Immediately after central venous catheter insertion into the right subclavian vein, a 60-year-old man becomes acutely distressed with tachypnoea, distended neck veins, tracheal deviation to the left, absent breath sounds on the right and hypotension. What is the immediate next step?

• A Perform endotracheal intubation and start mechanical ventilation
• B Obtain an urgent portable chest radiograph before any intervention
• C Insert an intercostal chest drain connected to an underwater seal
• D Immediate needle decompression in the second intercostal space at the midclavicular line on the right ✓

Explanation

This is tension pneumothorax, a clinical diagnosis that must be treated before imaging; waiting for a radiograph kills the patient. Immediate large-bore needle decompression in the second intercostal space at the midclavicular line relieves the positive intrapleural pressure, followed by definitive intercostal drain insertion. Intubation with positive pressure ventilation worsens tension physiology unless decompression precedes it. Chest drain alone delays relief of the obstructive shock and is done after needle decompression.

Reference: Bailey and Love's Short Practice of Surgery, 28th ed.

High-yield for: NEET PGINI-CETNExTFMGEUSMLEPLABMRCP

Written and medically reviewed by the StethoPrep medical team.