Written by Joshua Belfer
Spoon Feed
Thoracic trauma is common––and so are pneumothorax and hemothorax. This high-yield review walks through clear, evidence-based ways to recognize, image, and treat these injuries.
Let’s decompress…
When air is the problem – pneumothorax
Pneumothorax (PTX) is common in thoracic trauma and should be suspected in any patient with chest trauma, especially with hypoxia, crepitus, or tracheal deviation. Hemodynamically unstable patients require immediate intervention, typically (and ideally) with tube thoracostomy, although finger or needle thoracostomies are an option. In stable patients, the decision to observe or treat is based on imaging. A PTX >20% of the lung field on CXR or >35 mm in radial depth on CT should be drained. Smaller PTXs can often be safely observed, though ~10% will fail observation, especially those on positive pressure ventilation. Serial CXRs at 4-6 and 24 hours help monitor progression.
When blood is the problem – hemothorax
Hemothorax (HTX) also mandates immediate chest tube placement in unstable patients, and if there’s significant blood loss (>1,500 mL initially or 200 mL/hr for 4 hours), an operative thoracotomy. In stable patients, CT is preferred for volumetric analysis. A 300 mL cutoff is supported by several retrospective studies to guide intervention––HTXs larger than this are more likely to fail observation. Chest irrigation with 1L of warm saline after drainage can decrease retained HTX and reduce the need for secondary procedures.
Procedural details that matter
Chest Tube Size: For stable patients, small-bore percutaneous tubes (≤14 Fr) are as effective as large-bore open tubes and cause less pain, with similar rates of resolution and complications.
Antibiotics: If time allows, a single pre-procedural dose of antibiotics (commonly cefazolin) is beneficial, particularly in penetrating trauma.
How does this change my practice?
There’s been a wealth of research guiding the management of traumatic PTX and HTX, including use of POCUS, size cutoff for chest tube placement, and size of chest tubes. This review distills much of the relevant evidence into a clear and practical refresher. It highlights key cutoffs worth remembering and includes several high-yield pearls (i.e. when to give antibiotics, irrigating chest tubes in HTX) that can help refine your approach to these injuries in the ED.
Source
Traumatic pneumothorax and hemothorax: What you need to know. J Trauma Acute Care Surg. 2025 Jul 3. doi: 10.1097/TA.0000000000004692. Epub ahead of print. PMID: 40604368
