A 30-year-old restrained driver is brought to the trauma resuscitation bay following a high-speed motor vehicle collision. He is cyanotic and tachypneic (RR 36/min). Blood pressure is 74/40 mmHg. Breath sounds are completely absent over the right hemithorax, with hyperresonance on percussion and marked tracheal deviation to the left. What is the immediate life-saving procedure before obtaining a chest radiograph?

Answer and explanation

Correct answer: A. Immediate needle decompression in the 2nd intercostal space (or 5th anterior axillary) followed by chest tube

  1. Step 1: Recognize tension pneumothorax: Severe hypotension, unilateral absent breath sounds with hyperresonance, and contralateral tracheal deviation indicate positive-pressure intrathoracic air compressing the vena cava and collapsing cardiac return.
  2. Step 2: Tension pneumothorax is a clinical diagnosis requiring immediate needle decompression (large-bore catheter in the 2nd intercostal space midclavicular line or 5th intercostal space anterior axillary line) followed promptly by tube thoracostomy.
Answer
Immediate needle decompression in the 2nd intercostal space (or 5th anterior axillary) followed by chest tube.
Why not the others: 'Endotracheal intubation' with positive-pressure ventilation exacerbates tension pneumothorax, causing immediate cardiac arrest; 'Thoracotomy' is indicated in penetrating trauma with witnessed arrest; 'CT scan' delays treatment and leads to death in transit.

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