Suspected Thoracic Injury
Chest trauma with respiratory/circulatory compromise
All Pathways
Trauma SurgeryEmergency
Tension Pneumothorax Management
Tension Pneumothorax Management: Suspected Thoracic Injury → Signs of Tension Pneumothorax? → IMMEDIATE Needle Decompression → Definitive: Chest Tube → ...
Pathway Overview
14 steps
Algorithm Steps
14 total
01Start 02Decision Signs of Tension Pneumothorax?
Clinical diagnosis - immediate treatment
- Severe respiratory distress
- Hypotension/tachycardia (obstructive shock)
- Tracheal deviation (late sign)
- Absent breath sounds on affected side
- Distended neck veins (JVD)
- DO NOT DELAY FOR IMAGING
03Warning IMMEDIATE Needle Decompression
Life-saving intervention
- Site options:
- • 2nd ICS, midclavicular line (traditional)
- • 5th ICS, anterior axillary line (preferred - thinner)
- 14-16 gauge needle, ≥8cm length adults
- Insert perpendicular to chest wall
- Rush of air confirms diagnosis
- Leave catheter in place
04Action Definitive: Chest Tube
Follow needle decompression with tube thoracostomy
- 5th ICS, anterior to mid-axillary line
- Tube size: 28-32 Fr (hemothorax), 24-28 Fr (pneumothorax)
- Connect to underwater seal/Pleur-evac
- Confirm placement with CXR
05Decision Massive Hemothorax?
Indications for thoracotomy
- >1500mL immediate drainage
- >200mL/hr for 2-4 hours
- Continued transfusion requirement
- Persistent shock despite resuscitation
06Warning OR for Thoracotomy
Surgical exploration indicated
- Notify OR and thoracic/trauma surgery
- Continue resuscitation en route
- Prepare for autotransfusion if available
07Outcome Thoracic Injury Managed
Lung re-expanded, hemodynamically stable
08Action Monitor & Manage
Standard post-procedure care
- Confirm tube position with CXR
- Monitor output and air leak
- Pain control (intercostal blocks, PCA)
- Incentive spirometry
- Consider removal when <150mL/24h, no air leak
- Path rejoins step 07Shared downstream outcome
09Decision Open (Sucking) Chest Wound?
Visible chest wall defect
10Action 3-Sided Occlusive Dressing
Or vented chest seal
- Apply occlusive dressing (petroleum gauze)
- Tape on 3 sides (valve effect)
- Or use commercial vented chest seal
- Prepare for chest tube placement
11Action Chest Tube Insertion
Tube thoracostomy technique
- Position: supine, arm abducted 90°
- Site: 5th ICS, between ant/mid-axillary line
- Incision over rib, blunt dissect over superior border
- Finger sweep pleural space
- Direct tube posteriorly and superiorly
- Connect to drainage system, secure with suture
- Path rejoins step 05Shared downstream outcome
12Decision Simple Pneumothorax/Hemothorax
Stable patient, imaging obtained
- CXR or CT shows pneumothorax/hemothorax
- No tension physiology
- Assess size and symptoms
13Action Small Pneumothorax (<2cm)
Observation may be appropriate
- Stable, asymptomatic: observe 6h, repeat CXR
- Supplemental O2 (accelerates reabsorption)
- If stable on repeat: discharge with follow-up
- If symptomatic or progressing: chest tube
- Path rejoins step 07Shared downstream outcome
- Path rejoins step 11Shared downstream outcome
14Action Large Pneumothorax/Hemothorax
Chest tube indicated
- >2cm pneumothorax
- Symptomatic (dyspnea, hypoxia)
- Hemothorax >300-500mL
- Positive pressure ventilation planned
- Associated rib fractures
- Path rejoins step 11Shared downstream outcome
Guideline Source
WTA Critical Decisions: Traumatic Pneumothorax + ATLS 11
Clinical Safety Information
Clinical Decision Support — Not a Substitute for Clinical Judgment
Individual patient factors may require deviation from these recommendations.
Known Limitations
- Clinical diagnosis - do not delay treatment for imaging
- Needle decompression is temporizing, not definitive
- Chest wall thickness varies - may need longer needle
- Pediatric sizes differ
Applicable Regions
USEUGlobal
US: 5th ICS AAL increasingly preferred for needle decompression
Military: TCCC recommends 5th ICS AAL
Version 1Next review: 2027-01-01
Next steps
Finish the workflow by opening the most relevant calculator, then convert the session into a live account when you are ready.
Related Resources
Frequently Asked Questions
What is the Tension Pneumothorax Management?
The Tension Pneumothorax Management is a emergency clinical algorithm for Trauma Surgery. It provides a structured decision tree to guide clinical decision-making, based on WTA Critical Decisions: Traumatic Pneumothorax + ATLS 11.
What guideline is the Tension Pneumothorax Management based on?
This algorithm is based on WTA Critical Decisions: Traumatic Pneumothorax + ATLS 11 (DOI: N/A - WTA Algorithm PDF).
What are the limitations of the Tension Pneumothorax Management?
Known limitations include: Clinical diagnosis - do not delay treatment for imaging; Needle decompression is temporizing, not definitive; Chest wall thickness varies - may need longer needle; Pediatric sizes differ. Individual patient factors may require deviation from these recommendations.
Get AI-Powered Analysis Alongside This Algorithm
In AttendMe.ai, the Tension Pneumothorax Management appears automatically when your clinical question matches — alongside evidence from 3M+ peer-reviewed articles.
Try AttendMe Free