Pneumothorax, Hemothorax & Pleural Emergencies

Apply Non-Rebreather Mask at 15 L/min (100% FiO₂).
Do NOT delay decompression for a chest X-ray if shock (SBP < 90 mmHg), PEA arrest, or severe hypoxia is present.
Open (Sucking) Chest Wound: Apply a 3-sided occlusive dressing (vented Asherman/Russell seal) taped on 3 edges, leaving 1 dependent corner untaped.

Dalton's Law & Fick's Diffusion: Breathing 100% O₂ drops capillary nitrogen partial pressure (Pₙ₂) from 573 mmHg to near 0 mmHg, creating a steep diffusion gradient that accelerates pleural air reabsorption by 4- to 6-fold (1.25%/day → 5–7%/day). A 3-sided dressing creates a flutter valve that prevents air entry during inspiration while allowing air escape during exhalation.

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Spontaneously Breathing / Unstable: Needle Thoracostomy using a 14G (or 10G), 8.25 cm (3.25 inch) angiocatheter in the 4th or 5th Intercostal Space (ICS), Anterior-to-Mid-Axillary Line (AAL/MAL) (ATLS 10th Ed adult standard; 2nd ICS Mid-Clavicular Line [MCL] in pediatrics).
Intubated / Traumatic Arrest (PEA): Perform immediate bilateral Finger Thoracostomy (4th/5th ICS AAL/MAL) with a #10 or #22 Scalpel + curved Kelly clamp + gloved finger sweep.

Converts lethal positive intrapleural pressure (+15 to +30 cmH₂O) back to atmospheric zero, immediately relieving superior/inferior vena cava compression and restoring right atrial venous return. Finger thoracostomy prevents catheter kinking or chest-wall thickness failure.

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eFAST Ultrasound: High-frequency linear probe (5–10 MHz) at 2nd–3rd ICS anteriorly for pneumothorax + phased-array probe (2–5 MHz) at costophrenic angles for hemothorax.
Traumatic Hemothorax: Activate Massive Transfusion Protocol (1:1:1 PRBC:FFP:Platelets), give Tranexamic Acid (TXA) 1 g IV over 10 min (then 1 g over 8 hr), and give Calcium Chloride 1 g (10 mL of 10%) IV.

Identifies the Lung Point (100% specific for PTX) and Spine Sign (> 20 mL pleural blood). TXA competitively inhibits lysine-binding sites on plasminogen to prevent hyperfibrinolysis in the high-tPA pleural space; CaCl reverses citrate-induced hypocalcemic coagulopathy.

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Pre-Procedural Antibiotic (Trauma Hemothorax): Cefazolin 2 g IV (3 g if > 120 kg) before skin incision.
Analgesia/Sedation: Ketamine 0.5–1 mg/kg IV + 1% Lidocaine (5 mg/kg plain, 7 mg/kg with epi) infiltrated into skin, periosteum of inferior rib, and parietal pleura (or Ultrasound-Guided Serratus Anterior Plane Block with 30 mL of 0.25% Bupivacaine).
Tube Sizing:
• Spontaneous / Simple PTX: 8–14 Fr Pigtail Catheter (Seldinger) or conservative observation.
• Traumatic Hemothorax / Mechanically Ventilated Barotrauma: 28–32 Fr Surgical Chest Tube (blunt dissection; strictly identical efficacy to 36–40 Fr).

Pre-insertion Cefazolin reduces post-traumatic empyema and pneumonia by > 50% (EAST Guideline). Parietal pleura carries dense somatic pain fibers (intercostal nerves); blocking it prevents splinting and hypoxia. 28–32 Fr tubes evacuate blood without the severe intercostal neuralgia of 40 Fr tubes.

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Connect chest tube to a 3-chamber underwater seal system (2 cmH₂O water seal + −20 cmH₂O suction).
Massive Hemothorax Indications for Immediate Thoracotomy:
1. ≥ 1,500 mL blood evacuated immediately upon tube insertion.
2. ≥ 200 mL/hr for 2–4 consecutive hours.
3. Persistent hemodynamic instability / transfusion demand despite MTP.

Restores negative intrapleural pressure (−5 to −8 cmH₂O) so visceral and parietal pleura appose, tamponading low-pressure pulmonary parenchymal bleeding (15–25 mmHg). High-volume bright red drainage signifies a high-pressure systemic arterial source (intercostal or internal mammary artery, MAP 90 mmHg) requiring surgical ligation.

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