A 22-year-old man is brought to the emergency department via ambulance after sustaining a stab wound to the right anterior chest. He is in severe respiratory distress and appears agitated. His temperature is 37.0°C (98.6°F), blood pressure is 80/40 mmHg, heart rate is 135/min, and respiratory rate is 32/min. Pulse oximetry shows an oxygen saturation of 86% on room air. Physical examination reveals absent breath sounds over the right hemithorax, hyperresonance to percussion on the right side, and distended neck veins. Which of the following is the most appropriate immediate next step in the management of this patient?
- Needle decompression of the right pleural spaceAnswer
- BPortable chest radiograph
- CComputed tomography of the chest
- DEndotracheal intubation
- EImmediate transfer to the operating room
Answer
The correct answer is needle decompression of the right pleural space.
This patient presents with the classic signs of a tension pneumothorax: severe respiratory distress, hypotension, tachycardia, absent breath sounds on the affected side, hyperresonance to percussion, and jugular venous distention. The accumulating air in the pleural space increases intrathoracic pressure, shifting the mediastinum and severely impairing venous return to the heart, leading to obstructive shock. Tension pneumothorax is a clinical diagnosis. The most critical, immediate step is decompression of the pleural space (via needle thoracostomy or tube thoracostomy) to rapidly relieve the pressure, restore venous return, and improve cardiac output. Imaging should never delay this intervention in an unstable patient.
Step-by-Step Solution
Key Concept
Tension pneumothorax is a clinical diagnosis that requires immediate pleural decompression (needle thoracostomy or tube thoracostomy) before any imaging is obtained.