Hemodynamically stable

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Perform primary survey to assess ABCDEs

No

As standard practice, the initial assessment should begin with the primary survey, assessing the patient’s ABCDEs: airway, breathing, circulation, disability, and exposure.

Primary Survey

After assessing the patency of the patient’s airway, the next step is to evaluate breathing. When assessing breathing, pneumothorax should be suspected if the patient is tachypneic, dyspneic, hypoxic, or has increased work of breathing with use of accessory muscles. Supplemental oxygen should be administered if oxygen saturation is below normal or if intubation is being considered. Asymmetric or paradoxical chest wall movement can indicate injury to the lung and pleura, such as flail chest or tension pneumothorax.$^{19}$ The classic findings associated with pneumothorax on pulmonary auscultation are absent or diminished breath sounds with hyperresonance to percussion, although hyperresonance may be difficult to hear during a trauma survey due to noise in the resuscitation bay.$^{21,22}$ Subcutaneous emphysema may also be present with palpable crepitus of the chest wall; these signs are not specific for pneumothorax with significant blunt injury, but do indicate the potential for more significant trauma to the chest. Subcutaneous emphysema and crepitus are not specific for pneumothorax in patients with blunt trauma as compared to patients with penetrating trauma, but in both patients, subcutaneous emphysema and crepitus should raise suspicion for underlying chest injury. Evidence of chest wall trauma, such as bruising or tenderness to palpation, should also increase suspicion for the presence of underlying pneumothorax.$^{20}$

Secondary Survey

If pneumothorax is strongly suspected, evaluation should progress to the secondary survey once the patient has been stabilized. If a patient is unstable with signs of tension pneumothorax, emergent decompression is necessary before completing the secondary survey. If a chest tube cannot be placed immediately, needle decompression should be considered first. In the acute trauma evaluation, a chest tube may be placed or needle decompression undertaken during the course of the primary or secondary survey, potentially concurrent with other steps in the trauma algorithm. A CXR should be obtained after TT to evaluate for proper tube placement.