01Approach to the Critical Patient/attcp40

Immediate threats and triggers

›Time-critical recognition

›Tension pneumothorax physiology

›Shock with unilateral absent breath sounds

›Severe respiratory distress with hypoxemia

›Progressive hypotension after positive pressure ventilation

›Tracheal deviation as late finding

›Open pneumothorax physiology

›Large chest wall defect with audible air movement

›Worsening ventilation despite oxygen

›Rapid deterioration pattern

›If peri-arrest with suspected tension, immediate decompression without delay for imaging

›Primary survey integration

›Airway and ventilation priorities

›If respiratory failure, ventilatory support with preparation for immediate decompression

›If intubation planned, decompression readiness before or immediately after tube placement

›Circulation priorities

›If hypotension with thoracic trauma, parallel evaluation for tension pneumothorax and massive hemothorax

›If persistent shock after decompression, alternate causes and hemorrhage control pathway

›Monitoring and access

›Continuous pulse oximetry

›Target SpO2 at least 94% unless COPD hypercapnia concern

›Cardiac monitoring

›Dysrhythmia risk with hypoxemia

›Capnography if intubated

›Ventilation trend during decompression and tube thoracostomy

›Large-bore IV access

›Blood product readiness if associated hemothorax

02History/hx36

Focused trauma history

›Mechanism and context

›Blunt thoracic trauma

›MVC speed and intrusion

›Fall height and surface

›Crush injury duration

›Penetrating thoracic trauma

›Entry site and trajectory

›Weapon type and distance if known

›Iatrogenic risk

›Positive pressure ventilation

›Central venous access attempt

›Symptom profile

›Dyspnea

›Sudden onset

›Progressive worsening

›Pleuritic chest pain

›Unilateral localization

›Worse with inspiration or cough

›Cough

›Hemoptysis suggesting associated lung injury

›Timeline and evolution

›Time from injury to symptoms

›Interval deterioration during transport or after procedures

›Prior pulmonary history

›COPD or asthma

›Prior pneumothorax

›Blebs or bullous disease history

03Physical Exam/exam38

Thoracic exam and physiologic cues

›Vital sign pattern

›Respiratory rate and work of breathing

›Accessory muscle use

›Inability to speak full sentences

›Oxygen saturation

›Refractory hypoxemia despite oxygen

›Heart rate

›Tachycardia as early marker

›Blood pressure

›Hypotension suggesting tension physiology or hemorrhage

›Inspection

›Chest wall injury

›Penetrating wound

›Paradoxical movement suggesting flail segment

›Open chest wall defect

›Sucking wound

›Frothy bubbling

›Subcutaneous emphysema

›Neck or chest crepitus

›Palpation

›Tracheal position

›Deviation as late sign

›Rib tenderness and instability

›Crepitus tracking

›Percussion

›Hyperresonance on affected side

›Dullness suggesting hemothorax

04Differential Diagnosis/ddx27

Immediate life threats in chest trauma

›Obstructive and respiratory causes

›Tension pneumothorax (J93.9)

›Shock physiology with unilateral findings

›Massive hemothorax (J94.2)

›Dullness and hypovolemic shock

›Cardiac tamponade (I31.4)

›Beck triad incomplete in trauma

›Airway obstruction

›Facial trauma or aspiration

›Pulmonary parenchymal injury

›Pulmonary contusion (S27.3)

›Hypoxemia with crackles

›Flail chest (S22.5)

›Paradoxical movement and pain-limited ventilation

›Vascular and mediastinal injury

›Aortic injury (S25.0)

›Widened mediastinum and high-energy mechanism

›Non-traumatic mimics and overlaps

›Acute asthma exacerbation (J45.901)

›Wheeze and air trapping

›Pulmonary embolism (I26.99)

›Pleuritic pain and hypoxemia without trauma explanation

›Acute coronary syndrome (I21.9)

›Chest pain with risk factors

›Procedure-related complications

›Endotracheal tube mainstem intubation

›Unilateral breath sounds after intubation

05Laboratory Tests/lt25

Core trauma labs and interpretation

›Blood and hemostasis

›Complete blood count for bleeding concern

›Hemoglobin trend with suspected hemothorax

›Leukocytosis as nonspecific stress response

›Coagulation studies if anticoagulant use or major trauma

›INR interpretation with warfarin exposure

›aPTT interpretation with heparin exposure

›Type and screen for anticipated tube thoracostomy and trauma resuscitation

›Massive transfusion protocol readiness if shock

›Perfusion and shock markers

›Venous blood gas or arterial blood gas when severe respiratory distress

›PaO2 in mmHg for oxygenation severity

›PaCO2 in mmHg for ventilatory failure

›pH trend with fatigue

›Lactate in mmol/l

›Elevated lactate supporting occult shock

›Clearance trend supporting response

›Additional tests by context

›Basic metabolic panel for procedural planning

›Potassium abnormalities affecting dysrhythmia risk

›Troponin if blunt cardiac injury concern

›Abnormal troponin prompting ECG and monitoring pathway

›PITFALLS

›Normal hemoglobin early in acute bleeding

›Lactate elevation from seizure or adrenergic surge not specific to hemorrhage

06Diagnostic Tests/dt55

Scoring Systems

›Imaging decision support

›NEXUS Chest decision instrument for blunt trauma imaging

›Age greater than 60 years

›Rapid deceleration mechanism

›Chest pain

›Intoxication

›Altered mental status

›Distracting painful injury

›Chest wall tenderness

›Clinical application notes

›Tool for imaging selection

›Not a treatment rule for tension physiology

›Severity frameworks

›Trauma Severity Score concepts for thoracic injury

›Respiratory status contribution

›Associated injuries contribution

MRI

›Limited role

›Indications

›Suspected diaphragmatic injury when CT equivocal and stable

›Complex chest wall soft tissue assessment in stable patient

›Contraindications

›Unstable physiology

›Need for continuous resuscitation equipment

›Interpretation pearls

›Not first-line for pneumothorax detection

07Disposition/dispo25

Level of care and follow-up decisions

›Admission criteria

›Any traumatic pneumothorax requiring tube thoracostomy

›Inpatient monitoring for recurrence and air leak

›Associated injuries requiring observation

›Rib fractures with pain-limited ventilation

›Pulmonary contusion

›Oxygen requirement

›Persistent hypoxemia on room air

›ICU criteria

›Mechanical ventilation

›Risk of progression to tension physiology

›Ongoing hemodynamic instability

›Shock requiring vasopressors or transfusion

›Large or persistent air leak

›Concern for bronchopleural fistula

›Transfer criteria

›Lack of thoracic surgery capability with persistent air leak

›Need for interventional radiology or trauma center services

›Observation and potential discharge pathway

›Small traumatic pneumothorax with stability

›Normal vital signs over observation period

›No progression on repeat imaging

›Reliable follow-up and return precautions

›PITFALLS

›Discharge inappropriate if on positive pressure ventilation or pending major procedures

08Treatment/t95

Decompression and chest drainage

›Suspected tension pneumothorax

›Immediate decompression options

›Needle decompression

›Preferred site 4th or 5th intercostal space anterior axillary line

›Large-bore catheter at least 14 gauge

›Catheter length at least 8 cm in adults to reduce failure risk

›Alternate site 2nd intercostal space midclavicular line

›Higher failure risk in larger body habitus

›If no clinical improvement after attempt, immediate finger thoracostomy or tube thoracostomy

›Finger thoracostomy

›Preferred in profound shock or peri-arrest when trained and equipped

›Followed by definitive tube thoracostomy

›Traumatic pneumothorax definitive management

›Tube thoracostomy

›Typical adult tube size 28 to 32 French for traumatic pneumothorax and hemothorax risk

›Smaller pigtail catheter 14 French consideration in stable isolated pneumothorax by local protocol

›Higher clogging concern if blood present

›Insertion site safety

›Triangle of safety landmarking

›Tube direction anterior and superior for pneumothorax

›Drainage system

›Water seal after initial suction period by protocol

›Suction negative 20 cmH2O when incomplete expansion or ongoing air leak

›Post-procedure confirmation

›Chest radiograph for position and lung expansion

›POCUS for lung sliding return as adjunct

›Open pneumothorax

›Occlusive dressing strategy

›Ventilated dressing approach

›Three-sided dressing to allow egress if needed

›Commercial vented chest seal if available

›Definitive tube thoracostomy separate from wound

›Tube placed away from defect

›Surgical repair planning

›Early surgical consultation for large defects

Oxygenation and ventilation

›Oxygen therapy

›High-flow oxygen for symptomatic pneumothorax

›Nitrogen washout concept for resorption support

›Positive pressure ventilation considerations

›Higher risk of tension conversion

›Low threshold for tube thoracostomy with any pneumothorax on ventilation

›Ventilator strategy if intubated

›Lung-protective tidal volumes

›Avoid excessive PEEP when pneumothorax not fully controlled

Analgesia and procedural sedation

›Pain control goals

›Adequate ventilation and cough

›Prevention of atelectasis and pneumonia

›Multimodal analgesia

›Acetaminophen

›1 g PO or IV every 6 hours

›Maximum 4 g per 24 hours

›Ibuprofen

›400 mg PO every 6 to 8 hours

›Avoid in renal failure or high bleeding risk

›Opioid for severe pain

›Fentanyl IV 25 to 50 micrograms

›Repeat every 5 to 10 minutes to effect

›Respiratory depression monitoring

›Morphine IV 2 to 4 mg

›Repeat every 10 to 15 minutes to effect

›Hypotension risk in shock

›Procedural sedation for tube thoracostomy when needed

›Ketamine IV for hemodynamic support

›0.5 to 1 mg/kg IV for dissociation as needed

›Additional 0.25 to 0.5 mg/kg IV every 5 to 10 minutes if required

›Emergence reaction mitigation with calm environment

›Midazolam IV as adjunct

›0.5 to 1 mg IV titrated slowly

›Higher delirium risk in older adults

›Local anesthesia

›Lidocaine 1% infiltration

›Maximum 4.5 mg/kg without epinephrine

›Maximum 7 mg/kg with epinephrine

›Regional analgesia consideration

›Serratus anterior plane block

›Adjunct for rib fracture and tube pain when expertise available

Antibiotics and prophylaxis

›Antibiotic prophylaxis for tube thoracostomy in trauma

›Local protocol alignment

›Single-dose first-generation cephalosporin common practice

›Evidence mixed with some trauma guidelines supporting reduced empyema risk

›Tetanus prophylaxis for penetrating wounds

›Immunization status based dosing pathway

Complications and failure pathways

›Persistent air leak

›Chest tube system check

›Connections and water seal function

›Tube kinking or malposition

›Repeat imaging for malposition or retained pneumothorax

›If leak greater than 5 to 7 days, thoracic surgery consultation

›Re-expansion pulmonary edema risk

›Large chronic collapse caution

›Gradual drainage strategy consideration

›Tube complications

›Malposition intraparenchymal or fissural

›Organ injury risk

›Diaphragmatic level awareness

09Special Populations/sp51

Pregnancy

›Pregnancy physiology impacts

›Reduced functional residual capacity

›Faster desaturation during distress

›Elevated oxygen consumption

›Lower reserve during apnea

›Imaging considerations

›Ultrasound prioritization when feasible

›Lung POCUS for rapid confirmation

›Chest radiograph with shielding when indicated

›Maternal stabilization priority

›Treatment considerations

›Decompression and tube thoracostomy indications unchanged

›Maternal oxygenation as primary fetal support

›Analgesia selection

›Avoid NSAIDs in later pregnancy when possible

›Opioid use with monitoring

›Obstetric coordination

›If viable gestation with major trauma, obstetric consultation and fetal monitoring plan

Geriatric

›Atypical presentation risk

›Blunted tachycardia on beta-blockers

›Less obvious respiratory distress despite significant pathology

›Higher complication risk

›Frailty and rib fracture synergy

›Pneumonia risk

›Delirium risk with opioids

›Medication adjustments

10Background/b44

Epidemiology

›Frequency in trauma

›Traumatic pneumothorax common in blunt and penetrating thoracic injury

›Higher rates with rib fractures and pulmonary contusion

›Occult pneumothorax on CT with negative supine radiograph

›Approximate range 5% to 15% in blunt trauma cohorts

›Mortality and morbidity drivers

›Tension pneumothorax as preventable cause of traumatic cardiac arrest

›Time-to-decompression association with survival

›Complication burden

›Ventilator days increase with missed pneumothorax on positive pressure ventilation

Pathophysiology

›Air in pleural space

›Loss of negative intrapleural pressure

›Partial or complete lung collapse

›One-way valve effect in tension pneumothorax

›Progressive intrathoracic pressure rise

›Ipsilateral lung collapse

›Mediastinal shift

›Reduced venous return

›Obstructive shock and PEA arrest

›Open pneumothorax mechanics

›Preferential air flow through chest wall defect

›Ineffective ventilation

›Potential conversion to tension with occlusive sealing without venting

›Associated injury mechanisms

›Rib fracture puncture of pleura

›Penetrating pleural breach

11Patient Discharge Instructions/pdi22

Copy discharge instructions

›Discharge checklist

›Stable symptoms at rest

›Normal oxygen saturation on room air or stable baseline

›No progression on repeat imaging after observation

›Reliable supervision and return access

›Activity and care

›Avoid air travel until cleared

›Avoid scuba diving until specialist clearance

›Avoid heavy exertion until follow-up imaging

›Medications

›Analgesia plan with acetaminophen and ibuprofen if safe

›Opioid rescue only if prescribed with constipation prevention plan

›Follow-up

›Repeat chest imaging within 24 to 72 hours per local protocol

›Primary care or trauma clinic follow-up appointment timing

›Return to emergency criteria

›Worsening shortness of breath

›New or worsening chest pain

›Syncope or near-syncope

›Cyanosis

›Fever with pleuritic pain suggesting infection after tube removal

›Rapidly enlarging neck or chest swelling

12References/r12

Clinical guidelines and evidence sources

›Trauma and emergency references

›Advanced Trauma Life Support guidelines for pneumothorax and tension pneumothorax management

›Eastern Association for the Surgery of Trauma practice management guidelines on occult pneumothorax

›Western Trauma Association critical decisions algorithms for traumatic pneumothorax and chest tube use

›American College of Surgeons Trauma Quality Improvement Program guidance on chest trauma care

›Pleural disease references

›British Thoracic Society pleural disease guidance for pneumothorax principles and drainage systems

›Society consensus statements on lung ultrasound for pneumothorax detection

›Key evidence themes

›Lung ultrasound higher sensitivity than supine chest radiograph for pneumothorax detection in trauma cohorts

›Occult pneumothorax observational management acceptable in selected stable patients without positive pressure ventilation

›Catheter length and insertion site influence needle decompression success rates

Evidence & Review

Evidence & Review