Red flags
- Tension: hypotension, tracheal deviation, absent BS + hyperresonance
- Bilateral pneumothorax
- Underlying lung disease
First steps
- ABCDE + high-flow O₂
- Tension → needle decompression 4th-5th ICS anterior axillary line (or 2nd ICS MCL)
- Chest drain (28-32 F, 5th ICS mid-axillary)
Key investigations
- CXR erect PA (or CT if occult)
- USS (lung sliding absent)
- ABG
Differentials
- PE
- APO
- MI
Initial management
- Primary <2 cm asymptomatic: observe + O₂ (accelerates absorption 4×)
- Primary >2 cm or symptomatic: aspiration then chest drain if failed
- Secondary: chest drain
- Suction if persistent leak >48 h; VATS for recurrent
Referral
- Cardiothoracic if persistent leak/recurrent
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