A 24-year-old man is brought in after a stab wound to the left anterior chest wall. He is severely dyspnoeic, BP 70/40 mmHg, HR 140/min, SpO2 84%, trachea deviated to the right, left hemithorax hyper-resonant with absent breath sounds, and neck veins are engorged. What is the immediate next step?

• A Immediate endotracheal intubation and mechanical ventilation
• B Portable chest radiograph to confirm the diagnosis
• C Immediate needle decompression of the left pleural cavity ✓
• D Rapid infusion of 2 litres of crystalloid

Explanation

This is tension pneumothorax causing obstructive shock. It is a clinical diagnosis and any delay for imaging or airway instrumentation before decompression can be fatal. Needle decompression at the fifth intercostal space anterior axillary line (or fourth intercostal space midclavicular line) relieves the intrathoracic pressure immediately, followed by definitive tube thoracostomy. Intubation with positive pressure before decompression worsens the problem by increasing intrapleural pressure.

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.