A rapid response team is activated for a patient on the medical ward who has experienced a… — USMLE Step 3

A rapid response team is activated for a patient on the medical ward who has experienced an acute clinical deterioration. The patient is a 22-year-old man who was admitted 24 hours ago for a severe asthma exacerbation. Over the past 15 minutes, he has become extremely agitated, diaphoretic, and severely dyspneic. Vital signs are temperature $37.1^\circ\text{C}$ ( $98.8^\circ\text{F}$ ), blood pressure $76/40\text{ mm Hg}$ , heart rate $146/\text{min}$ , respiratory rate $36/\text{min}$ , and oxygen saturation $82\%$ despite receiving oxygen via a non-rebreather mask. Physical examination reveals absent breath sounds over the right hemithorax with hyperresonance to percussion. The neck veins are visibly distended, and the trachea is deviated to the left. The patient's extremities are cool to the touch with delayed capillary refill. Which of the following is the most appropriate initial step in the management of this patient?

Needle thoracostomy of the right hemithoraxAnswer
B
Portable anteroposterior chest radiograph
C
Computed tomography angiography of the chest
D
Administration of intravenous magnesium sulfate
E
Immediate transfer to the intensive care unit

Answer

Needle thoracostomy of the right hemithorax

The patient is presenting with classic signs of a tension pneumothorax, including severe respiratory distress, hypotension, unilateral absent breath sounds, hyperresonance to percussion, jugular venous distention, and tracheal deviation. In the setting of a severe asthma exacerbation, air trapping and high intra-alveolar pressures can lead to barotrauma, allowing air to enter the pleural space without a route of escape. This rapidly increasing intrathoracic pressure compresses the superior and inferior vena cava, drastically decreasing venous return and cardiac output, culminating in obstructive shock. Tension pneumothorax is a clinical diagnosis, and the most urgent initial step is immediate decompression of the pleural space, typically via needle thoracostomy followed by tube thoracostomy, to restore venous return and prevent imminent cardiac arrest.

Step-by-Step Solution

Analyze the patient's vital signs and physical examination findings.

The patient is in shock (hypotension, tachycardia, cool extremities) with severe hypoxemia. Exam shows unilateral absent breath sounds, hyperresonance, jugular venous distention (JVD), and tracheal deviation.

Identifying the constellation of findings points toward a specific etiology of obstructive shock.

Synthesize the findings to establish a clinical diagnosis.

The presentation is classic for a tension pneumothorax, likely secondary to barotrauma or ruptured blebs from his severe asthma exacerbation.

Tension pneumothorax traps air in the pleural space, shifting the mediastinum and compressing the vena cava, which severely restricts venous return to the heart.

Determine the most urgent initial step in management.

Immediate pleural decompression using a needle thoracostomy (or finger/tube thoracostomy) must be performed at the bedside.

Tension pneumothorax is a clinical diagnosis. Life-saving decompression must not be delayed by diagnostic imaging or patient transport.

Key Concept

Tension pneumothorax is a clinical diagnosis presenting with obstructive shock, JVD, and unilateral absent breath sounds. It requires immediate pleural decompression before any imaging or patient transfer is attempted.

Estimated Time:1m 15s

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