Advanced Trauma Life Support ATLS Student Course Manual 2018

SECONDARY SURVEY 73
this finding is extremely difficult to hear in a noisy
resuscitation bay.
An upright expiratory chest x-ray aids in the
diagnosis. Patients with blunt polytrauma are not
candidates for this evaluation, although patients with
penetrating chest trauma may be.
Any pneumothorax is best treated with a chest tube
placed in the fifth intercostal space, just anterior to the
midaxillary line. Observation and aspiration of a small,
asymptomatic pneumothorax may be appropriate,
but a qualified doctor should make this treatment
decision. After inserting a chest tube and connecting
it to an underwater seal apparatus with or without
suction, a chest x-ray examination is done to confirm
appropriate placement and reexpansion of the lung.
Ideally, a patient with a known pneumothorax should
not undergo general anesthesia or receive positive
pressure ventilation without having a chest tube
inserted. In selected circumstances, such as when a
“subclinical pneumothorax” (i.e., occult) has been
diagnosed, the trauma team may decide to carefully
observe the patient for signs that the pneumothorax is
expanding. The safest approach is to place a chest tube
before a tension pneumothorax can develop.
A patient with a pneumothorax should also
undergo chest decompression before transport
via air ambulance due to the potential risk of
expansion of the pneumothorax at altitude, even in a
pressurized cabin.
Hemothorax
A hemothorax is a type of pleural effusion in which
blood (