A 25-year-old motorcyclist arrives after a road traffic accident. Primary survey: GCS 12, BP 88/60 mmHg, HR 128/min. Chest X-ray shows rightward tracheal deviation with absent breath sounds on the left and hyper-resonance. The immediate management is:
- A Portable CXR to confirm pneumothorax before any intervention
- B Emergent thoracotomy for suspected cardiac tamponade
- C Needle decompression at left 2nd intercostal space, midclavicular line, followed by chest drain ✓
- D Endotracheal intubation first, then reassess
Explanation
The clinical triad of absent breath sounds, hyper-resonance, and tracheal deviation away from the affected side in a hemodynamically unstable trauma patient is diagnostic of tension pneumothorax — a clinical diagnosis requiring immediate intervention without waiting for imaging. Initial management is needle decompression (2nd ICS, MCL or 5th ICS, anterior axillary line per updated ATLS), converting it to a simple pneumothorax, followed by definitive large-bore intercostal drain. Delay for CXR confirmation is contraindicated as the condition is immediately life-threatening.
Reference: Bailey & Love's Short Practice of Surgery, 27th ed.
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Written and medically reviewed by the StethoPrep medical team.