Overview
This lecture covers the causes, presentations, and EMT-level management of pneumothorax (air in the pleural space) and hemothorax (blood in the pleural space) in trauma patients.
Pneumothorax Types and Causes
- Pneumothorax is the presence of air in the pleural space, impairing lung expansion.
- Three types: simple, open (“sucking chest wound”), and tension pneumothorax.
- Simple pneumothorax often results from rib fractures or ruptured blebs (e.g., emphysema).
- Open pneumothorax is typically due to penetrating chest trauma.
- Tension pneumothorax occurs when a one-way valve mechanism traps air, increasing inner thoracic pressure.
Clinical Features and Recognition
- Simple pneumothorax: minor breathing difficulty, often after trauma.
- Open pneumothorax: external wound, “sucking” sound, high risk for severe bleeding.
- Tension pneumothorax: progressive respiratory distress, hypotension, JVD, tracheal deviation (late), and shock.
- Key signs: unequal breath sounds, reduced chest expansion, hyper-resonance for pneumothorax, hypo-resonance for hemothorax.
Management of Pneumothorax
- Provide high-flow oxygen via non-rebreather mask (12–15 LPM).
- Monitor with cardiac monitors, pulse oximetry, and consider IV access.
- Open pneumothorax: apply occlusive dressing taped on three sides, leaving one side open to create a one-way valve.
- Tension pneumothorax: perform needle decompression at 2nd intercostal space midclavicular or 4th–5th space anterior axillary line; use a large (14G or higher) needle.
- Continue monitoring for recurrence or worsening symptoms.
Hemothorax Overview, Signs, and Management
- Hemothorax is blood filling the pleural space, impairing breathing and causing shock.
- Commonly caused by blunt or penetrating chest trauma.
- Presents with tachycardia, tachypnea, cold/clammy skin, diaphoresis, hypotension, and dullness to percussion.
- JVD is absent in hemothorax but present in tension pneumothorax.
- Manage with high-flow oxygen, two large-bore IVs, and watch for signs of hemorrhagic shock.
- Use permissive hypotension, avoiding excessive fluid resuscitation to prevent dilution of clotting factors.
Key Terms & Definitions
- Pneumothorax — Air in the pleural cavity, causing lung compression.
- Hemothorax — Blood in the pleural cavity, limiting lung expansion.
- Simple Pneumothorax — Air enters pleural space via lung lining injury.
- Open Pneumothorax — Air enters through a chest wall wound.
- Tension Pneumothorax — Air trapped under pressure in chest cavity, compressing the heart and lungs.
- JVD (Jugular Venous Distension) — Bulging neck veins, a sign of tension pneumothorax.
Action Items / Next Steps
- Practice identifying pneumothorax and hemothorax signs and differentiating between them.
- Review the steps of needle decompression and indication criteria.
- Study the percussion findings (hyper- vs. hypo-resonant) for chest trauma assessment.
- Prepare to apply occlusive dressings and manage shock in trauma scenarios.