Thoracic Trauma — Simple Versus Tension Pneumothorax
A 19-year-old man is brought to the emergency department after a hard tackle to the right chest during a football match. He has right-sided chest pain and mild breathlessness. Blood pressure is 100/70 mm Hg, heart rate 96 beats/min, and oxygen saturation 94% on oxygen. Breath sounds are absent on the right, with crepitus over the chest wall. The trachea is midline. What is the initial step?
- A.Needle decompression of the right chest
- B.Rapid sequence endotracheal intubation
- C.CT of the chest before any intervention
- D.Right tube thoracostomyCorrect
Explanation
Absent breath sounds with subcutaneous emphysema after blunt chest trauma indicate a traumatic pneumothorax. The decision turns on whether it is under tension. Tension pneumothorax is a clinical diagnosis of obstructive shock: hypotension, marked respiratory distress, tachycardia, distended neck veins and sometimes tracheal deviation, and it needs immediate decompression. This young man is normotensive, only mildly tachycardic, adequately oxygenated and has a midline trachea, so the pneumothorax is not under tension. ATLS recommends tube thoracostomy in the fifth intercostal space, just anterior to the mid-axillary line, for a traumatic pneumothorax large enough to abolish breath sounds; a chest radiograph confirms position afterwards. Needle decompression in a stable patient adds little, often fails to reach the pleura, and still leaves him needing a chest tube. Intubation is not needed in a patient who is protecting his airway and oxygenating, and positive-pressure ventilation can convert a simple pneumothorax into a tension one. CT would delay treatment of a clinically obvious pneumothorax. The point most easily missed is that a falling blood pressure or rising distress at any stage changes the priority to immediate decompression.
Why each option
- A.
- Needle decompression is reserved for tension physiology with shock or severe distress, which this normotensive patient with a midline trachea lacks.
- B.
- He maintains his airway and oxygenates, and positive-pressure ventilation before draining the pleura risks converting the pneumothorax into tension.
- C.
- Imaging delays treatment of a clinically evident pneumothorax; CT suits occult pneumothoraces found in stable patients, not absent breath sounds.
- D.
- Correct. A clinically evident traumatic pneumothorax without tension physiology is treated with a chest tube in the fifth intercostal space.
Reference: ATLS Advanced Trauma Life Support, 10th edition (American College of Surgeons, 2018) — Thoracic Trauma; UpToDate — Initial evaluation and management of blunt thoracic trauma in adults (2025)
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