Chest Injuries / Pneumothorax (Adult)
 
Status
Chest injury
- Traumatic
- Spontaneous
- Iatrogenic
   
Assess
• Respiratory status
• Type of chest injury
   
Supplemental oxygen
Pain relief as per Pain Relief (adult)
Position Pt upright if possible unless:
- less than adequate perfusion, altered consciousness, associated barotrauma or potential spinal injury
               
Flail segment / Rib fractures
May require ventilatory support if decreased Tidal Volume
 
 
Open chest wound
3 sided sterile occlusive dressing
 
Pneumothorax
Signs of pneumothorax
See below
   
   
   
   
   
Status
Pneumothorax
- Simple
- Tension
   
Assess
Criteria for Simple Pneumothorax vs Tension Pneumothorax
   
Simple pneumothorax
Any of the following:
- Unequal breath sounds in spontaneously ventilating Pt
- Low SpO2 on room air
- Subcutaneous emphysema
Continue BLS and supplemental O2
Monitor closely for possible development of TPT
 
 
   
Tension pneumothorax (TPT)
Any of the following +/- signs of Simple Pneumothorax:
- Increased Peak inspiratory pressure (ventilator) / stiff bag
- Decreased EtCO2
- Poor Perfusion or increased HR +/- decreased BP
- Increased Jugular Venous Pressure (JVP)
- Decreased Conscious state in the awake Pt
- Tracheal shift
- Low SpO2 on supplemental O2 (late)
Chest decompression as per General Care (Selected Rural QAP)
 
Special Notes
In IPPV setting, equal air entry is NOT an exclusion criteria for TPT.
Chest injury Pts receiving IPPV have a high risk of developing a TPT. Solution for poor perfusion in this setting includes bilateral chest decompression.
Cardiac arrest Pts are at risk of developing chest injury during CPR.
Troubleshooting
- Pt may re-tension as lung inflates if catheter kinks off.
- Catheter may also clot off. Flush with sterile Normal Saline.
If a 14G Cannula is used initially, it should be replaced with an intercostal catheter (if available) as soon as practicable.
Insertion site for cannula/intercostal catheter
- Second intercostal space
- Mid clavicular line (avoiding medial placement)
- Above rib below (avoiding neurovascular bundle)
- Right angles to chest (towards body of vertebrae)
 
General Care
Tension Pneumothorax (TPT)
- If some clinical signs of TPT are present and the Pt is deteriorating with decreasing conscious state and/ or poor perfusion, immediately decompress chest by inserting a long 14G cannula or Intercostal Catheter.
- If air escapes, or air and blood bubble through the cannula/intercostal catheter, or no air/blood detected, leave insitu and secure.
- If no air escapes but copious blood flows through the cannula/intercostal Catheter then a major haemothorax is present. Remove, then cover the insertion site.

Needle Test
- If TPT suspected, but the assessment is not obvious, test for a TPT with a needle at least 45mm length (long 14/16G) attached to Normal Saline filled syringe.
- If needle test is suggestive of TPT, withdraw needle and immediately decompress chest.
- If needle test is not suggestive of TPT, withdraw needle, cover insertion site with a clear adhesive dressing and circle the insertion site with a pen
- Be aware that a needle test for TPT can be prone to false readings and does not exclude TPT in all cases.