information repository image repository discussion group interactive trauma professional resources about trauma.org search trauma.org directory related sites new content

THORACIC TRAUMA
FAST ULTRASOUND

 

 

Chest Trauma
Pneumothorax - Open

Introduction

An open pneumothorax occurs when there is a pneumothorax associated with a chest wall defect, such that the pneumothorax communicates with the exterior.

Pathophysiology

During inspiration, when a negative intra-thoracic pressure is generated, air is entrained into the chest cavity not through the trachea but through the hole in the chest wall. This is because the chest wall defect is much shorter than the trachea, and hence provides less resistance to flow. Once the size of the hole is more than 0.75 times the size of the trachea, air preferentially enters through the thoracic cavity.

This results in inadequate oxygenation and ventilation, and a progressive build-up of air in the pleural space. The pneumothorax may tension if a flap has been created that allows air in, but not out.

Diagnosis

Diagnosis should be made clinically during the primary survey. A wound in the chest wall is identified that appears to be 'sucking air' into the chest and may be visibly bubbling - this is diagnostic.

Breathing is rapid, shallow and laboured. There is reduced expansion of the hemithorax, accompanied by reduced breath sounds and an increased percussion note. One or all of these signs may not be appreciated in the noisy trauma room.

Stab wounds to back
Video: Sucking wound

Management

100% oxygen should be delivered via a facemask. Consideration should be given to intubation where oxygenation or ventilation is inadequate. Intubation should not delay placement of a chest tube and closure of the wound.

The definitive management of the open pneumothorax is to place an occlusive dressing over the wound and immediately place an intercostal chest drain.

Rarely, if a chest drain is not available and the patient is far from a definitive care facility, a bandage may be applied over the wound and taped on 3 sides. This, in theory, acts as a flap-valve to allow air to escape from the pneumothorax during expiration, but not to enter during inspiration. This dressing may be difficult to apply to a large wound and it's effect is very variable. As soon as possible a chest drain should be placed and the wound closed.
 

CHEST TRAUMA

INITIAL EVALUATION
PNEUMOTHORAX
TENSION PNEUMO
OPEN PNEUMO
HAEMOTHORAX
CONTUSION
RIB FRACTURE / FLAIL
AORTIC INJURY
CHEST DRAINS

Classic signs of
open pneumothorax
(+ sucking chest wound)

Trachea  
Expansion  
Percussion Note  
Breath sounds  

PNEUMOTHORAX
(SIMPLE)

PRIMARY SURVEY
AIRWAY
BREATHING
CIRCULATION
DISABILITY
EXPOSURE

ADJUNCTS
CXR

SECONDARY SURVEY


Open pneumothorax


CT - Anterior defect
Chest drain in place

References

Mattox KL, Allen MK. Systematic approach to pneumothorax, haemothorax, pneumomediastinum and subcutaneous emphysema. Injury. 1986;17:309-312. Symposium paper

CHEST TRAUMA

INITIAL EVALUATION
PNEUMOTHORAX
TENSION PNEUMO
OPEN PNEUMO
HAEMOTHORAX
CONTUSION
RIB FRACTURE / FLAIL
AORTIC INJURY
CHEST DRAINS

trauma.org 9:3, March 2004