The breathing assessment in the primary survey

The breathing assessment identifies a right-sided tension pneumothorax: respiratory distress (RR 32), hypotension (80/50), hyper-resonance and absent breath sounds on the right. The diagnosis is clinical — made at the bedside during the B step of the primary survey, without waiting for imaging.^[1]

Immediate treatment: needle decompression closely followed by chest-tube insertion (de Lesquen, Grade D). Do not send this patient for CT. In obesity, chest-wall thickness is greater at the 4th/5th ICS anterior axillary line than at the 2nd ICS midclavicular line; 50 mm needles failed the wall in 82 per cent at ICS 4/5-AAL versus 22 per cent at ICS 2-MCL, and no patient exceeded 83 mm at ICS 2-MCL. If the needle fails, convert to finger thoracostomy then a formal drain.^[1][2]

Definitive treatment: a chest drain by blunt dissection in the mid-axillary safe triangle, connected to an underwater seal, then a chest radiograph. All traumatic pneumothoraces are considered for a tube; selected small unilateral pneumothoraces without respiratory disease or positive-pressure ventilation may be observed — this shocked patient is not in that group.^[1]

Continuing management: high-flow oxygen; finish ABCDE; blood products if he is bleeding; tranexamic acid 1 g over 10 minutes then 1 g over 8 hours if haemorrhage is significant and injury was within 3 hours (CRASH-2). Re-examine for massive haemothorax, tamponade, and the other immediately life-threatening injuries. Damage-control thoracotomy is on the table if drain output exceeds 1500 mL initially or 200 mL/h for 3 hours with refractory shock (Grade D).^[3][1]