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Recurrent traumatic tension pneumothorax after needle decompression — MRCEM SBA MCQ

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HardTraumaRecurrent traumatic tension pneumothorax after needle decompressionMRCEM SBA

A 34-year-old man arrives at a major trauma centre after a motorcycle collision. Paramedics performed right-sided needle decompression for suspected tension pneumothorax, with immediate improvement. During the primary survey he becomes acutely breathless. His airway is patent, respiratory rate is 38/min, oxygen saturation is 82% despite high-flow oxygen, and blood pressure is 74/46 mmHg. Breath sounds are absent on the right. There is no evident external haemorrhage, and a clinician skilled in open thoracostomy is at the bedside. What is the most appropriate next management step?

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

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Correct answer: A — Perform immediate open thoracostomy, followed by chest drain insertion.

The transient response to needle decompression, followed by recurrent unilateral absent breath sounds, profound hypoxaemia and hypotension, strongly indicates recurrent right tension pneumothorax. His haemodynamic instability and severe respiratory compromise make decompression the immediate priority: imaging must not delay it. In hospital, NICE recommends open thoracostomy followed by a chest drain for tension pneumothorax. The available expertise makes this preferable to another needle attempt. ([nice.org.uk](https://www.nice.org.uk/guidance/ng39/chapter/Recommendations)) B is tempting because the first needle decompression worked, and a further needle may be a temporising measure if open thoracostomy expertise is unavailable; it is not the best intervention here. C could help assess a patient stable enough for imaging, but this patient needs decompression first. D is similarly attractive as a rapid bedside test, yet it would delay treatment of a clinically apparent, life-threatening problem. E places intubation before relief of suspected tension physiology despite a patent airway; airway intervention may subsequently be needed, but it does not take priority over immediate chest decompression in this presentation.

Reference: Major trauma: assessment and initial management — recommendations 1.4.1–1.4.2 (2016) — https://www.nice.org.uk/guidance/ng39/chapter/Recommendations Major trauma: assessment and initial management — recommendations 1.3.5–1.3.6 (2016) — https://www.nice.org.uk/guidance/ng39/chapter/Recommendations