Perform immediate emergency chest decompression using the local trauma technique. The unstable clinical presentation supports tension pneumothorax and requires immediate decompression, without waiting for radiography. Needle or finger thoracostomy technique/site depends on setting, skill and protocol, followed by definitive chest drainage. Reassess the response and other shock causes.

Q: A 34-year-old construction worker is brought to the resuscitation bay after falling three storeys onto scaffolding, sustaining penetrating trauma to the left chest. On arrival, his blood pressure is 82/50 mmHg, heart rate is 128 beats per minute, and oxygen saturation is 90% on high-flow oxygen. A 32-French intercostal catheter is inserted into the left fifth intercostal space, yielding an immediate return of 1700 mL of dark red blood. Following this initial drainage, the underwater seal drain continues to evacuate 250 mL of blood per hour over the next two hours despite ongoing balanced resuscitation. Which of the following is the most appropriate next step in management?

Transfer the patient urgently to the operating theatre for thoracotomy. The patient has a massive haemothorax meeting both standard operative thresholds for emergency surgical intervention: an initial immediate chest tube evacuation of at least 1500 mL of blood, and ongoing persistent haemorrhage exceeding 200 mL per hour for two to four consecutive hours. The definitive management is urgent transfer to the operating theatre for emergency open thoracotomy or video-assisted thoracoscopic surgery to achieve direct surgical haemostasis (such as ligation of bleeding intercostal or internal mammary vessels). Inserting a second chest tube does not control active arterial or parenchymal bleeding. Clamping the chest drain is strictly contraindicated because it converts an evacuated haemothorax into a tension haemothorax, accelerating cardiovascular collapse. Pericardiocentesis is indicated for cardiac tamponade, not for intrapleural exsanguination from a massive haemothorax.

Q: A 22-year-old cyclist is struck by a vehicle and sustains a 4-centimetre full-thickness wound over his right lateral chest wall. On examination, a prominent sucking sound is audible with each inspiration, accompanied by bubbling of frothy blood. He is tachypnoeic at 32 breaths per minute, heart rate is 114 beats per minute, and blood pressure is 108/68 mmHg. Breath sounds are markedly reduced on the right side. Which of the following is the most appropriate initial management for this thoracic defect?

Apply a sterile three-sided occlusive dressing over the open chest defect. An open chest defect requires the local protocol for a vented seal or three-sided dressing, urgent trauma care and a chest drain at a separate site when indicated. Monitor continuously and release/remove the dressing if breathing deteriorates or tension develops. A dressing is temporary management, not definitive source control.

Q: A 52-year-old male pedestrian is admitted following a motor vehicle collision. Physical examination reveals an isolated segment of the left anterior chest wall that sinks inwards during inspiration and bulges outwards during expiration. Palpation identifies crepitus and tenderness over the left fifth through eighth ribs. An arterial blood gas on room air shows a pH of 7.34, PaO2 of 58 mmHg, and PaCO2 of 48 mmHg. Chest radiography confirms segmental fractures of ribs five, six, seven, and eight. Which of the following represents the primary foundation of initial clinical management?

Aggressive multimodal analgesia combined with positive pressure ventilation. This patient has a flail chest, defined by fractures of at least two contiguous ribs in two or more places, leading to an unstable floating segment and paradoxical chest wall movement. The underlying pathophysiological driver of hypoxaemia and respiratory compromise in flail chest is the severe pulmonary contusion situated beneath the fractured ribs. The cornerstones of initial management are aggressive multimodal analgesia (such as thoracic epidural analgesia, paravertebral nerve block, or patient-controlled intravenous opioids) to permit adequate chest expansion and pulmonary toilet, combined with positive pressure ventilation (non-invasive CPAP or invasive mechanical ventilation) for acute respiratory failure. Immediate surgical rib plating is reserved for select patients who fail medical management or require thoracotomy for other indications. Tight circumferential chest binding or heavy sandbags severely restricts thoracic excursion, worsens atelectasis, and accelerates respiratory collapse. Bilateral prophylactic chest drains are not indicated in the absence of an identifiable pneumothorax or haemothorax.

Key Takeaways

Tension pneumothorax is a clinical emergency and treatment must not wait for radiography.
Flail chest involves adjacent ribs fractured in multiple places with an unstable segment.
Traumatic tamponade requires urgent surgical involvement and a context-specific drainage plan.

Last updated: October 2026

Resuscitation Radiography

Chest Radiograph (AP supine mobile film): Identifies major pneumothoraces, haemothoraces, mediastinal widening, and endotracheal/chest tube placement.
Pelvic Radiograph (AP mobile film): Screen for unstable pelvic ring disruptions in blunt trauma patients with shock or altered mental status.
Unstable patients must never be transported out of the resuscitation bay to the CT scanner.

Immediately Life-Threatening Thoracic Injuries

1. Tension Pneumothorax

Pathophysiology: A one-way valve defect in the lung parenchyma or chest wall allows air into the pleural space during inspiration but prevents its escape during expiration. Progressive accumulation of air causes positive intrathoracic pressure, complete ipsilateral lung collapse, mediastinal shift to the contralateral side, compression of the superior and inferior vena cavae, dramatic reduction in venous return, and immediate obstructive cardiovascular collapse.
Clinical Features: Severe respiratory distress, tachypnoea, unilateral absent or diminished breath sounds, hyperresonance to percussion, distended neck veins (elevated JVP), tracheal deviation away from the affected hemithorax, and profound hypotension with tachycardia.
Emergency Management:
- Never wait for a chest X-ray: Tension pneumothorax is a clinical diagnosis.
- Immediate needle decompression: Insert a large-bore cannula (14-gauge or 16-gauge, $\ge 5\text{ cm}$ length) into the 2nd intercostal space in the midclavicular line or the 5th intercostal space in the anterior axillary line.
- Immediate definitive drainage: Follow needle thoracostomy immediately with finger thoracostomy (in ventilated patients) or formal intercostal catheter (ICC) insertion connected to an underwater seal drain.

2. Open Pneumothorax ("Sucking Chest Wound")

Pathophysiology: A full-thickness defect in the chest wall that exceeds two-thirds of the diameter of the trachea ( $> 2\text{ to }3\text{ cm}$ ). Because air follows the path of least resistance, atmospheric air rushes through the chest wall wound during inspiration rather than through the trachea, resulting in severe ventilation-perfusion mismatch, hypoxia, and lung collapse.
Emergency Management:
Open chest wound: Follow the local trauma protocol for an appropriate vented seal or three-sided occlusive dressing. Monitor closely; remove or release the dressing if ventilation deteriorates or tension develops. A chest drain is inserted separately from the wound; a seal is not definitive management.
- Avoid sealing all four sides without a chest drain, as this converts an open pneumothorax into a tension pneumothorax.
- Place a formal large-bore intercostal catheter at a separate, non-injured anatomical site (e.g., 5th intercostal space, anterior axillary line).
- Arrange definitive operative surgical closure and debridement of the wound.

3. Massive Haemothorax

Pathophysiology: Rapid accumulation of blood within the pleural space, defined as an immediate drainage of $\ge 1500\text{ mL}$ of blood (or $> 1/3$ of circulating blood volume) upon chest tube insertion, or ongoing blood loss $> 200\text{ mL/h}$ for 2 to 4 consecutive hours. Usually caused by laceration of systemic vessels (intercostal arteries, internal mammary artery) or hilar vascular disruption.
Clinical Features: Severe shock (hypotension, marked tachycardia), unilateral dullness to percussion, absent or diminished breath sounds, and flat or collapsed neck veins (due to profound hypovolaemia, though veins may be distended if mediastinal shift occurs).
Emergency Management:
- Rapid fluid and blood resuscitation via the Massive Transfusion Protocol; autotransfusion of drained blood via cell saver when available.
- Insert a large-bore intercostal catheter (28-French to 32-French) in the 5th intercostal space anterior axillary line to evacuate blood and track output.
- Indications for Emergency Operative Thoracotomy:
  1. Initial immediate drainage of $\ge 1500\text{ mL}$ of blood upon tube insertion.
  2. Ongoing haemorrhage $> 200\text{ mL/h}$ for 2 to 4 hours.
  3. Haemodynamic instability refractory to aggressive balanced blood product resuscitation.

4. Flail Chest

Pathophysiology: Occurs when two or more contiguous ribs are fractured in two or more places, creating an isolated, unanchored segment of the thoracic cage that moves independently of the chest wall.
Clinical Features: Paradoxical chest wall movement—the flail segment collapses inwards during inspiration (due to negative intrathoracic pressure) and balloons outwards during expiration. The primary cause of hypoxaemia is not the mechanical flail itself, but the underlying severe pulmonary contusion (alveolar haemorrhage, atelectasis, and interstitial oedema).
Emergency Management:
- Multimodal Analgesia: Aggressive regional anaesthesia (thoracic epidural, paravertebral nerve block, erector spinae plane block, or intercostal nerve blocks) is the cornerstone of treatment to facilitate deep breathing, coughing, and chest physiotherapy.
- Oxygenation & Ventilatory Support: High-flow humidified oxygen. If the patient develops progressive respiratory failure or severe contusion, initiate non-invasive continuous positive airway pressure (CPAP) or endotracheal intubation with positive end-expiratory pressure (PEEP) to provide "internal pneumatic stabilization".
- Cautious Fluid Resuscitation: Over-resuscitation with crystalloids exacerbates fluid extravasation into contused lung parenchyma, worsening alveolar-capillary block.
Flail chest: Analgesia, pulmonary care and respiratory support are central. Selected patients may benefit from early surgical rib fixation; waiting for failed ventilator weaning is not the only indication. Associated contusion can be the main driver of respiratory impairment.

5. Cardiac Tamponade

Pathophysiology: Accumulation of blood or pericardial fluid within the rigid pericardial sac, most commonly resulting from penetrating chest trauma. Elevated intrapericardial pressure impairs ventricular diastolic filling, severely reducing stroke volume and cardiac output.
Clinical Features:
- Beck's Triad: Hypotension, elevated jugular venous pressure (distended neck veins), and muffled/distant heart sounds.
- Pulsus Paradoxus: An abnormally large decrease in systolic blood pressure ( $> 10\text{ mmHg}$ ) during normal inspiration.
- eFAST confirms pericardial effusion and diastolic collapse of the thin-walled right ventricle.
Emergency Management:
- Judicious intravenous fluid bolus to augment right ventricular filling pressures as a temporary bridge.
- Emergency Department Resuscitative Thoracotomy (EDRT): For penetrating thoracic trauma presenting with cardiac arrest or witnessed loss of vitals in transit ( $< 15\text{ minutes}$ ). Left anterolateral thoracotomy allows pericardiotomy, evacuation of clot, digital control of cardiac lacerations, and cross-clamping of the descending aorta.
- Ultrasound-guided pericardiocentesis is reserved for subacute tamponade or when emergency thoracotomy capabilities are unavailable.

Clinical comparison: Differential Diagnosis of Life-Threatening Chest Trauma

Tension Pneumothorax: Pathophysiology: One-way air valve; high intrathoracic pressure; Percussion: Hyperresonant; Breath Sounds: Absent / diminished; Neck Veins: Distended (elevated JVP); Tracheal Position: Deviated to contralateral side; First-Line Emergency Action: Immediate needle or finger thoracostomy, then intercostal catheter
Massive Haemothorax: Pathophysiology: $\ge 1500\text{ mL}$ blood in pleural cavity; Percussion: Dull; Breath Sounds: Absent / diminished; Neck Veins: Collapsed (flat); Tracheal Position: Usually midline; may deviate contralaterally; First-Line Emergency Action: 28–32 Fr chest tube; blood transfusion; thoracotomy if bleeding persists
Cardiac Tamponade: Pathophysiology: Pericardial blood restricting ventricular filling; Percussion: Normal; Breath Sounds: Normal; Neck Veins: Distended (elevated JVP); Tracheal Position: Midline; First-Line Emergency Action: eFAST confirmation; fluid loading; emergency thoracotomy or pericardiocentesis
Flail Chest: Pathophysiology: $\ge 2$ contiguous ribs broken in $\ge 2$ places; Percussion: Normal or dull (contusion); Breath Sounds: Diminished over contusion; Neck Veins: Normal; Tracheal Position: Midline; First-Line Emergency Action: Multimodal regional analgesia, pulmonary toilet, positive pressure ventilation

Primary references (checked 7 October 2026): NSW trauma pathway.

Test Your Knowledge

A 28-year-old unrestrained driver is brought to the emergency department following a high-speed motor vehicle collision. On arrival, he is in marked respiratory distress with a respiratory rate of 38 breaths per minute, heart rate of 136 beats per minute, blood pressure of 74/42 mmHg, and oxygen saturation of 82% on high-flow oxygen. Clinical examination reveals absent breath sounds and hyperresonance across the right hemithorax, with jugular venous distension and palpable tracheal deviation toward the left side. Which of the following is the most appropriate immediate management step?

Perform immediate emergency chest decompression using the local trauma technique

Arrange an urgent portable anteroposterior chest radiograph in resuscitation

Perform rapid sequence endotracheal intubation with in-line stabilization

Insert a twenty-gauge central venous line into the right internal jugular vein

Test Your Knowledge

A 34-year-old construction worker is brought to the resuscitation bay after falling three storeys onto scaffolding, sustaining penetrating trauma to the left chest. On arrival, his blood pressure is 82/50 mmHg, heart rate is 128 beats per minute, and oxygen saturation is 90% on high-flow oxygen. A 32-French intercostal catheter is inserted into the left fifth intercostal space, yielding an immediate return of 1700 mL of dark red blood. Following this initial drainage, the underwater seal drain continues to evacuate 250 mL of blood per hour over the next two hours despite ongoing balanced resuscitation. Which of the following is the most appropriate next step in management?

Insert a second large-bore intercostal catheter into the left hemithorax

Transfer the patient urgently to the operating theatre for thoracotomy

Clamp the intercostal catheter to allow an intrapleural tamponade effect

Perform immediate bedside ultrasound-guided pericardiocentesis drainage

Test Your Knowledge

A 22-year-old cyclist is struck by a vehicle and sustains a 4-centimetre full-thickness wound over his right lateral chest wall. On examination, a prominent sucking sound is audible with each inspiration, accompanied by bubbling of frothy blood. He is tachypnoeic at 32 breaths per minute, heart rate is 114 beats per minute, and blood pressure is 108/68 mmHg. Breath sounds are markedly reduced on the right side. Which of the following is the most appropriate initial management for this thoracic defect?

Pack the chest wall defect tightly with sterile gauze and adhesive tape

Perform immediate primary suture closure of the chest wall defect at the bedside

Apply a sterile three-sided occlusive dressing over the open chest defect

Insert a large-bore intercostal catheter directly through the chest wound

Test Your Knowledge

A 52-year-old male pedestrian is admitted following a motor vehicle collision. Physical examination reveals an isolated segment of the left anterior chest wall that sinks inwards during inspiration and bulges outwards during expiration. Palpation identifies crepitus and tenderness over the left fifth through eighth ribs. An arterial blood gas on room air shows a pH of 7.34, PaO2 of 58 mmHg, and PaCO2 of 48 mmHg. Chest radiography confirms segmental fractures of ribs five, six, seven, and eight. Which of the following represents the primary foundation of initial clinical management?

Emergency operative rib plating and open surgical stabilization in theatre

Application of external compression sandbags and tight circular chest binding

Immediate placement of bilateral large-bore chest drains into both pleural spaces

Aggressive multimodal analgesia combined with positive pressure ventilation

Sections you finish are checked off in the contents.

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