R — Respiration
Updated 2026-01-03R Respiration
Fix the breathing — chest injuries kill fast
Assessment
- Expose the chest — front AND back
- Look: Wounds, asymmetry, paradoxical movement
- Listen: Breath sounds both sides (if possible)
- Feel: Trachea position, crepitus (crackling)
Open Pneumothorax
“Sucking Chest Wound”
Signs:
- Wound bubbles or hisses with breathing
- Air movement through chest wall
Treatment:
- Apply vented chest seal over wound
- If no vented seal: tape 3 sides, leave 1 open
- Check for exit wound — seal both
Vented seals allow air out but not in. Prevents tension pneumothorax from developing.
Tension Pneumothorax
Pressure building in chest — immediately life-threatening
Signs (progressive):
- Increasing respiratory distress
- Decreasing breath sounds (affected side)
- Hypotension
- Tracheal deviation (late sign)
- Distended neck veins (may be absent if hypovolemic)
Treatment: Needle Decompression
- Identify site:
- 2nd intercostal space, midclavicular line (preferred), OR
- 5th intercostal space, anterior axillary line
- Insert 14ga needle/catheter perpendicular to chest wall
- Enter just above the rib (nerves/vessels below ribs)
- Listen/feel for air rush
- Remove needle, leave catheter
- Secure catheter, apply chest seal over
Do not delay if tension pneumo suspected. Needle decompression can be lifesaving. If wrong, minimal harm.
Massive Hemothorax
Blood filling chest cavity
Signs:
- Shock symptoms (tachycardia, hypotension, pale)
- Decreased breath sounds
- Dull to percussion (vs. hyperresonant in pneumothorax)
Treatment:
- Seal chest wounds
- Treat shock
- Expedite evacuation — requires surgery
Flail Chest
Multiple rib fractures creating free segment
Signs:
- Section of chest wall moves opposite to breathing (paradoxical)
- Severe pain
- May have underlying pulmonary contusion
Treatment:
- Position of comfort (injured side down if possible)
- Do NOT tape or bind
- Pain management if available
- Monitor for deterioration
Decision Table
| Finding | Likely Problem | Action |
|---|---|---|
| Wound bubbling | Open pneumo | Chest seal |
| Distress + no breath sounds | Tension pneumo | Needle decomp |
| Shock + decreased sounds | Hemothorax | Seal, treat shock, evac |
| Paradoxical movement | Flail chest | Position, monitor |
Reassess
- After every chest intervention
- Watch for tension pneumothorax developing
- Monitor respiratory rate and effort
- Check seals haven’t dislodged