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Difficulty: EasyTrauma and Burns

A 33-year-old construction worker is brought to the emergency department after falling approximately 20 feet from scaffolding. On arrival, he is in severe respiratory distress and is unable to answer questions. His blood pressure is 74/42 mm Hg, and his heart rate is 138/min. Physical examination reveals severely distended jugular veins, a trachea that is deviated to the right, and completely absent breath sounds over the left hemithorax. Which of the following is the most appropriate immediate next step in the management of this patient?

  1. Tube thoracostomy placementAnswer
  2. B
    Computed tomography scan of the chest
  3. C
    Endotracheal intubation with mechanical ventilation
  4. D
    Focused assessment with sonography for trauma examination
  5. E
    Intravenous fluid resuscitation with 2 liters of crystalloid

Answer

Placement of a thoracostomy tube is the correct next step to immediately decompress the tension pneumothorax.
The correct answer is tube thoracostomy placement because the patient exhibits the classic clinical signs of a tension pneumothorax: severe hypotension, tachycardia, jugular venous distention, tracheal deviation, and absent breath sounds. In the setting of trauma, a tension pneumothorax causes obstructive shock by increasing intrathoracic pressure to the point where venous return to the heart is severely impaired. Because this is a rapidly fatal condition, it must be diagnosed clinically and treated immediately with decompression (such as tube thoracostomy or needle thoracostomy) without waiting for any diagnostic imaging.

Step-by-Step Solution

1
Analyze the patient's vital signs and physical examination findings.
The patient is hemodynamically unstable (hypotension, tachycardia) and exhibits absent unilateral breath sounds, tracheal deviation, and jugular venous distention.
These findings represent the classic triad for a tension pneumothorax, which causes obstructive shock.
2
Determine the therapeutic priority for this condition.
Tension pneumothorax is a clinical diagnosis that requires immediate intervention rather than radiographic confirmation.
Delaying treatment for imaging (like a CT scan or X-ray) can result in cardiovascular collapse and death.
3
Identify the definitive initial management step.
Select tube thoracostomy placement (or needle decompression) to immediately relieve the pleural pressure.
Evacuating the trapped air allows the mediastinum to return to midline, immediately restoring venous return and cardiac output.

Key Concept

Tension pneumothorax is a clinical diagnosis in trauma characterized by hypotension, tracheal deviation, jugular venous distention, and absent breath sounds; it requires immediate decompression (e.g., tube thoracostomy) prior to any diagnostic imaging.
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Topics

Trauma and Burns

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