 Welcome back to EM Ottawa trauma video. By now, you would have finished securing the patient's airway. However, just because the patient's airway is secure, does not mean that they are ventilating and oxygenating effectively. This is what we are assessing in the breathing assessment, the second part of the primary survey of the trauma patient. There are four major issues that can affect a trauma patient's breathing. They include tension pneumothorax, open pneumothorax, massive hemothorax, and flail chest. We will discuss why each is a problem, how to diagnose it, and how to fix it. First, let's talk about a pneumothorax, the parietal and visceral. Plura are usually closely adhered together. In a pneumothorax, there is a puncture of the visceral pleura, and air now rushes out into the pleural cavity. You can see on this x-ray, the right lung is partially collapsed, and this line outlines the edge of the lung. This has to be fixed, but not right away. However, if we have a tension pneumothorax, when there is a one-way valve where the air keeps on accumulating in this space, it will start to compress the heart and all the mediastinal structure to the opposite side. As a result, venous return drops. Because of not enough blood going back to the heart, cardiac output drops, and now the blood pressure plummets. This is a tension pneumothorax. On examination, the patient with a tension pneumothorax rather than just a regular pneumothorax will have obvious respiratory distress, such as in-drawing and tachypnea. Breath sounds will be markedly decreased on the affected side. The trachea deviates to the opposite side. The JVP is high because of poor venous return. Blood pressure is low. These findings alone should give you the diagnosis of tension pneumothorax. This is not a diagnosis that we should wait for X-ray confirmation. If you did do an X-ray, you may start to see the mediastinal structure shifting away from the side of the pneumothorax to the unaffected side. How do we treat it? The treatment of a tension pneumothorax is to release the air. To do this quickly, we insert a large bore intravenous catheter of 14 gauge or 16 gauge into the second intercostal space in mid-clavicular line in the affected side. This should release a gush of air. We then insert a chest tube in the fifth intercostal space in the anterior axillary line. We hope this to suction to extract the remaining air. The patient should respond by normalizing their blood pressure. Next, open pneumothorax. This is similar to a regular pneumothorax, except that there is also a wound in the skin. Now there is a communication between the pleural space to the outside. Therefore, when a patient takes a breath, the air preferentially enters through the hole in the chest and not through the trachea. That leads to more air in the space, causing potentially a tension pneumothorax. The diagnosis can be made by inspecting the skin for a deep open wound with air going through it. The most often cause of open pneumothorax is penetrating trauma such as stab wounds or gunshot wounds. The treatment for open pneumothorax is to apply a three-sided occlusive dressing that is a dressing that only has three edges taped, leaving one open. When the patient breathes in, the dressing is pulled closer to the skin, sealing the tract. When the patient breathes out, the air leaks out from the pleural space. This is essentially a one-way valve. This is a temporary treatment. The patient should also receive a chest tube in the fifth intercostal space. Interior axillary line. Next, massive pneumothorax. In a pneumothorax, there is blood in the pleural space. In a massive pneumothorax, the blood makes it harder for the affected lung to expand fully. This is also a source of significant blood loss. The treatment is very similar to the treatment for pneumothorax. A chest tube is used. It is inserted in the fifth intercostal space. The only difference is it is inserted in the posterior axillary line. It is done this way, since the patient are often going to be supine, and blood will pull more posteriorly. If there is lots of blood by chest tube, the diagnosis of massive pneumothorax is made. The patient likely will need surgical repair of the bleeding structures in the operating room. Next, phthalo chest. Phthalo chest occurs when there are more than two rib fractures in more than two spots within each rib. As a result, there is a flale section of the chest that does not move in time with the rest of the thorax. As seen in the illustration, during inspiration, the chest wall is expanding. While the flale segment moves inwards, from the bottom panel, during expiration, the chest wall is retracting. While the flale segment moves outwards. As you can see, this makes ventilation very inefficient. The diagnosis is made by watching for a symmetry of the chest rise during breathing. The treatment is early intubation and ventilation control. To return to our trauma patient, how should we look for these four things in his breathing assessment? For a tension pneumothorax, hypotension, increased JVP, trigger deviation and decreased breath sounds. For an open pneumothorax and a flale chest, a close inspection of the chest wall, specifically looking for a symmetry. A supine x-ray of the chest can tell us whether there is a hemothorax. After a chest tube is being put in, the amount of blood will tell us whether this is a massive hemothorax. After we fix any of these four issues during the breathing assessment, we can now proceed with the next part of the primary survey, circulation. Please refer to your next video.