Traumatic pneumothorax and haemothorax — Rapid

Synopsis

Detect life-threatening pleural air or blood during trauma resuscitation, decompress physiological compromise without imaging delay, and integrate definitive drainage with haemorrhage control and major-trauma transfer.

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.

Key red flags

Tension pneumothorax

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.

Investigation priorities

Trauma ABCDE with repeated chest and haemodynamic examinationFirst step

Identify immediate threats and measure response to decompression, drainage and resuscitation.

Management branches

Primary surveyTreat tension as a clinical diagnosis

Chest trauma has haemodynamic instability or severe respiratory compromise compatible with tension pneumothorax.

Call the trauma team, give high-concentration oxygen initially, support the airway and expose the chest while maintaining spinal and temperature precautions.
Decompress immediately: use open thoracostomy if trained expertise is available, or the locally approved needle technique when it is the available life-saving option.

Stable injuryImage occult and associated damage

The patient is physiologically stable after the primary survey.

Key medicines

Tranexamic acid for active or suspected major bleedingIn 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.

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

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