A 32-year-old man is brought to the emergency department following a high-speed motor vehicle collision. On arrival, he is conscious but agitated, with a respiratory rate of 28/min, heart rate of 118/min, and blood pressure of 94/62 mmHg. Examination reveals absent breath sounds on the left side, tracheal deviation to the right, and severe distress. What is the most appropriate immediate management during the primary survey?

Question

Accepted Answer

A. Needle decompression of the left hemithorax followed by chest tube insertion. ## Tension Pneumothorax Recognition and Management

**Key Point:** Tension pneumothorax is a clinical diagnosis requiring immediate intervention without waiting for imaging confirmation. The classic triad of absent breath sounds, tracheal deviation, and hypotension with respiratory distress is pathognomonic.

**High-Yield:** In the primary survey (Airway, Breathing, Circulation), life-threatening thoracic injuries must be identified and treated immediately. Tension pneumothorax is a "treat first, confirm later" emergency.

**Clinical Pearl:** The patient's presentation—tachypnea (28/min), tachycardia (118/min), hypotension (94/62), tracheal deviation, and unilateral absent breath sounds—is classic for tension pneumothorax. This is a Class I emergency in ATLS.

### Management Algorithm

```mermaid
flowchart TD
  A[Trauma patient with respiratory distress]:::outcome
  A --> B{Absent breath sounds + tracheal deviation + hypotension?}:::decision
  B -->|Yes| C[Clinical diagnosis: Tension pneumothorax]:::outcome
  C --> D[Needle decompression immediately]:::action
  D --> E[14-16G needle, 2nd ICS midclavicular line]:::action
  E --> F[Chest tube insertion after decompression]:::action
  B -->|No| G[Continue primary survey]:::action
```

**Procedure:** Needle decompression is performed using a 14–16 gauge needle inserted at the 2nd intercostal space, midclavicular line on the affected side. This converts tension pneumothorax to simple pneumothorax, restoring hemodynamics. A chest tube (28–32 Fr) is then inserted at the 4th–5th ICS, anterior axillary line for definitive management.

**Why Immediate Action?** Tension pneumothorax causes progressive cardiovascular collapse due to increased intrathoracic pressure compressing the heart and great vessels. Delay in decompression is fatal.

[cite:ATLS 10th Edition, Chapter 4]

Answer

B. Immediate intubation and mechanical ventilation

Answer

C. Fluid resuscitation with 2 units of packed red blood cells

Answer

D. Portable chest X-ray to confirm diagnosis before intervention

Explanation

Tension Pneumothorax Recognition and Management

Management Algorithm

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