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Bedside diagnosis and immediate intervention by the emergency provider may be lifesaving for significant injuries associated with severe chest trauma such as tension pneumothorax, hemothorax, and cardiac tamponade. Initial resuscitation and airway management should follow established principles, as discussed in Chapter 156, “Trauma in Adults.” It is important to avoid hypoxia and hypotension to prevent secondary injury in head-injured patients. In the hemodynamically unstable, polytrauma patient who requires emergency surgery without CT imaging, exclude immediate life threats rapidly at the bedside using ultrasound, radiographs, and physical examination.
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Physical examination should include assessment for visible trauma to the chest wall including any “seat belt sign,” focal areas of tenderness, subcutaneous emphysema, and open chest wounds. Tracheal deviation, unequal chest rise, abnormal breath sounds, and bowel sounds in the chest are less frequent but also important to note. Consider endotracheal intubation for patients in respiratory distress (Table 164-1).
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Tension pneumothorax occurs when air enters the pleural space, either by escaping from damaged lung, tracheobronchial tissue, or an open chest wound. The pneumothorax may become pressurized during respiration causing tension with resultant respiratory and circulatory compromise. Patients may have dyspnea, tachycardia, hypotension, distended neck veins, tracheal deviation, and unequal breath sounds. Recognize and treat tension pneumothorax immediately with needle decompression without waiting for radiographs. Insert a 14-G, 4.5-cm over-the-needle catheter in the second intercostal space at the midclavicular line (a standard 14-G IV catheter may not reach the pleural space in many patients). A rush of air through the catheter is confirmatory. Leave the catheter in until a chest tube can be inserted, as the catheter converts the tension pneumothorax to an open pneumothorax.
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Treat a small pneumothorax with inpatient observation; tube thoracostomy may not be necessary. Treat a large pneumothorax with tube thoracostomy (24 to 28 F (8.0 to 9.3 mm)). Patients with pneumothoraces of any size and those with subcutaneous emphysema (requiring presumption of an occult pneumothorax) who will be intubated or who will be transported by air should receive a tube thoracostomy, as positive pressure ventilation and decreased barometric pressure can cause expansion of trapped air and progression to a tension pneumothorax. Never clamp a chest tube, but always place it on water seal when taken off suction. See Table 164-2 for causes of failure of the lung to fully reinflate after tube thoracostomy.
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