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Occult tension pneumothorax discovered following imaging for adult trauma patients in the modern major trauma system: a multicentre observational study
  1. David N Naumann1,2,
  2. E Sellon3,
  3. S Mitchinson4,
  4. H Tucker5,
  5. M E R Marsden1,4,
  6. E Norris-Cervetto3,
  7. V Bafitis3,
  8. T Smith2,
  9. R Bradley4,
  10. A Alzarrad4,
  11. S Naeem4,
  12. G Smith4,
  13. S Dillane5,
  14. A Humphrys-Eveleigh5,
  15. M Wordsworth1,6,
  16. N Sanchez-Thompson6,
  17. D Bootland7 and
  18. L Brown7
  19. FORTRESS Collaborative
    1. 1Academic Department of Military Surgery and Trauma, Royal Centre for Defence Medicine, Birmingham, UK
    2. 2Department of Surgery, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
    3. 3Department of Radiology, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
    4. 4Emergency Department, Barts Health NHS Trust, London, UK
    5. 5Emergency Department, St George's Healthcare NHS Trust, London, UK
    6. 6Department of Surgery, Imperial College Healthcare NHS Trust, London, UK
    7. 7Emergency Department, Brighton and Sussex University Hospitals NHS Trust, Worthing, UK
    1. Correspondence to Maj David N Naumann, Academic Department of Military Surgery and Trauma, Royal Centre for Defence Medicine, Birmingham B152TH, UK; david.naumann{at}


    Background Tension pneumothorax following trauma is a life-threatening emergency and radiological investigation is normally discouraged prior to treatment in traditional trauma doctrines such as ATLS. Some trauma patients may be physiologically stable enough for diagnostic imaging and occult tension pneumothorax is discovered radiologically. We assessed the outcomes of these patients and compared them with those with clinical diagnosis of tension pneumothorax prior to imaging.

    Methods A multicentre civilian–military collaborative network of six major trauma centres in the UK collected observational data from adult patients who had a diagnosis of traumatic tension pneumothorax during a 33-month period. Patients were divided into ‘radiological’ (diagnosis following CT/CXR) or ‘clinical’ (no prior CT/CXR) groups. The effect of radiological diagnosis on survival was analysed using multivariable logistic regression that included the covariates of age, gender, comorbidities and Injury Severity Score.

    Results There were 133 patients, with a median age of 41 (IQR 24–61); 108 (81%) were male. Survivors included 49 of 59 (83%) in the radiological group and 59 of 74 (80%) in the clinical group (p=0.487). Multivariable logistic regression showed no significant association between radiological diagnosis and survival (OR 2.40, 95% CI 0.80 to 7.95; p=0.130). There was no significant difference in mortality between the groups.

    Conclusion Radiological imaging may be appropriate for selected trauma patients at risk of tension pneumothorax if they are considered haemodynamically stable. Trauma patients may be physiologically stable enough for radiological imaging but have occult tension pneumothorax because they did not have the typical clinical presentation. The historical dogma of the ‘forbidden scan’ no longer applies to such patients.

    • Respiratory physiology
    • Adult thoracic medicine
    • Thoracic surgery
    • Chest imaging

    Data availability statement

    Data are available upon reasonable request.

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    • Twitter @davidnnaumann, @maxmarsden83

    • Collaborators The FORTRESS Collaborative: David Naumann, Edward Sellon, Max Marsden, Tom Smith, Matthew Wordsworth, Phill Pearce, Tom König, William Charlton, Alastair Beaven, Kieran Campbell, Robert Staruch.

    • Contributors DNN and the members of the FORTRESS Collaborative designed the study. Data collection was undertaken by all authors. Data analysis was conducted by DNN and data interpretation was undertaken by all authors. The first draft of the manuscript was written by DNN, and critical appraisal and revisions were made by all authors. All authors have approved the final manuscript. DNN acts as a guarantor.

    • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

    • Competing interests None declared.

    • Provenance and peer review Not commissioned; externally peer reviewed.

    • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.