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Step 1: Perform ATLS Primary Survey (B- Breathing)

  • Signs of respiratory distress/injury
    • Shortness of breath
    • Hypoxemia
    • Tracheal deviation
    • Diminished breath sounds

Step 2: Consider Performing Bedside Tube Thoracostomy

  • Insert at 5th intercostal space just anterior to mid-axillary line

Step 3: Imaging

  • Start with portable bedside chest x-ray
  • Pneumothorax can also be diagnosed by thoracic ultrasound

Step 4: Consider the 3 Critical Diagnoses

  • Tension pneumothorax
    • Pressure builds up between chest wall and lung
    • Eventually decreases cardiac preload -> Hypotension/Death
    • Treatment
      • Needle decompression
      • Tube thoracostomy
  • Open pneumothorax
    • Lung unable to expand during inspiration
    • Treatment
      • 3-sided occlusive dressing over open (“sucking”) chest wound
      • Tube thoracostomy
  • Hemothorax
    • Chest cavity fills with blood
    • Eventual decreases cardiac preload -> Hypotension/Death
    • Treat with tube thoracostomy

Step 5: Consider the 3 Other Common Diagnoses

  • Rib fractures
    • Diagnose with chest x-ray
    • Treatment
      • Pain control
      • Incentive spirometry
  • Small pneumothorax
    • Worsens with positive pressure ventilation (intubation, BiPAP)
    • Treatment
      • Supplemental oxygen
      • Supportive care
  • Pulmonary contusion
    • Supportive care

Additional Reading