Tension Under the Drapes: Intraoperative Tension Pneumothorax During One-Lung Ventilation
Tension Under the Drapes: Intraoperative Tension Pneumothorax During One-Lung Ventilation - Anesthesiology clinical simulation case. A 58-year-old male...
Age: 58 • Gender: Male • Setting: Emergency Triage
Clinical Presentation & History
A 58-year-old male undergoing elective right video-assisted thoracoscopic surgery (VATS) for a peripheral right upper lobe nodule under general anesthesia with one-lung ventilation. Sudden intraoperative hemodynamic and respiratory deterioration with rising airway pressures, falling oxygen saturation, hypotension, and contralateral tracheal deviation is highly suggestive of tension pneumothorax in the dependent (left) lung.
Acute Resuscitation Milestones & Priorities
Clinical phases and key interventions encountered in this emergency module:
Tension pneumothorax during one-lung ventilation is a clinical diagnosis. Do not delay decompression for a chest film.
The 4th–5th intercostal space anterior axillary line has superseded the 2nd intercostal space midclavicular line as the preferred ATLS adult needle decompression site due to lower failure rates.
Falling EtCO2 in this setting signals falling cardiac output from mediastinal shift and impaired venous return — a late but ominous hemodynamic signature.
Definitive surgical source control (blebectomy + pleurodesis) is required to prevent recurrence; chest tube drainage alone is insufficient.
Thoracic epidural analgesia is the standard of care for post-thoracotomy pain and reduces pulmonary morbidity.
Test Your Clinical Reasoning in Real Time
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