Tension Pneumothorax: The Daily PANCE Blueprint
A 24-year-old man is brought in after a stab wound to the right chest. He is anxious, gasping, and diaphoretic. His blood pressure is 78/44, heart rate 130, and oxygen saturation 84%. The right side of his chest is hyperresonant with absent breath sounds, his neck veins are distended, and his trachea is deviated to the left. Which of the following is the most appropriate immediate next step?
A. Order a portable chest radiograph
B. Obtain a CT of the chest
C. Immediate needle thoracostomy (needle decompression)
D. Intubate and start mechanical ventilation
E. Give a fluid bolus and observe
Answer and topic summary
The answer is C. Immediate needle thoracostomy (needle decompression)
Hypotension, distended neck veins, and a trachea deviated away from a hyperresonant, silent hemithorax after penetrating trauma is a tension pneumothorax — air trapped under pressure that collapses the lung and kinks the great veins so blood cannot return to the heart (obstructive shock). This is a clinical diagnosis and a true emergency: the move is immediate needle decompression (a large-bore needle or catheter, classically at the 2nd intercostal space midclavicular line or the 5th intercostal space anterior axillary line), followed by a chest tube. The trap is ordering a chest X-ray or CT first — imaging wastes minutes the patient does not have and can be fatal. Intubation with positive pressure before decompression can worsen the tension, and fluids alone will not relieve the obstruction.
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Smarty PANCE Content Blueprint Review:
Covered under ⇒ PANCE Blueprint Pulmonary ⇒ ⇒
