A 25-year-old tall thin man develops sudden severe right-sided pleuritic chest pain and dyspnoea while watching television. On arrival he is drowsy, trachea deviated to the left, right chest hyper-resonant with absent breath sounds, distended neck veins, SpO2 82%. What is the correct immediate step?
- A Obtain an urgent erect posteroanterior chest X-ray
- B Immediate large-bore needle decompression of the right hemithorax followed by intercostal drain insertion ✓
- C High-flow oxygen and reassessment in 30 minutes
- D CT pulmonary angiography to exclude embolism
Correct answer: B. Immediate large-bore needle decompression of the right hemithorax followed by intercostal drain insertion
Explanation
Tracheal shift away from the affected side with hyper-resonance, absent breath sounds, hypotension, distended neck veins and falling saturation defines tension pneumothorax. It is a clinical diagnosis and imaging must never delay decompression, since death occurs from impaired venous return. Large-bore needle decompression is done immediately, conventionally described at the second intercostal space midclavicular line in Indian texts, then a formal intercostal chest tube is placed. Oxygen alone or CT would be fatal delays.
Reference: Bailey and Love's Short Practice of Surgery, 28th ed.
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Written and medically reviewed by the StethoPrep medical team.