Of the several causes that may alter respiration after trauma, tension pneumothorax, flail chest, and open pneumothorax are life threatening.

1. Although cyanosis, tachypnea, hypotension, neck vein distention, tracheal deviation, and diminished breath sounds on the affected side are the classic signs of tension pneumothorax, neck vein distention may be absent in hypovolemic patients, and tracheal deviation may be difficult to appreciate.
   1. The definitive diagnosis is made by CT scanning.
   2. In hypoxemic and hypotensive patients, immediate insertion of a 14-gauge angiocatheter through the fourth intercostal space in the midaxillary line or, at times, through the second intercostal space at the midclavicular line is essential. (There is no time for radiologic confirmation in this setting.)
2. A flail chest results from fractures of more than two sites of at least three adjacent ribs or rib fractures with associated costochondral separation or sternal fracture.
   1. It often develops over a 3- to 6-hour period, causing gradual deterioration of the chest radiograph and arterial blood gases (ABGs).
   2. Effective pain relief by itself can improve respiratory function and often avoid the need for mechanical ventilation (continuous epidural analgesia).
   3. Ventilation with low tidal volumes (6–8 mL/kg) and moderate positive end-expiratory pressure (PEEP) producing low inspiratory alveolar or plateau pressures appears to be the best pattern to prevent deterioration of hemodynamics and decrease the likelihood of acute respiratory distress syndrome (ARDS).
   4. Systemic air embolism occurs mainly after penetrating lung trauma and blast injuries or less frequently after blunt thoracic trauma that produces lacerations of both distal air passages and pulmonary veins. (Positive-pressure ventilation after tracheal intubation may then result in entrainment of air into the systemic circulation.)
      1. Respiratory maneuvers that minimize or prevent air entry into the systemic circulation include isolating and collapsing the lacerated lung by means of a double-lumen tube or ventilation with the lowest possible tidal volumes via a single-lumen tube.
      2. Transesophageal echocardiography (TEE) of the left side of the heart may permit visualization of air bubbles and their disappearance with therapeutic maneuvers.

Trauma and Burns

1. Initial Evaluation and Resuscitation
2. Cervical Spine Injury
3. Direct Airway Injuries
4. Management of Breathing Abnormalities
5. Management of Shock
6. Early Management of Specific Injuries
7. Burns
8. Operative Management
9. Management of Intraoperative Complications
10. Electrolyte and Acid–Base Disturbances
11. Early Postoperative Considerations