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Chest trauma
Most chest injuries are treated with a chest drain, oxygen and analgesia; the few that kill quickly — tension pneumothorax, tamponade, massive haemothorax and aortic injury — must be recognised clinically and treated before imaging.
Why it matters in the exam
Chest trauma questions present a patient after a crash or a stab wound with breathlessness and hypotension, and test whether you can tell the life-threatening conditions apart by examination: tension pneumothorax (absent breath sounds, distended neck veins, tracheal deviation), massive haemothorax (absent breath sounds with dullness to percussion and shock), tamponade (distended neck veins, muffled heart sounds, hypotension — Beck's triad) and flail chest. Each has a different immediate action.
Candidates are also asked about the indications for thoracotomy after drain insertion (the initial volume and the hourly rate), the chest X-ray finding that suggests aortic rupture (a wide mediastinum) and the test that confirms it (CT angiography), and rib fractures in older patients — where the danger is pneumonia and respiratory failure, so good analgesia (including a regional block) is a life-saving treatment. Another classic question is a stab wound in the "box" between the nipples, the clavicles and the costal margin — suspected cardiac injury.
Key points
- Tension pneumothorax — immediate needle decompression then a drain; no X-ray.
- Massive haemothorax — drain and blood; thoracotomy above 1500 mL at once or 200 mL per hour.
- Tamponade — Beck's triad, FAST and surgery.
- Wide mediastinum after deceleration — CT angiography; TEVAR.
- Rib fractures in an older patient — regional analgesia to prevent pneumonia.
Summary table
| Condition | Findings | Immediate treatment |
|---|---|---|
| Tension pneumothorax | Absent breath sounds, distended neck veins, tracheal deviation, hypotension | Needle or finger decompression, then a chest drain |
| Open pneumothorax | A "sucking" wound in the chest wall | Three-sided occlusive dressing, then a chest drain |
| Massive haemothorax | Absent breath sounds, dullness to percussion, shock | Chest drain and blood resuscitation; thoracotomy if more than 1500 mL drain at once or more than 200 mL per hour for 2–4 hours |
| Cardiac tamponade | Beck's triad: hypotension, distended neck veins, muffled heart sounds; pericardial FAST | Surgery (pericardial window or thoracotomy); pericardiocentesis only as a bridge |
| Flail chest and lung contusion | A chest-wall segment moving paradoxically, hypoxia | Oxygen, regional analgesia, ventilation as needed; caution with fluids |
| Aortic rupture | Wide mediastinum on X-ray after rapid deceleration | CT angiography; blood pressure control and endovascular repair (TEVAR) |
In the full version for subscribers
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Sources
- ATLS Advanced Trauma Life Support, Student Course Manual (American College of Surgeons), 10th edition (2018) — Thoracic Trauma
- Sabiston Textbook of Surgery, 21st edition (2022) — Management of Acute Trauma
- EAST practice management guideline on pain management in blunt thoracic trauma, 2016 — Analgesia for rib fractures
Sources are given for further reading; the text is written afresh and not copied from them.
Reviewed by the Examqo AI Professor · 2026-11-02. The text may contain errors; when in doubt, check the source.