A -year-old tall, thin man is brought to the emergency department by emergency medical services with sudden-onset severe right-sided chest pain and profound shortness of breath. He is in severe respiratory distress. His blood pressure is mmHg, heart rate is /min, and oxygen saturation is on high-flow oxygen. Physical examination reveals absent breath sounds over the right hemithorax, hyperresonance to percussion on the right, and the trachea is visibly deviated to the left. The patient has markedly distended neck veins. Arrange the following management steps in the most appropriate chronological order.
- 1Perform immediate needle or finger thoracostomy
- 2Insert a right-sided tube thoracostomy
- 3Obtain a portable chest radiograph
Answer
The correct sequence is to perform immediate needle or finger thoracostomy, followed by insertion of a tube thoracostomy, and finally obtaining a portable chest radiograph.
Tension pneumothorax causes rapidly progressive obstructive shock and requires emergent clinical diagnosis based on physical examination findings (absent breath sounds, tracheal deviation, hypotension, jugular venous distention). The life-saving priority is immediate decompression (via needle or finger thoracostomy) to release trapped air and restore venous return. Once decompressed and the patient's hemodynamics improve, a definitive tube thoracostomy (chest tube) is placed. Only after these life-saving interventions are complete should a chest radiograph be obtained to verify correct tube placement and lung re-expansion.
Step-by-Step Solution
Key Concept
Tension pneumothorax is a clinical diagnosis requiring immediate decompression before diagnostic imaging, followed by definitive tube thoracostomy.