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Difficulty: EasyCardiothoracic and Vascular Surgery

A 28-year-old woman is brought to the emergency department 20 minutes after being involved in a high-speed motor vehicle collision. She is in severe respiratory distress and complains of sharp, right-sided chest pain. Her blood pressure is 70/40 mmHg, pulse is 135/min, and respirations are 32/min. Pulse oximetry shows an oxygen saturation of 84% on room air. Physical examination reveals a deviated trachea to the left, markedly distended neck veins, and absent breath sounds over the right hemithorax. Which of the following is the most appropriate next step in management?

  1. Immediate tube thoracostomyAnswer
  2. B
    Computed tomography of the chest
  3. C
    Intravenous administration of furosemide
  4. D
    Continuous observation with supplemental oxygen
  5. E
    Administration of broad-spectrum intravenous antibiotics

Answer

Immediate tube thoracostomy
The correct answer is immediate decompression via tube thoracostomy (or needle thoracostomy). The patient's presentation of trauma, hypotension, absent unilateral breath sounds, tracheal deviation, and jugular venous distention is the classic triad for a tension pneumothorax. This is a clinical diagnosis, and immediate decompression is required to relieve the elevated intrathoracic pressure, thereby restoring venous return and cardiac output.

Step-by-Step Solution

1
Analyze the patient's vital signs and clinical presentation.
The patient is hemodynamically unstable (hypotension, tachycardia) with respiratory distress, tracheal deviation, jugular venous distention, and unilaterally absent breath sounds.
Identifying the constellation of these physical exam findings is the key to diagnosing tension pneumothorax.
2
Determine the pathophysiology causing the shock state.
Air accumulating in the pleural space is increasing intrathoracic pressure, collapsing the lung, shifting the mediastinum, and compressing the vena cava, which severely decreases venous return to the heart.
Understanding the mechanism explains why the patient is hypotensive and has distended neck veins.
3
Select the appropriate intervention.
Needle thoracostomy or tube thoracostomy must be performed immediately.
Tension pneumothorax is a clinical diagnosis that requires emergent decompression before any imaging is obtained.

Key Concept

Diagnosis and emergent management of tension pneumothorax in an unstable trauma patient.
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Topics

Cardiothoracic and Vascular Surgery

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