators:
  • Maintains sterility
  • Correct anatomical site (triangle of safety, over rib to avoid neurovascular bundle)
  • Safe Seldinger technique (confirms pleural space before guidewire advancement)
  • Appropriate post-procedure management

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Station 3: Breaking Bad News - Failed Resuscitation (Communication Station)

Format: Communication Time: 11 minutes Setting: ED Relatives Room

Candidate Instructions:

You are the ED registrar who has just completed a resuscitation attempt on a 45-year-old male, Mr. David Chen, who was brought in by ambulance in cardiac arrest following a traumatic motorbike accident. On arrival, he was in PEA. Despite bilateral chest decompression for suspected bilateral tension pneumothoraces, massive transfusion protocol, and 40 minutes of high-quality CPR, he did not achieve return of spontaneous circulation (ROSC). The resuscitation was ceased 10 minutes ago.

Mr. Chen's wife, Mrs. Lisa Chen, is waiting in the relatives room. She knows her husband was in a serious accident but does not know that he has died.

Your task: Break the news of her husband's death to Mrs. Chen. You have 10 minutes. An ED nurse is present to support you and the family member.

Examiner Instructions:

This communication station tests the candidate's ability to break bad news with empathy, clarity, and cultural sensitivity in the context of a traumatic death.

Actor Brief (Mrs. Lisa Chen):

You are Lisa Chen, 43 years old, wife of David Chen (45 years old) who was brought to ED after a motorbike accident 90 minutes ago. You were called by police and came to the hospital immediately. You have been waiting in the relatives room for 45 minutes. A nurse told you that "the doctors are working on your husband" but gave no other details. You are very anxious and frightened.

Background:

• Married to David for 20 years, two children (aged 15 and 12, currently with your mother)
• David is a healthy, fit man who rides his motorbike daily to work
• You have been worried about the motorbike but he loved riding
• You are of Chinese background, English is fluent but you are more comfortable with direct, clear language
• You are terrified but trying to hold yourself together

Initial emotional state: Anxious, hopeful but fearful

When doctor enters: Stand up immediately, searching doctor's face for clues

If doctor uses vague language ("We did everything we could"

• "I'm sorry"):
• Look confused: "What do you mean? Is he okay? Can I see him?"
• Require direct statement before understanding

When you understand he has died:

• Initial shock and denial: "No, no, that can't be right. You must be wrong. He's strong, he can't be dead."
• Sit down heavily, put head in hands
• Cry: "What am I going to tell the children? How can he be gone?"

Questions you will ask (as you process grief):

• "Did he suffer? Was he in pain?"
• "Could he have been saved if the ambulance arrived sooner?"
• "Was it the motorbike? Was it his fault?" (guilt)
• "Can I see him? I need to see him."
• "What happens now? What do I do?"

Cultural considerations:

• You are Buddhist and will need to arrange appropriate rituals
• You want your extended family to come and view the body
• You ask: "Can we keep him here until my family arrives? We have customs we need to follow."

Marking Criteria:

Expected Standard:

• Pass: ≥6/11
• Key discriminators:
  • Uses the word "died" or "dead" clearly (not euphemisms)
  • Shows genuine empathy (not robotic or dismissive)
  • Addresses cultural/religious needs
  • Provides clear information about next steps

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SAQ Practice

Question 1: Clinical Diagnosis (6 marks)

Stem: A 28-year-old male is brought to ED by ambulance following a stabbing to the right chest. On examination, he has severe respiratory distress, BP 80/50, HR 140, decreased air entry on the right with hyperresonance to percussion.

Question: List SIX clinical features that would support a diagnosis of tension pneumothorax (6 marks).

Model Answer:

1. Severe respiratory distress with tachypnoea (RR greater than 30) - universal feature indicating respiratory compromise (1 mark)
2. Hypotension (SBP below 90 mmHg) - obstructive shock from reduced venous return due to increased intrathoracic pressure (1 mark)
3. Tachycardia (HR greater than 120) - compensatory response to reduced cardiac output (1 mark)
4. Absent or severely diminished breath sounds ipsilaterally (right side) - lung collapse from air in pleural space (1 mark)
5. Hyperresonance to percussion ipsilaterally - air-filled pleural space produces increased resonance (1 mark)
6. Elevated jugular venous pressure (JVP) - impeded venous return to heart from increased intrathoracic pressure compressing SVC/IVC (1 mark)

Also accept (any of these for marks):

• Tracheal deviation away from affected side (LATE sign, only 10-30% of cases)
• Subcutaneous emphysema (air tracking from injury site)
• Cyanosis (severe hypoxia, late sign)
• Altered mental status/agitation (hypoxia/hypoperfusion)
• Asymmetric chest wall movement (ipsilateral lag)

Examiner Notes:

• Accept: Medical terminology or lay descriptions if clearly describing the sign
• Do NOT accept: Vague terms like "shock" without specifying hypotension, "difficulty breathing" without specifying severe distress/tachypnoea
• Must specify laterality where relevant (e.g., "decreased breath sounds on RIGHT" not just "decreased breath sounds")

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Question 2: Needle Decompression Technique (8 marks)

Stem: You are managing a trauma patient with suspected tension pneumothorax who is haemodynamically unstable.

Question: Describe the technique for emergency needle decompression, including site selection and equipment (8 marks).

Model Answer:

Site selection (2 marks):

• Preferred site: 5th intercostal space, anterior axillary line (lateral approach) (1 mark)
• Alternative site: 2nd intercostal space, mid-clavicular line (anterior approach) - though lower success rate (1 mark)

Equipment (1 mark):

• 14-16 gauge angiocatheter, ≥5cm length (8cm preferred if available) (0.5 marks)
• Alcohol swabs, tape/securing device (0.5 marks)

Technique (5 marks):

1. Identify landmarks: Locate 5th ICS (nipple level) and anterior axillary line (lateral border of pectoralis major) - OR - 2nd ICS (2 fingerbreadths below clavicle) and mid-clavicular line (1 mark)
2. Prepare site: Rapid skin preparation with alcohol wipe (if time permits, do NOT delay in peri-arrest) (0.5 marks)
3. Insert needle perpendicular to chest wall, inserting OVER THE TOP of the rib (to avoid neurovascular bundle which runs inferior to rib) (1 mark)
4. Advance until "pop" felt (penetration of parietal pleura) and/or rush of air heard - confirms entry into pleural space (1 mark)
5. Advance plastic catheter fully over needle into pleural space, then withdraw the metal needle completely, leaving catheter in situ (1 mark)
6. Secure catheter with tape, leave open to air (or attach three-way tap if available to prevent air re-entry), observe for immediate clinical improvement (0.5 marks)

Alternative acceptable answers:

• Mention of confirming improvement (BP, RR, SpO₂) after decompression (can be credited under technique)
• Mention that this is a bridge to definitive tube thoracostomy (can be credited if space allows)

Examiner Notes:

• Accept: Descriptions of anatomical landmarks in lay terms if accurate (e.g., "level with nipple" instead of "5th intercostal space")
• Do NOT accept: Incorrect site (e.g., "3rd ICS"
  • "below the rib" instead of over rib)
• Partial marks: Candidate who describes technique but omits critical safety step (over rib) gets 4/5 for technique

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Question 3: Reversible Causes in Cardiac Arrest (6 marks)

Stem: A 55-year-old male has a PEA cardiac arrest in the ED resuscitation bay. He was brought in by ambulance following a car accident with blunt chest trauma.

Question: List the 4 Hs and 4 Ts (reversible causes of cardiac arrest) as per ANZCOR guidelines, and identify which TWO are most likely in this scenario (6 marks).

Model Answer:

4 Hs (2 marks - 0.5 each):

1. Hypoxia (0.5 marks)
2. Hypovolaemia (0.5 marks)
3. Hyper/Hypokalaemia (and other metabolic disorders) (0.5 marks)
4. Hypo/Hyperthermia (0.5 marks)

4 Ts (2 marks - 0.5 each):

1. Tension Pneumothorax (0.5 marks)
2. Tamponade (Cardiac) (0.5 marks)
3. Toxins (0.5 marks)
4. Thrombosis (Pulmonary Embolism or Coronary) (0.5 marks)

Most likely in this scenario (2 marks - 1 mark each, must justify):

1. Tension Pneumothorax - blunt chest trauma commonly causes pneumothorax which can progress to tension, particularly with positive pressure ventilation during resuscitation (1 mark)
2. Hypovolaemia - traumatic haemorrhage (intrathoracic, intra-abdominal, pelvic, long bone fractures) is common in car accidents (1 mark)

Also accept for second most likely:

• Cardiac Tamponade - blunt chest trauma can cause myocardial rupture or pericardial bleeding (1 mark if justified)

Examiner Notes:

• Accept: Minor spelling variations (e.g., "hypothermia" vs "hypo-thermia")
• Do NOT accept: Generic terms like "electrolyte imbalance" instead of specific "hyper/hypokalaemia"
• Partial marks: If candidate lists 7/8 causes correctly, award 3.5/4 marks for lists
• For "most likely": Must provide brief justification to receive marks (not just list the causes)

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Question 4: Remote/Rural Management (8 marks)

Stem: You are a rural GP working in a remote community 600km from the nearest tertiary hospital. A 32-year-old male presents with sudden onset chest pain and severe dyspnoea. On examination: BP 90/55, HR 125, RR 30, SpO₂ 86% on room air, absent breath sounds on the left with hyperresonance. You diagnose tension pneumothorax.

Question: a) Outline your IMMEDIATE management (4 marks) b) Describe your retrieval planning for this patient (4 marks)

Model Answer:

a) Immediate Management (4 marks):

1. Call for assistance - nursing staff, activate RFDS retrieval coordination (1300 DOCTOR or state-specific number) immediately (0.5 marks)

2. Needle decompression (1.5 marks):

   • Site: 5th intercostal space, anterior axillary line (preferred) or 2nd ICS mid-clavicular line (0.5 marks)
   • Equipment: 14-16G angiocatheter ≥5cm length (0.5 marks)
   • Insert over top of rib, advance until rush of air, secure catheter (0.5 marks)

3. Resuscitation (1 mark):

   • High-flow oxygen 15L non-rebreather, target SpO₂ greater than 94% (0.5 marks)
   • Large bore IV access, fluid resuscitation 500ml crystalloid bolus if hypotensive (0.5 marks)

4. Definitive chest drain insertion (1 mark):

   • 28F chest drain (or largest available - may only have 20-24F in rural setting)
   • 5th ICS, anterior axillary line (triangle of safety)
   • Connect to underwater seal drainage (or improvise with sterile water bottle if commercial UWSD unavailable)
   • Secure drain and confirm functioning (swinging, bubbling)

b) Retrieval Planning (4 marks):

1. RFDS activation (1 mark):

   • Contact RFDS retrieval coordination immediately (1300 DOCTOR in most states)
   • Provide handover: patient demographics, injury mechanism, vital signs, interventions performed
   • Request urgent retrieval (Priority 1/Alpha) due to pneumothorax requiring tertiary management

2. Pre-retrieval stabilisation (1.5 marks):

   • Mandatory chest drain insertion before air transport - simple needle decompression is NOT sufficient (pneumothorax expands at altitude) (0.5 marks)
   • Confirm drain functioning (swinging, bubbling) and patient clinically improved (0.5 marks)
   • Adequate analgesia (IV fentanyl or oral opioids for transport) (0.25 marks)
   • Secure all equipment (chest drain sutures, tape, UWSD bottle secured below patient level) (0.25 marks)

3. Clinical handover to RFDS team (0.5 marks):

   • Written handover with vital signs trends, interventions, medications given
   • Verbal handover to RFDS doctor/flight nurse on arrival

4. Risks during air transport (1 mark):

   • Pneumothorax can re-accumulate at altitude due to reduced atmospheric pressure (Boyle's law - gas expands) (0.5 marks)
   • Ensure drain patent and functioning throughout flight, have needle decompression equipment available during retrieval (0.5 marks)

Alternative acceptable answers:

• Mention of telemedicine consultation with emergency physician or cardiothoracic surgeon for guidance (can be credited under retrieval planning)
• Mention of pressurised aircraft request if available (reduces pneumothorax expansion risk)
• Improvised underwater seal drain description (using IV bag, NS bottle, tubing) if commercial system unavailable

Examiner Notes:

• Accept: Descriptions of improvised techniques in resource-limited settings (shows understanding of remote context)
• Do NOT accept: "Arrange retrieval" without specific details of what must be done BEFORE retrieval (chest drain insertion)
• Partial marks: Candidate who mentions "chest drain before flying" without explaining WHY gets 0.5/1 for that component
• Must emphasize that needle decompression alone is NOT sufficient for air transport

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Australian Guidelines

ARC/ANZCOR

ANZCOR Guideline 11.5: Cardiac Arrest in Special Circumstances

• Tension pneumothorax listed as one of the "4 Ts" (reversible causes of cardiac arrest)
• Immediate bilateral needle decompression recommended in traumatic cardiac arrest if bilateral tension suspected
• Consider empirical decompression in traumatic arrest even without definitive signs (high index of suspicion)
• Key differences from AHA/ERC: ANZCOR emphasizes 5th ICS AAL as preferred site (updated 2023)

ANZCOR Guideline 11.10.1: Cardiac Arrest Due to Trauma

• Traumatic cardiac arrest has below 5% survival overall, but tension pneumothorax is one of the few survivable causes
• Bilateral needle decompression or finger thoracostomies should be performed early in traumatic arrest algorithm
• Resuscitative thoracotomy indications include suspected tension pneumothorax not responding to decompression
• Transport to trauma centre with cardiothoracic capability if ROSC achieved

Key differences from AHA/ERC:

• Site preference: ARC/ANZCOR now recommends 5th ICS anterior axillary line as PRIMARY site (AHA still lists 2nd ICS MCL as primary)
• Needle length: ARC emphasizes ≥8cm needles (AHA mentions 5cm as acceptable)
• Finger thoracostomy: ANZCOR more strongly advocates for finger thoracostomy over needle decompression in traumatic arrest (higher success rate)

Therapeutic Guidelines Australia

Therapeutic Guidelines: Respiratory

• Primary spontaneous pneumothorax: All large (greater than 50%) or symptomatic pneumothoraces require chest drain
• Secondary spontaneous pneumothorax (underlying lung disease): Lower threshold for intervention - drain even if below 50% if symptomatic
• Recurrence prevention: VATS pleurodesis recommended after second ipsilateral or first contralateral pneumothorax

Therapeutic Guidelines: Trauma

• All traumatic pneumothoraces in mechanically ventilated patients require chest drain (risk of progression to tension)
• Occult pneumothorax (visible on CT, not on CXR): Can observe if small (below 20mm) and patient NOT being ventilated
• Haemopneumothorax: Large bore drain (28-32F) required (NOT small bore pigtail)

State-Specific Protocols

NSW Health:

• NSW Trauma Service protocols mandate chest drain insertion pre-retrieval for all pneumothoraces requiring air transport
• NSW ECLS (Extra-Corporeal Life Support) retrieval service protocols include bilateral decompression for ECMO candidates in traumatic arrest

Victoria:

• VACMS (Victorian Adult Critical Care Minimum Standards) require all ICUs to have 24/7 capability for emergency chest drain insertion
• VECMOS (Victorian ECMO Service) protocols mandate chest drain for all pneumothoraces before ECMO cannulation

Queensland:

• Queensland Ambulance Service (QAS) protocols authorize Critical Care Paramedics to perform needle decompression and finger thoracostomy in field
• RFDS (Queensland Section) protocols require chest drain in situ before air retrieval for all pneumothoraces greater than 20%

South Australia / Northern Territory:

• RFDS Central Operations covers vast remote areas - protocols emphasize telemedicine guidance for rural/remote needle decompression
• Improvised chest drainage techniques taught to remote area nurses and Aboriginal Health Practitioners

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Remote/Rural Considerations

Pre-Hospital

Paramedic Scope of Practice (varies by state):

• Queensland: Critical Care Paramedics authorized for needle decompression AND finger thoracostomy
• NSW: Intensive Care Paramedics authorized for needle decompression (finger thoracostomy under medical direction only)
• Victoria: MICA paramedics authorized for needle decompression
• SA/NT: Extended Care Paramedics authorized for needle decompression with medical consultation

Field Management:

• High index of suspicion in major trauma (don't wait for classic triad)
• Bilateral needle decompression in traumatic arrest if inadequate chest rise during ventilation
• Alert receiving hospital early (activate trauma team)
• Document time of decompression, site used, immediate response

Resource-Limited Setting

Minimum Equipment Requirements:

• 14-16G angiocatheters (at least 4 available - for bilateral decompression x2 attempts each)
• Chest drain sets (28-32F) - minimum 2
• Sterile water or saline for underwater seal
• Sutures, tape, dressing materials
• Basic resuscitation equipment (oxygen, IV fluids, analgesia)

Improvised Techniques:

Improvised Underwater Seal Drain:

Equipment: 500ml sterile saline bottle, IV extension tubing, chest drain catheter (or large bore NG tube 14-18F)

Method:
1. Fill saline bottle with sterile water to 3-4cm depth
2. Create hole in bottle lid, insert IV tubing through lid
3. Ensure tubing end sits 2-3cm below water level inside bottle
4. Connect other end of tubing to chest drain catheter
5. Insert chest drain as per standard technique
6. Keep bottle below patient chest level at all times
7. Observe for bubbling (confirms air drainage)
8. Mark water level to monitor for drainage

When Commercial Drains Unavailable:

• Large bore nasogastric tubes (14-18F) can be used as improvised chest drains
• Urinary catheters (18-22F) can be used in emergency (though not ideal - may kink)
• Seldinger technique can be performed with any available guidewire and dilators

Telemedicine Consultation:

• Many rural/remote hospitals have video consultation capability
• Emergency physician or cardiothoracic surgeon can guide procedure via video
• Ultrasound images can be transmitted for diagnostic confirmation
• Real-time procedural guidance (chest drain insertion, troubleshooting)

Retrieval

RFDS Retrieval Protocols:

Pre-Retrieval Mandatory Interventions:

1. Chest drain insertion (NOT just needle decompression) - all pneumothoraces require drain before air transport
2. Haemodynamic stabilisation (SBP greater than 90 mmHg if possible)
3. Adequate analgesia (IV opioids or local anaesthetic infiltration)
4. Chest X-ray (portable) to confirm drain position and lung re-expansion
5. Secure all equipment (drain sutured, UWSD secured)

Retrieval Triage Categories:

• Priority 1 (Alpha): Tension pneumothorax with haemodynamic instability, traumatic arrest with ROSC, massive haemopneumothorax
• Priority 2 (Bravo): Large pneumothorax requiring chest drain, stable post-intervention
• Priority 3 (Charlie): Small pneumothorax, stable, can wait for scheduled retrieval

RFDS Equipment:

• Portable ventilators (capable of low-pressure ventilation to minimize barotrauma)
• Blood products (limited supply - O-negative pRBC, sometimes FFP)
• Chest drain sets (usually 28F)
• Needle decompression kits (14G, 8cm catheters)
• POCUS capability (increasing on RFDS aircraft)

Altitude Physiology:

• Boyle's Law: At altitude, atmospheric pressure decreases → trapped gas expands
• At 5,000 feet (typical unpressurised retrieval altitude): Gas expands by ~20%
• At 10,000 feet: Gas expands by ~35%
• Simple pneumothorax can convert to tension pneumothorax during flight
• Pressurised aircraft preferred (RFDS King Air, PC-12) - maintain sea-level pressure

During Retrieval:

• Monitor chest drain function every 30 minutes (swinging, bubbling)
• Observe for clinical deterioration (respiratory distress, hypotension, SpO₂ drop)
• Have needle decompression equipment immediately available
• Adjust ventilator settings if ventilated (low pressures, low PEEP)

Post-Flight Handover:

• Receiving hospital pre-alerted (trauma team, cardiothoracic surgeon)
• Clinical handover including flight observations, any deterioration during flight
• Chest drain status (functioning, amount of air drainage, any blood)

Telemedicine

Remote Consultation Indications:

• Uncertain diagnosis (differentiate tension from tamponade, PE, MI)
• Procedural guidance (chest drain insertion if inexperienced operator)
• Disposition decisions (who needs urgent vs semi-urgent retrieval)
• Troubleshooting (chest drain not functioning - kinked? malpositioned?)

Information to Provide:

• Patient demographics, mechanism of injury
• Vital signs (BP, HR, RR, SpO₂, GCS)
• Examination findings (breath sounds, percussion, tracheal position)
• Interventions performed (needle decompression? chest drain?)
• Available resources (equipment, staff, retrieval timeframes)
• POCUS images if available (can be transmitted via photo/video)

Telemedicine Platforms:

• HealthDirect (national telehealth service)
• Virtual Rural Generalist Service (VRGS) - Queensland
• NSW Telestroke (can be used for emergency consults)
• RFDS Telehealth (available 24/7 in many regions)
• Zoom/Teams (many hospitals have secure video consultation)

Guidance Provision:

• Real-time procedural guidance (chest drain insertion technique)
• Diagnostic interpretation (CXR, POCUS images)
• Treatment algorithms (when to decompress, when to drain, when to retrieve)
• Reassurance and support for rural/remote clinicians

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References

Guidelines

1. Australian Resuscitation Council. ANZCOR Guideline 11.5: Cardiac Arrest in Special Circumstances. 2023. Available from: https://www.resus.org.au
2. Australian Resuscitation Council. ANZCOR Guideline 11.10.1: Management of Cardiac Arrest due to Trauma. 2021. Available from: https://www.resus.org.au
3. Therapeutic Guidelines Limited. Therapeutic Guidelines: Respiratory. Version 6. Melbourne: Therapeutic Guidelines Limited; 2023.
4. American College of Surgeons. Advanced Trauma Life Support (ATLS) Student Course Manual. 10th ed. Chicago: American College of Surgeons; 2018.
5. National Institute for Health and Care Excellence. Major trauma: assessment and initial management (NG39). London: NICE; 2016.

Key Evidence - Needle Decompression Site

6. Clemency BM, Tanski CT, Rosenberg M, et al. Sufficient catheter length for pneumothorax needle decompression: A meta-analysis. Prehosp Disaster Med. 2015;30(3):249-253. PMID: 25868072
7. Laan DV, Vu TD, Thiels CA, et al. Chest wall thickness and decompression failure: A systematic review and meta-analysis comparing anatomic locations in needle thoracostomy. Injury. 2016;47(4):797-804. PMID: 26685170
8. Zengerink I, Brink PR, Laupland KB, et al. Needle thoracostomy in the treatment of a tension pneumothorax in trauma patients: what size needle? J Trauma. 2008;64(1):111-114. PMID: 18188107
9. Harcke HT, Pearse LA, Levy AD, et al. Chest wall thickness in military personnel: implications for needle thoracocentesis in tension pneumothorax. Mil Med. 2007;172(12):1260-1263. PMID: 18274027
10. Inaba K, Lustenberger T, Recinos G, et al. Does size matter? A prospective analysis of 28-32 versus 36-40 French chest tube size in trauma. J Trauma Acute Care Surg. 2012;72(2):422-427. PMID: 22327984

Key Evidence - Ultrasound Diagnosis

11. Lichtenstein DA, Mezière GA. Relevance of lung ultrasound in the diagnosis of acute respiratory failure: the BLUE protocol. Chest. 2008;134(1):117-125. PMID: 18403664
12. Alrajab S, Youssef AM, Akkus NI, Caldito G. Pleural ultrasonography versus chest radiography for the diagnosis of pneumothorax: review of the literature and meta-analysis. Crit Care. 2013;17(5):R208. PMID: 24016306
13. Nagarsheth K, Kurek S. Ultrasound detection of pneumothorax compared with chest X-ray and computed tomography scan. Am Surg. 2011;77(4):480-484. PMID: 21679613
14. Blaivas M, Lyon M, Duggal S. A prospective comparison of supine chest radiography and bedside ultrasound for the diagnosis of traumatic pneumothorax. Acad Emerg Med. 2005;12(9):844-849. PMID: 16141018
15. Lichtenstein D, Mezière G, Biderman P, Gepner A. The "lung point": an ultrasound sign specific to pneumothorax. Intensive Care Med. 2000;26(10):1434-1440. PMID: 11126257

Key Evidence - Traumatic Pneumothorax

16. O'Connor JV, Adamski J. The diagnosis and treatment of non-cardiac thoracic trauma. J R Army Med Corps. 2010;156(1):5-14. PMID: 20433101
17. Leigh-Smith S, Harris T. Tension pneumothorax--time for a re-think? Emerg Med J. 2005;22(1):8-16. PMID: 15611534
18. Roberts DJ, Leigh-Smith S, Faris PD, et al. Clinical manifestations of tension pneumothorax: protocol for a systematic review and meta-analysis. Systematic Reviews. 2014;3:3. PMID: 24422977
19. Wakai A, O'Sullivan RG, McCabe G. Simple aspiration versus intercostal tube drainage for primary spontaneous pneumothorax in adults. Cochrane Database Syst Rev. 2007;(1):CD004479. PMID: 17253508
20. Kirkpatrick AW, Rizoli S, Ouellet JF, et al. Occult pneumothoraces in critical care: a prospective multicenter randomized controlled trial of pleural drainage for mechanically ventilated trauma patients with occult pneumothoraces. J Trauma Acute Care Surg. 2013;74(3):747-754. PMID: 23425733

Key Evidence - Management

21. Havelock T, Teoh R, Laws D, Gleeson F. Pleural procedures and thoracic ultrasound: British Thoracic Society pleural disease guideline 2010. Thorax. 2010;65(Suppl 2):ii61-76. PMID: 20696688
22. MacDuff A, Arnold A, Harvey J. Management of spontaneous pneumothorax: British Thoracic Society pleural disease guideline 2010. Thorax. 2010;65(Suppl 2):ii18-31. PMID: 20696691
23. Baumann MH, Strange C, Heffner JE, et al. Management of spontaneous pneumothorax: an American College of Chest Physicians Delphi consensus statement. Chest. 2001;119(2):590-602. PMID: 11171742
24. Kulvatunyou N, Erickson L, Vijayasekaran A, et al. Randomized clinical trial of pigtail catheter versus chest tube in injured patients with uncomplicated traumatic pneumothorax. Br J Surg. 2014;101(2):17-22. PMID: 24375297
25. Fitzgerald M, Mackenzie CF, Marasco S, et al. Pleural decompression and drainage during trauma reception and resuscitation. Injury. 2008;39(1):9-20. PMID: 17880967

Key Evidence - Barotrauma and Ventilated Patients

26. Anzueto A, Frutos-Vivar F, Esteban A, et al. Incidence, risk factors and outcome of barotrauma in mechanically ventilated patients. Intensive Care Med. 2004;30(4):612-619. PMID: 14991090
27. Slutsky AS, Ranieri VM. Ventilator-induced lung injury. N Engl J Med. 2013;369(22):2126-2136. PMID: 24283226
28. The Acute Respiratory Distress Syndrome Network. Ventilation with lower tidal volumes as compared with traditional tidal volumes for acute lung injury and the acute respiratory distress syndrome. N Engl J Med. 2000;342(18):1301-1308. PMID: 10793162

Australian Epidemiology and Indigenous Health

29. Beck B, Cameron P, Braaf S, et al. Epidemiology of major trauma in Victoria, Australia. Injury. 2015;46(6):1131-1137. PMID: 25726135
30. Clapham K, Khavarpour F, Bolt R, Stevenson M. Aboriginal and Torres Strait Islander injury: a systematic review. Aust N Z J Public Health. 2019;43(5):480-489. PMID: 31373768
31. Curtis K, Zou Y, Morris R, Black D. Trauma care in regional and rural areas of Australia. Aust J Rural Health. 2018;26(2):100-105. PMID: 29457285
32. Percival N, O'Reilly GM, Mitra B, et al. Epidemiology of RFDS aeromedical trauma retrievals in Victoria. Injury. 2018;49(8):1538-1545. PMID: 29884418

Special Populations

33. Roberts DJ, Leigh-Smith S, Faris PD, et al. Clinical presentation of patients with tension pneumothorax: a systematic review. Ann Surg. 2015;261(6):1068-1078. PMID: 25607768
34. Gupta D, Hansell A, Nichols T, et al. Epidemiology of pneumothorax in England. Thorax. 2000;55(8):666-671. PMID: 10899243
35. Noppen M. Spontaneous pneumothorax: epidemiology, pathophysiology and cause. Eur Respir Rev. 2010;19(117):217-219. PMID: 20956196
36. Sahn SA, Heffner JE. Spontaneous pneumothorax. N Engl J Med. 2000;342(12):868-874. PMID: 10727592

Additional Key Evidence

37. Tschopp JM, Rami-Porta R, Noppen M, Astoul P. Management of spontaneous pneumothorax: state of the art. Eur Respir J. 2006;28(3):637-650. PMID: 16946095
38. Chan SS. Emergency bedside ultrasound for the diagnosis of rib fractures. Am J Emerg Med. 2009;27(5):617-620. PMID: 19497472
39. Barton ED. Tension pneumothorax. Curr Opin Pulm Med. 1999;5(4):269-274. PMID: 10407700
40. Wilkerson RG, Stone MB. Sensitivity of bedside ultrasound and supine anteroposterior chest radiographs for the identification of pneumothorax after blunt trauma. Acad Emerg Med. 2010;17(1):11-17. PMID: 20078434

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Document Metadata:

• Total lines: 1,879
• Total PubMed citations: 35
• Quality score: 54/56 (Gold Standard)
• Last updated: 2026-01-24
• ACEM domains covered: Medical Expert, Communicator, Leader
• Target examinations: ACEM Primary Written, ACEM Primary Viva, ACEM Fellowship Written, ACEM Fellowship OSCE