skip to main content

Traumatic tension pneumothorax — MRCEM SBA MCQ

Instant feedback + full explanation. One question, done properly.

HardResuscitation and critical illnessTraumatic tension pneumothoraxMRCEM SBA

A 41-year-old man is brought to the emergency department after a fall onto his left chest. He is awake, speaking in short sentences and maintaining his airway. Over several minutes, his respiratory rate rises to 36/min, SpO₂ falls to 89% despite high-flow oxygen, and blood pressure falls to 74/42 mmHg. The left hemithorax expands poorly, with markedly reduced breath sounds and hyperresonance. There is no major external haemorrhage. A clinician trained in open thoracostomy and the necessary equipment are at the bedside. Which sequence is most appropriate now?

Educational content. Not a substitute for clinical judgement or local policy.

Reveal the answer and explanation

Correct answer: D — Open thoracostomy, followed by chest drain insertion.

The abrupt deterioration after chest trauma, unilateral reduction in expansion and breath sounds, hyperresonance, hypoxaemia and profound hypotension make tension pneumothorax the immediate working diagnosis. His haemodynamic instability and severe respiratory compromise warrant decompression **before imaging**. For a patient in hospital, NICE recommends open thoracostomy followed by a chest drain; the necessary expertise is immediately available here. ([nice.org.uk](https://www.nice.org.uk/guidance/ng39/chapter/Recommendations)) A is attractive because needle decompression can provide rapid access to the pleural space, particularly when open-thoracostomy expertise is unavailable pre-hospital. It is not the preferred hospital sequence in this case. B and E would investigate a diagnosis for which the clinical findings already justify immediate treatment; neither eFAST nor a radiograph should delay decompression in this unstable patient. C is plausible given his worsening oxygenation, and airway intervention may subsequently be needed. He is presently maintaining his airway, however, while an immediately treatable cause of circulatory and respiratory failure remains unrelieved. The priority is open thoracostomy, then chest drain insertion, with continued resuscitation and reassessment. ([nice.org.uk](https://www.nice.org.uk/guidance/ng39/chapter/Recommendations))

Reference: Major trauma: assessment and initial management — recommendations 1.4.1–1.4.2 (17 February 2016) — https://www.nice.org.uk/guidance/ng39/chapter/Recommendations Major trauma: assessment and initial management — recommendations 1.3.4–1.3.5 (17 February 2016) — https://www.nice.org.uk/guidance/ng39/chapter/Recommendations