Traumatic pneumothorax and haemothorax

01OverviewDefinition, clinical context and the essential points that orientate the chapter.

Blunt or penetrating trauma can tear lung, pleura, chest wall, intercostal vessels, diaphragm or major hilar structures. Pleural air reduces ventilation and, under positive pressure, may raise intrathoracic pressure enough to obstruct venous return. Pleural blood both compresses lung and represents potentially life-threatening haemorrhage; the chest can conceal a large volume before external signs appear.

Assessment and treatment occur in parallel. The mechanism, wounds, asymmetric movement, percussion, breath sounds, subcutaneous emphysema, shock and ventilatory pressures guide immediate action. eFAST and portable radiography augment the primary survey, while CT defines occult pneumothorax, lung contusion, active bleeding, vascular injury and retained clot in patients stable enough to leave resuscitation.

Definitive care is networked. A drain treats the pleural consequence but not an injured intercostal artery, lung laceration or major airway disruption. Major haemorrhage, thoracotomy, VATS, interventional radiology and transfer decisions belong to the trauma team and receiving major trauma centre under current NICE NG39, BTS procedure standards and local trauma protocols.

Key points

Traumatic pneumothorax may be open, closed or tension; haemothorax is blood in the pleural space, and both often coexist with rib, lung, diaphragmatic or vascular injury.
Use an iterative trauma ABCDE approach. Treat immediately fatal breathing problems as they are found and reassess after every intervention.
Tension is diagnosed from physiological compromise, not tracheal deviation or imaging. Positive-pressure ventilation can convert a small pleural leak into rapid obstructive shock.
NICE advises chest decompression before imaging only when haemodynamic instability or severe respiratory compromise is present.
When trained expertise is available, open thoracostomy is more reliable than needle decompression in major trauma and is followed by an intercostal drain.
eFAST can detect pleural air and fluid rapidly, but a negative scan does not exclude a small pneumothorax, diaphragmatic injury or evolving haemothorax.
Stable patients usually receive early chest radiography and contrast trauma CT according to the injury pattern; never send an unstable patient to CT instead of controlling airway, breathing and bleeding.
A haemothorax needs drainage to restore ventilation, quantify bleeding and reduce retained clot or empyema. Large initial or continuing blood loss requires immediate surgical discussion, not threshold-watching in isolation.
Use warmed blood-component resuscitation and haemorrhage control rather than large crystalloid volumes in active major bleeding. Give tranexamic acid early under the current NICE/local major-haemorrhage protocol when indicated.
Persistent air leak, failure of lung re-expansion, retained haemothorax or suspected diaphragmatic or major airway injury needs early cardiothoracic and major-trauma-centre management.

02AetiologyUnderlying causes, associations and risk factors, with why each one matters.

Blunt chest trauma

Rib fracture, sudden compression and deceleration can tear lung, pleura or intercostal vessels and introduce air or blood into pleural space.

Penetrating injury

Stab, gunshot and impalement can breach chest wall, lung and major thoracic vessels, often producing combined haemopneumothorax.

Iatrogenic trauma

Central venous access, pleural procedures, biopsy and positive-pressure ventilation can injure pleura, lung or vessels, especially when other respiratory vulnerabilities are present.

Underlying vulnerability

Anticoagulation, bullous disease and frailty increase the severity of bleeding or air leak after apparently modest trauma.

03PathophysiologyThe causal sequence from the underlying abnormality to symptoms and harm.

1
Pleural breach
Air enters from lung or chest wall, or blood enters from injured systemic or pulmonary vessels.
2
Lung compression
The expanding collection separates pleural surfaces and reduces ventilated lung volume, causing ventilation-perfusion mismatch, which helps produce the characteristic physiological impairment.
3
Pressure or volume shock
Tension air obstructs venous return, while major blood loss reduces circulating volume; both impair cardiac output.
4
Combined thoracic injury
Pulmonary contusion, flail chest, cardiac injury and pain compound hypoxaemia and ventilatory failure beyond the pleural collection alone.

04Clinical features and red flagsSymptoms, examination findings, patterns of presentation and time-critical warnings.

Tension pneumothoraxRed flag

Severe respiratory distress or falling saturation with unilateral reduced ventilation, tachycardia and hypotension after chest trauma or positive-pressure ventilation indicates obstructive physiology and requires immediate decompression.

Open pneumothoraxRed flag

A communicating chest-wall wound may suck air, bubble or impair ventilation; cover with an appropriate vented seal and obtain definitive trauma drainage without creating a sealed tension system.

HaemothoraxRed flag

Reduced breath sounds with dullness, pleural fluid on eFAST and shock after chest trauma suggests intrathoracic bleeding; the chest may conceal substantial blood without external haemorrhage.

Massive or ongoing intrathoracic haemorrhageRed flag

Haemodynamic instability, rapid drain filling, continuing high output or transfusion dependence requires immediate trauma and thoracic surgery rather than observation for a numeric threshold.

Occult pneumothorax

CT may show pleural air missed on supine radiography. Observation is possible in selected stable patients, but positive-pressure ventilation, transfer or progression lowers the threshold for drainage.

Major airway or diaphragmatic injuryRed flag

A large continuous air leak, failure of lung expansion, persistent ventilation difficulty, abdominal viscera in the chest or an abnormal nasogastric-tube course needs urgent specialist imaging and surgery.

05InvestigationsWhat to request, why it matters and how to interpret it.

Investigation order

Read from the initial assessment onwards. Tests may run in parallel in urgent care; first-line, preferred, confirmatory, definitive and gold-standard labels appear only when the chapter explicitly states them.

01
Trauma ABCDE with repeated chest and haemodynamic examinationFirst step
Why
Identify immediate threats and measure response to decompression, drainage and resuscitation.
Interpretation and limitations
Do not rely on one examination. Deterioration after intubation can reveal tension pneumothorax; persistent shock after decompression requires a search for bleeding and other obstructive causes.
02
eFAST
Why
Detect absent lung sliding, pleural fluid, pericardial fluid and intra-abdominal bleeding during resuscitation.
Interpretation and limitations
Operator skill and adhesions limit sensitivity. Treat convincing tension physiology even if ultrasound is unavailable or equivocal, and use CT for occult injury only when stable.
03
Portable chest radiograph
Why
Show pneumothorax, haemothorax, mediastinal abnormality, rib injury and tube position without leaving resuscitation.
Interpretation and limitations
Supine films can hide anterior pneumothorax and layer pleural blood diffusely. A normal film does not exclude important injury after a high-risk mechanism.
04
Contrast-enhanced trauma CT
Why
Define lung, pleural, vascular, mediastinal, diaphragmatic and other torso injuries and plan intervention.
Interpretation and limitations
Use only after sufficient stabilisation. Active contrast extravasation, major vascular injury, retained clot or airway disruption requires immediate specialty action.
05
FBC, coagulation, fibrinogen, blood gas, lactate and crossmatch
Why
Assess haemorrhage, coagulopathy, ventilation and perfusion and prepare balanced transfusion.
Interpretation and limitations
Initial haemoglobin can be normal in acute blood loss. Trend physiology, lactate or base deficit, clotting and transfusion requirement rather than one number.
06
Chest-drain output and system assessment
Why
Confirm evacuation and quantify ongoing air or blood loss.
Interpretation and limitations
Document initial volume and time-linked output. Sudden cessation may indicate clot obstruction, while persistent brisk bleeding or large air leak mandates surgical review.
07
Repeat imaging for retained haemothorax
Why
Identify residual clot that increases infection and fibrothorax risk after initial drainage.
Interpretation and limitations
Ultrasound or CT defines retained collections and supports early VATS planning; a poorly functioning drain should not be left indefinitely.

06Differential diagnosisRealistic alternatives and the features that help distinguish them.

Pulmonary contusion

Alveolar haemorrhage within lung causes hypoxaemia and patchy opacities without a pleural air or fluid collection, though injuries often coexist.

Cardiac tamponade

Obstructive shock with pericardial fluid and chamber compromise rather than pleural signs suggests tamponade, and corroborating objective findings prevent an incorrect diagnostic label.

Diaphragmatic rupture

Abdominal viscera above the diaphragm and abnormal gastric or bowel sounds indicate rupture that can mimic pleural opacity or reduced breath sounds.

Aortic or major-vessel injury

High-energy mechanism, mediastinal abnormality and ongoing shock out of proportion to pleural findings require urgent vascular assessment.

Simple chest-wall injury

Local pain and rib fracture without pleural air, blood or physiological compromise still require surveillance because delayed complications occur.

07ManagementImmediate care, first-line treatment, alternatives and escalation.

01Primary surveyTreat tension as a clinical diagnosisFirst stepChest trauma has haemodynamic instability or severe respiratory compromise compatible with tension pneumothorax.

1Call the trauma team, give high-concentration oxygen initially, support the airway and expose the chest while maintaining spinal and temperature precautions.
2Decompress immediately: use open thoracostomy if trained expertise is available, or the locally approved needle technique when it is the available life-saving option.
3DefinitiveFollow with a definitive chest drain, secure it and connect to a functioning one-way drainage system.
4Reassess breath sounds, saturation, blood pressure and ventilation; investigate persistent instability for haemorrhage, tamponade, airway injury or contralateral tension.

02Pleural bloodDrain and control haemorrhage togetherHaemothorax is causing respiratory compromise, is clinically significant or accompanies shock.

1Activate the major-haemorrhage pathway when indicated, obtain large-bore access and use warmed blood components with early coagulation monitoring.
2Insert an appropriately selected trauma chest drain through trained practice and record the immediate output.
3Contact thoracic or trauma surgery immediately for instability, substantial initial evacuation, ongoing brisk output or transfusion dependence.
4Treat the bleeding source by surgery or interventional radiology and transfer through the major-trauma network when local capability is insufficient.

03Stable injuryImage occult and associated damageThe patient is physiologically stable after the primary survey.

1Use chest radiograph and eFAST, then CT according to mechanism and whole-body trauma criteria.
2Observe a small occult pneumothorax only through a protocol that accounts for ventilation, transfer, symptoms and reliable repeat imaging.
3Provide effective analgesia, pulmonary hygiene and early mobilisation while treating rib, lung and other organ injuries.
4Repeat assessment after procedures, transport and initiation of positive pressure because pleural air or blood can progress.

04Failure or complicationEscalate persistent air or retained bloodEscalationThe lung does not expand, air leak remains large, blood is retained or sepsis develops.

1Check the drain, tubing and imaging for blockage, malposition or an unaddressed second pleural collection.
2Suspect major bronchial injury with a continuous large air leak and ventilation failure; obtain immediate thoracic input and bronchoscopy when appropriate.
3Arrange early VATS evacuation for clinically important retained haemothorax according to trauma and thoracic protocols.
4Monitor and treat empyema, fibrothorax, diaphragmatic injury and venous thromboembolism during recovery.

Key medicines and prescribing safety4 treatments · regimens, roles and cautions

Reduces fibrinolysis and mortality in appropriate bleeding trauma patients while definitive haemorrhage control proceeds.

Tranexamic acid for active or suspected major bleeding

In an adult with major trauma and active or suspected active bleeding, give tranexamic acid as soon as possible and within 3 hours of injury: 1 g intravenously over 10 minutes followed by 1 g intravenously over 8 hours. Do not give after 3 hours unless there is evidence of hyperfibrinolysis. Follow the local major-haemorrhage protocol; trauma use is off-label in NICE NG39.

Do not delay surgery, interventional radiology or blood-component resuscitation. Verify timing, indication, renal considerations and the local preparation; it does not treat isolated pleural air.

Restores oxygen carriage and haemostasis during significant haemothorax and associated traumatic bleeding.

Blood components

Activate the local major-haemorrhage pack and give warmed components in protocol ratios, then individualise using clinical response and coagulation results.

Monitor temperature, ionised calcium, potassium, fibrinogen, coagulation and transfusion reactions. Crystalloid-heavy resuscitation worsens dilutional coagulopathy and hypothermia.

Enables ventilation, coughing and mobilisation and reduces pulmonary complications from rib and pleural pain.

Multimodal trauma analgesia

Use regular non-opioid therapy with titrated intravenous opioid and regional techniques when appropriate under the acute-pain and trauma protocol.

Balance analgesia against hypotension, renal injury, bleeding, sedation and respiratory depression. Regional blocks require anticoagulation and injury review.

Prevents or treats infection in selected open or contaminated thoracic injuries and empyema.

Antimicrobial prophylaxis or treatment

Use only when indicated by the current local penetrating-trauma, open-wound, drain or established-infection protocol and tailor to contamination and cultures.

A chest drain alone is not a reason for prolonged broad-spectrum antibiotics in every patient. Review allergies, renal function, duration and source control.

08ComplicationsImportant consequences, why they occur and why they matter clinically.

Tension pneumothorax

A one-way air leak raises intrathoracic pressure, causing rapidly progressive hypoxaemia, obstructive shock and arrest, and potentially prolonging treatment and functional recovery.

Haemorrhagic shock

Pleural space can conceal a large blood volume, with continuing vascular injury causing exsanguination, and potentially prolonging treatment and functional recovery.

Retained haemothorax and empyema

Undrained clot prevents lung expansion and provides a substrate for infection and fibrothorax, particularly when baseline cardiopulmonary reserve is limited.

Respiratory failure

Pleural compression combined with contusion, pain and chest-wall instability can require escalating ventilatory support, with severity determined by its extent and the patient's underlying reserve.

Persistent air leak

Major lung or airway disruption may create prolonged bronchopleural fistula and need thoracic surgical management, creating an additional need for recognition and targeted treatment.

09Monitoring and follow-upTreatment response, safety checks and longer-term review.

Repeat ABCDE assessment after decompression, intubation, drain insertion, transfusion, transfer and any physiological change.
Continuously monitor respiratory rate, saturation, airway pressures, pulse, blood pressure, temperature, consciousness and perfusion in major injury.
Record chest-drain output by time, colour, bubbling, swinging, patency, fixation and subcutaneous emphysema; escalate brisk or recurrent bleeding immediately.
Trend blood gas, lactate or base deficit, haemoglobin, platelets, fibrinogen, coagulation, calcium, potassium and core temperature during haemorrhage.
Use repeat radiography, ultrasound or CT to confirm drain position, lung expansion and absence of retained haemothorax according to trajectory.
During recovery monitor pneumonia, empyema, atelectasis, venous thromboembolism, pain, mobility and psychological effects and arrange trauma follow-up.

10Special situationsVariants, exceptions and circumstances that change the usual approach.

Needles can fail

Chest-wall thickness, catheter kinking and wrong landmark can make needle decompression ineffective. Open thoracostomy is preferred by NICE when trained expertise is available in major trauma.

The chest hides haemorrhage

External bleeding may be absent while pleural blood compresses the lung and drives shock. A normal early haemoglobin does not reassure.

Drain output is a trend

One threshold cannot replace physiology, transfusion need and trajectory. Sudden stoppage may mean clot blockage rather than haemostasis.

Positive pressure changes risk

A small occult pneumothorax can enlarge during ventilation, anaesthesia or air transfer. Reassess the drainage plan before these transitions.

Retained blood is not benign

Clot that remains after tube drainage increases empyema and fibrothorax risk; early imaging and VATS planning are preferable to prolonged ineffective drainage.

11Common pitfallsFrequent interpretation and management errors.

01
Waiting for CT or radiography before treating tension physiology.
02
Assuming failed needle decompression excludes tension pneumothorax.
03
Placing a chest seal that cannot vent an open pneumothorax.
04
Using large crystalloid volumes instead of a major-haemorrhage blood-component strategy.
05
Watching a single drain-output threshold while the patient remains shocked or transfusion-dependent.
06
Leaving a blocked drain and retained haemothorax without early surgical review.
07
Forgetting to reassess after positive-pressure ventilation or transfer.