Step 1: Perform ATLS Primary Survey (B- Breathing)

* Signs of respiratory distress/injury* Shortness of breath* Hypoxemia* Tracheal deviation* Diminished breath sounds

Step 2: Consider Performing Bedside Tube Thoracostomy

* Insert at 5th intercostal space just anterior to mid-axillary line

Step 3: Imaging

* Start with portable bedside chest x-ray* Pneumothorax can also be diagnosed by thoracic ultrasound

Step 4: Consider the 3 Critical Diagnoses

* Tension pneumothorax* Pressure builds up between chest wall and lung* Eventually decreases cardiac preload -> Hypotension/Death* Treatment* Needle decompression* Tube thoracostomy* Open pneumothorax* Lung unable to expand during inspiration* Treatment* 3-sided occlusive dressing over open (“sucking”) chest wound* Tube thoracostomy* Hemothorax* Chest cavity fills with blood* Eventual decreases cardiac preload -> Hypotension/Death* Treat with tube thoracostomy

Step 5: Consider the 3 Other Common Diagnoses

* Rib fractures* Diagnose with chest x-ray* Treatment* Pain control* Incentive spirometry* Small pneumothorax* Worsens with positive pressure ventilation (intubation, BiPAP)* Treatment* Supplemental oxygen* Supportive care* Pulmonary contusion* Supportive care

Additional Reading

* Round 12 – Difficulty Breathing (EM Clerkship)* Chest Tube Thoracotomy Demonstration (YouTube)