A 60-year-old man on mechanical ventilation in ICU suddenly deteriorates: blood pressure 70/40 mmHg, distended neck veins, trachea deviated to the left, and absent breath sounds over the right hemithorax. What is the correct immediate next step?

• A Portable chest radiograph before any intervention
• B Deepen sedation and increase ventilator tidal volume
• C Rapid infusion of 1 litre crystalloid
• D Immediate large-bore needle decompression at the second intercostal space in the midclavicular line on the right ✓

Explanation

The picture of hypotension, raised jugular venous pressure, tracheal shift away, and unilateral silent hemithorax in a ventilated patient is tension pneumothorax, a clinical diagnosis. Decompression must precede imaging because a supine radiograph can miss it and delay costs lives; definitive intercostal drain follows once decompressed. Fluid boluses treat the wrong problem and raising tidal volume worsens air trapping through the ball-valve effect of the pleural leak.

Reference: Harrison's Principles of Internal Medicine, 21st ed.

High-yield for: NEET PGINI-CETNExTFMGEUSMLEPLABMRCP

Written and medically reviewed by the StethoPrep medical team.