Simulated Patient Scenario

Spontaneous Pneumothorax

Scenario Details

Scenario: Primary Spontaneous Pneumothorax

Simulated Patient: 21-year-old Male

Actor/Actress: Student Actor (Patient)

MDT Information

Urgent Response - Chest Pain / Difficulty Breathing
21-year-old male
Sudden onset sharp chest pain and shortness of breath
No known trauma
Patient is conscious and alert
Location: University Campus Cafe

On Arrival

You arrive at a busy university cafe. Staff direct you to a table where a young man is sitting upright, leaning slightly forward. He appears anxious and is breathing rapidly. He occasionally winces and holds his right chest wall. He looks pale.

Initial Impression and Primary Survey

Category	Finding
Initial Impression	Alert, anxious, tachypnoeic, appears uncomfortable.
Response	Alert and oriented, speaks in short sentences due to breathlessness. (AVPU = A)
Airway	Clear and self-maintaining.
Breathing	Rapid respiratory rate, shallow breaths. Complains of shortness of breath and sharp pain on inspiration. Possible splinting of right chest.
Circulation	Skin pale, warm centrally. Radial pulse rapid but regular and strong.
Disability	Alert (GCS 15), anxious.
Exposure/Environment	Indoor cafe environment. Patient wearing casual clothes. No obvious signs of trauma.

Secondary Survey and Simulation Progression

History (obtained from patient)

Allergies	NKDA
Medications	None regular. Occasional Ventolin use (diagnosed mild asthma as child, rarely symptomatic).
Past Medical History	Mild childhood asthma. Otherwise healthy. Smoker (5-10 cigarettes/day). Tall, thin build.
Last Oral Intake	Coffee and sandwich ~1 hour ago.
Events Preceding	Was sitting studying when experienced sudden onset of sharp, pleuritic right-sided chest pain about 45 minutes ago. Pain worsened on deep inspiration. Shortly after, developed shortness of breath which has gradually worsened. Denies any trauma, heavy lifting, coughing fits, or recent illness.

Vital Signs/Assessment (Initial)

Parameter	Value
Resp. Rate (/min.)	28 (shallow)
Lung Sounds (L/R)	Decreased/Absent air entry on the Right side, particularly apically. Left side clear.
Percussion Note (L/R)	Hyperresonant on the Right side. Normal resonance on Left.
SpO2 (%)	93% (Room Air)
EtCO2 (mmHg)	30 mmHg (Low due to tachypnoea initially)
Pulse Rate (/min.)	115, regular
CRT (sec.)	< 2 sec
ECG rhythm	Sinus Tachycardia
12-lead ECG	Sinus Tachycardia. No acute ischaemic changes. (May show right axis deviation or T wave changes in some cases, but often normal).
BP (mmHg)	130/75
Skin	Pale, warm, dry.
Pain (/10)	7/10 sharp right-sided chest pain, worse on inspiration.
GCS (/15: E,V,M)	15/15 (E4, V5, M6)
BGL (mmol/L)	5.9
Pupils (mmL/mmR)	3mm L / 3mm R, Equal and Reactive (PERL)
Temp. (°C)	36.8

Physical Examination

General Appearance: Anxious, tachypnoeic, mild-moderate respiratory distress. Prefers sitting upright.
Respiratory: Tachypnoea, shallow respirations. Unilateral (Right) decreased or absent breath sounds on auscultation. Hyperresonant percussion note on Right. Trachea midline. Chest expansion may appear symmetrical or slightly reduced on the right. No subcutaneous emphysema palpable. No signs of external trauma.
Cardiovascular: Tachycardia. Pulses strong and regular. BP normal. No JVD.
Neurological: Alert, oriented, anxious. GCS 15.

Assessment and Treatment

Appropriate Management Focus

Primary Survey (ABCDE): Recognize potential pneumothorax based on presentation and examination findings. High index of suspicion.
Oxygen Therapy: Apply high-flow oxygen via non-rebreather mask aiming for SpO2 >94-95%.
Positioning: Allow patient to adopt position of comfort (usually sitting upright).
Assessment for Tension Pneumothorax: Continuously monitor for signs of tension pneumothorax:
- Increasing respiratory distress
- Worsening hypoxia despite high-flow O2
- Hypotension
- Tachycardia (may become bradycardic late)
- Tracheal deviation (late and unreliable sign)
- Jugular vein distension (JVD)
- Cyanosis
- Decreased level of consciousness
Needle Decompression (Thoracostomy): **Perform ONLY if signs of tension pneumothorax develop.** Follow local protocols for landmarking (e.g., 2nd intercostal space, mid-clavicular line OR 4th/5th intercostal space, anterior axillary line) and procedure. This is a life-saving intervention for tension pneumothorax.
Pain Management: Provide analgesia for pleuritic chest pain (e.g., Methoxyflurane, consider IV opioids cautiously if severe pain and haemodynamically stable).
Vascular Access: Establish IV access.
Monitoring: Continuous ECG, SpO2, EtCO2 (if available), and frequent vital signs reassessment (every 5-10 mins). Closely monitor respiratory status and for signs of tension.
Transport: Transport patient gently, avoiding bumps, to the nearest appropriate Emergency Department. Pre-notify receiving hospital (Suspected pneumothorax, vitals, SpO2, respiratory status, any interventions).
Teamwork & Communication: Clear roles, effective communication. Reassure anxious patient. Clear handover.

Debrief Focus Points

Recognizing the clinical presentation of spontaneous pneumothorax.
Key physical examination findings (decreased breath sounds, hyperresonance).
Importance of differentiating simple vs. tension pneumothorax.
Recognizing the signs and symptoms of tension pneumothorax.
Indications and procedure for needle decompression.
Appropriate oxygen therapy and analgesia.
Importance of continuous monitoring and reassessment.
Gentle handling and transport considerations.