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Educational draft · awaiting clinical reviewUse Rapid for revision, not patient-care decisions. Check current national and local guidance and the BNF or BNFC before acting.

Traumatic pneumothorax and haemothorax

Respiratory · UK scope · Sources checked 27 Aug 2026 · Clinical review pending

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Suspected tension pneumothorax with haemodynamic instability or severe respiratory compromise requires immediate chest decompression. NICE recommends open thoracostomy when the expertise is available, followed by a chest drain; use needle decompression only when that is the available life-saving skill. Massive haemothorax requires simultaneous major-haemorrhage resuscitation, drain placement and urgent thoracic or trauma surgery.

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.
  • 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.

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.

Open pneumothorax

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.

Haemothorax

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 haemorrhage

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

Major airway or diaphragmatic injury

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.

Investigation priorities

01
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.

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

The patient is physiologically stable after the primary survey.

  1. Use chest radiograph and eFAST, then CT according to mechanism and whole-body trauma criteria.
  2. Observe a small occult pneumothorax only through a protocol that accounts for ventilation, transfer, symptoms and reliable repeat imaging.
  3. Provide effective analgesia, pulmonary hygiene and early mobilisation while treating rib, lung and other organ injuries.

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.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.
Blood componentsActivate 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.
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Sources and review status5 sources · checked 27 Aug 2026 · clinical review pending+
Sources

Sources and review status

National guidance is shown before implementation-dependent detail. Typical adult dose examples remain subject to patient factors, contraindications and the live BNF or specialist protocol. Source check completed 27 Aug 2026; clinical approval remains outstanding.

  • NICE NG39 major trauma recommendationsPrimary-survey imaging, chest decompression, open thoracostomy, haemorrhage and tranexamic-acid recommendations.
  • BTS Clinical Statement on Pleural ProceduresSafe intercostal-drain insertion, securing and drainage-system practice.
  • Resuscitation Council UK ABCDE approachTreat life-threatening abnormalities as found and reassess after intervention.
  • NHS England major trauma and burns commissioning hubNational major-trauma service and network context.
  • NHS England specialised clinical network specificationsCurrent major-trauma network functions and transfer coordination.

Editorial contact: Doctor’s Passport editorial team. Source-check date is separate from clinical approval. Report a content problem · Content changes

Authoring stateRapid draftClinical stateAwaiting reviewJurisdictionUnited Kingdom
  • Repeat assessment after procedures, transport and initiation of positive pressure because pleural air or blood can progress.