A 30-year-old motorcyclist is brought to the emergency department following a high-speed collision. Primary survey reveals: airway patent, respiratory rate 32/min with absent breath sounds on the left, tracheal deviation to the right, oxygen saturation 80% on high-flow O2, blood pressure 80/50 mmHg, and distended neck veins. What is the immediate management?

• A Urgent chest X-ray to confirm diagnosis before intervention
• B Endotracheal intubation and positive pressure ventilation
• C Immediate needle thoracostomy of the left second intercostal space, mid-clavicular line ✓
• D Insertion of a left intercostal chest drain (tube thoracostomy)

Explanation

This patient has a clinical tension pneumothorax — absent ipsilateral breath sounds, tracheal deviation away from the affected side, hypoxia, hypotension, and distended neck veins (obstructive shock). This is a life-threatening emergency requiring immediate decompression without waiting for imaging. Needle thoracostomy (14G cannula at the 2nd ICS, MCL on the affected side) converts tension to open pneumothorax and must be done instantly. A chest drain is the definitive treatment and follows after needle decompression. Intubation and positive pressure ventilation would worsen a tension pneumothorax. Never delay treatment for imaging when tension pneumothorax is clinically diagnosed.

Reference: Bailey & Love's Short Practice of Surgery, 27th ed.

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Written and medically reviewed by the StethoPrep medical team.