Tension pneumothorax: absent breath sounds, worsening distress, hypotension; tracheal shift is late and JVD may be absent if hypovolemic.
Before you read
Test yourself first: 5 questions
Question 1 of 5
A hypovolemic trauma patient becomes markedly more hypotensive within a minute of assisted ventilation being started at a fast rate with large breaths. The best explanation is that:
Answer: A. Every delivered breath raises intrathoracic pressure, and a patient whose filling already depends on a low right atrial pressure loses preload each time the bag is squeezed — so an over-zealous rate and volume drop the output further, and slowing down restores it. Oxygen does not meaningfully dilate vessels, and correcting acidosis would improve rather than worsen perfusion.
Question 2 of 5
Why does a pneumothorax progress to tension more quickly once the patient is receiving positive-pressure ventilation?
Answer: A. A spontaneously breathing patient generates negative pressure and may move only a little air through a small leak; positive-pressure breaths force air through the injury with every ventilation, so pleural pressure climbs fast. Bagging raises, not lowers, intrathoracic pressure, and oxygen does not selectively accumulate in the pleural space.
Question 3 of 5
A stab wound lies at the base of the neck, below the level of the cricoid cartilage. This zone is of particular concern because it threatens:
Answer: A. Below the cricoid the neck becomes continuous with the thoracic inlet, so a wound there can involve the subclavian and carotid vessels, the trachea and the apex of the lung — and bleeding from it may be impossible to compress. Dismissing the area as superficial, or thinking of facial nerves that run well above it, misjudges what actually lies beneath that skin.
Question 4 of 5
A patient with a thoracic spine injury cannot move his hips or knees, but he can feel a light touch near the anus and can weakly flex his great toes on command. What is the significance of these findings?
Answer: A. Preserved perianal sensation or voluntary toe flexion (sacral sparing) proves some tracts cross the injury, making it incomplete and more likely to recover. Voluntary movement is not a reflex, and preserved sacral function does not mean the cord is intact. Sacral sparing does not predict neurogenic shock.
Question 5 of 5
A patient with a high thoracic spinal injury is hypotensive with a heart rate of 58, and warm, dry skin below the level of injury. Compared with hemorrhagic shock, this presentation is explained by:
Answer: A. When the sympathetic outflow is interrupted the vessels below the injury dilate and the heart cannot mount a compensatory tachycardia, so the patient is hypotensive, warm and bradycardic — the opposite of the cool, pale, tachycardic picture of blood loss. The cord itself loses no volume, and bleeding remains the first thing to exclude before accepting a neurogenic cause.
Keep the streak going with more questions like these, each with a full rationale.
What is thoracic trauma?
The examinable skill is telling tension pneumothorax, tamponade and massive hemothorax apart at the bedside and knowing the one intervention each needs.
Key points to remember
- Tension pneumothorax: absent breath sounds, worsening distress, hypotension; tracheal shift is late and JVD may be absent if hypovolemic.
- Needle decompression (paramedic): 2nd intercostal space midclavicular or 4th–5th anterior axillary line.
- Cardiac tamponade — Beck's triad: hypotension, JVD, muffled heart sounds.
- Massive hemothorax: absent breath sounds with flat neck veins and shock.
- Flail chest: paradoxical segment; the underlying pulmonary contusion drives the hypoxia.
Field priorities
- Open chest wound: vented or occlusive seal; burp it if the patient worsens.
- Positive-pressure ventilation can convert a simple pneumothorax to tension — watch for it.
- Rapid transport; tamponade and hemothorax need surgery.
Coaching the patient
- Neck veins separate them: distended in tension and tamponade, flat in hemothorax.
- Sudden collapse after a blow to the chest in sport: commotio cordis — start CPR and use the AED.
Red flags: act now
- Rising ventilation pressure in a bagged trauma patient
- Hypotension with distended neck veins
- Chest trauma with pulses unequal between arms
Thoracic Trauma: FAQs
What are the priority actions for Thoracic Trauma in the field?
Open chest wound: vented or occlusive seal; burp it if the patient worsens. Positive-pressure ventilation can convert a simple pneumothorax to tension — watch for it. Rapid transport; tamponade and hemothorax need surgery.
What findings in Thoracic Trauma change your plan or your transport decision?
Rising ventilation pressure in a bagged trauma patient. Hypotension with distended neck veins. Chest trauma with pulses unequal between arms.
What do I need to know about Thoracic Trauma for the NREMT?
Tension pneumothorax: absent breath sounds, worsening distress, hypotension; tracheal shift is late and JVD may be absent if hypovolemic. Needle decompression (paramedic): 2nd intercostal space midclavicular or 4th–5th anterior axillary line. Cardiac tamponade — Beck's triad: hypotension, JVD, muffled heart sounds. Massive hemothorax: absent breath sounds with flat neck veins and shock.
What should the crew communicate or document for Thoracic Trauma?
Neck veins separate them: distended in tension and tamponade, flat in hemothorax. Sudden collapse after a blow to the chest in sport: commotio cordis — start CPR and use the AED.
