A 28-year-old unrestrained driver is brought to the trauma center following a high-speed motor vehicle collision. He is cyanotic and in severe respiratory distress. Vital signs: BP 75/40 mmHg, HR 140 bpm, SpO2 78%. Examination reveals absent breath sounds over the right hemithorax, hyperresonance to percussion, and tracheal deviation to the left. What is the immediate life-saving intervention?

Answer and explanation

Correct answer: C. Immediate needle thoracostomy (decompression) followed by tube thoracostomy

  1. Step 1: Recognize clinical emergency: Tension pneumothorax (hyperresonance, absent breath sounds, tracheal deviation, and obstructive shock from vena cava compression).
  2. Step 2: Prioritize life support: Tension pneumothorax is a clinical diagnosis requiring immediate needle decompression without delaying for diagnostic radiography.
  3. Step 3: Execute action: Insert a large-bore needle/cannula into the 2nd intercostal space midclavicular line or 4th/5th intercostal space anterior axillary line, immediately followed by tube thoracostomy (chest tube).
Answer
Immediate needle thoracostomy (decompression) followed by tube thoracostomy.
Why not the others: 'Waiting for a chest radiograph' fatally delays decompression in tension pneumothorax; 'intubation with bronchoscopy' increases intrathoracic pressure; 'thoracotomy' is not the first decompression step.

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