Tension pneumothorax: eyes may be more diagnostic than ears

A case is presented of unilateral tension pneumothorax in an awake patient who was seen in prehospital care after a significant fall. Because of extrication difficulties it was 40 minutes after the accident when he was first seen and by this stage the tension pneumothorax was well developed. Many features that are taught as "classic" of tension pneumothorax were absent but various other clinical signs were present to aid the diagnosis, and these are reviewed.