Emergency Medicine

Surgical Emergencies 231

Chest Injuries

Pneumothorax

DIAGNOSIS

1 Tension pneumothorax
(i) This causes severe respiratory distress, tachypnoea and
hypotension. There is tracheal deviation away from the affected
side, distended neck veins, loss of chest expansion on the affected
side, a hyper-resonant percussion note, and diminished or absent
breath sounds.
(ii) Perform immediate decompression. Use a large-bore i.v. cannula
inserted into the second intercostal space in the mid-clavicular
line, followed by placement of an intercostal drain (see p. 471).

2 Simple pneumothorax
(i) This is caused by blunt or penetrating chest trauma, and
penetrating abdominal trauma breaching the diaphragm.
(ii) It is surprisingly easy to miss. Examine for subcutaneous
emphysema, decreased chest expansion, and quiet breath sounds.
(iii) Confirm the diagnosis with an erect CXR to highlight a small
apical pneumothorax, provided there is no possibility of spinal
injury
(a) the supine CXR may, however, appear normal and miss a
small pneumothorax lying anteriorly.

MANAGEMENT

1 Most cases of traumatic pneumothorax require chest-drain insertion to
avoid the subsequent development of tension, particularly if positive-
pressure ventilation is necessary.

2 Insert an intercostal drain into the fifth or sixth intercostal space in the
mid-a xillar y line (see p. 473).

Haemothorax

DIAGNOSIS

1 This results from chest wall damage, penetrating or blunt lung injury and
great vessel damage.

2 It causes hypotension, respiratory difficulty with reduced chest expansion,
quiet breath sounds and a dull percussion note at the base of the affected
lung.

3 Request an erect or semi-erect CXR to identify a f luid level, provided there is
no possibility of spinal injury.