Monitor SimulatorTension pneumothorax simulation scenario
A chest-injured patient who is managing on a mask gets intubated, and then gets worse. The saturation drops first, the pressure follows. The fix takes seconds once someone thinks of it.
Brief
- Patient
- Female, 45, fell about four metres from a ladder onto her right side. Painful breathing, tender right chest wall.
- Setting
- Trauma room. The team decides to intubate because of a falling GCS.
- Learners
- Trauma or anaesthesia team with an airway lead.
- Time
- About 10 minutes plus debrief.
Learning goals
- Think of tension pneumothorax when a trauma patient deteriorates after positive pressure ventilation.
- Use lung ultrasound to support the diagnosis without delaying treatment.
- Decompress: needle or finger thoracostomy, followed by a chest drain.
Monitor values
| Phase | Rhythm | HR | SBP | SpO2 | RR | EtCO2 | Change over |
|---|---|---|---|---|---|---|---|
| 1. ArrivalSimple pneumothorax | Sinus tachycardia | 108 | 124 | 93 | 26 | 35 | Set before the start |
| 2. After intubationTension develops | Sinus tachycardia | 128 | 96 | 86 | 16 | 33 | 2 min trend once the tube is in |
| 3. Not decompressedObstructive shock | Sinus tachycardia | 142 | 68 | 78 | 16 | 22 | 3 min trend, Poor perfusion on |
| 4. Decompressed | Sinus tachycardia | 112 | 112 | 95 | 16 | 36 | 1 min trend, Poor perfusion off |
| 5. Still nothingOptional | PEA – pulseless electrical activity | 120 | – | – | – | – | Instant |
SBP is systolic in mmHg; the app sets the diastolic. EtCO2 in mmHg. RR 16 after intubation is the ventilator rate.
Lung ultrasound findings
Show these from the eFAST menu on the controller when the learner scans the right chest. The left side stays normal.
- Lung sliding: pathological. No sliding on the right.
- M-mode: pathological. The barcode pattern instead of the seashore.
- Lung point: available as a pathological loop. It confirms a pneumothorax but is often hard to find in a large tension pneumothorax, so a useful debrief point.
The patient is paused while a loop is on the monitor, so the scan does not cost the team time unless you want it to. Go back to the monitor from the same menu.
Running it in the app
- Set phase 1. Leave EtCO2 off until the tube is in, then switch it on with the phase 2 values. A capnography trace appearing is a nice detail for the airway lead.
- Apply phase 2 over 2 minutes as soon as the team starts ventilating.
- If nobody has thought of a pneumothorax by the time the saturation is in the 80s, apply phase 3.
- When decompression is done, apply phase 4 over 1 minute. The improvement should be fast, because that is what happens.
Debrief questions
- What made you suspect the chest, and what else did you consider?
- Did the ultrasound change the decision, or confirm one already made?
- Who said "decompress" first, and was it heard?
Questions
What vital signs suggest a tension pneumothorax?
Falling saturation, rising heart rate and then falling blood pressure, often soon after positive pressure ventilation starts. In a ventilated patient, rising airway pressures come with it, though those are not shown on the patient monitor.
Can I simulate lung ultrasound for pneumothorax?
Yes. The eFAST menu includes absent lung sliding, the M-mode barcode sign and a lung point, plus normal lung sliding and the seashore sign for comparison.
How quickly should the patient improve after decompression?
Within a minute or so. A fast recovery on the monitor is the reward for getting it right, and a slow one would teach the wrong thing.