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 34-year-old man arrives at a major trauma centre after a motorcycle collision. He is awake and maintaining his airway but can speak only in short phrases. Despite oxygen at 15 L/min via a reservoir mask, his SpO₂ is 84%; his blood pressure is 72/40 mmHg and pulse is 136/min. There is bruising and rib crepitus over the right chest, markedly reduced right-sided breath sounds and right-sided hyperresonance. No major external bleeding is evident. Intravenous access and monitoring are established. A trauma clinician skilled in open thoracostomy is at the bedside; chest imaging has not yet been performed. Which management sequence is most appropriate?

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

Reveal the answer and explanation

Correct answer: D — Perform right open thoracostomy, insert a chest drain, then reassess for CT.

The combination of blunt right-sided chest injury, unilateral loss of breath sounds with hyperresonance, severe hypoxaemia and shock makes a right tension pneumothorax the immediate working diagnosis. He meets NICE’s threshold for decompression **before imaging**: haemodynamic instability or severe respiratory compromise. In hospital, NICE recommends open thoracostomy followed by a chest drain. The requisite expertise is already at the bedside; reassessment and further trauma imaging follow stabilisation. ([nice.org.uk](https://www.nice.org.uk/guidance/ng39/chapter/Recommendations)) A is attractive because needle decompression can provide rapid temporary relief, but it is not the recommended in-hospital technique when open thoracostomy can be performed immediately. B recognises the need for respiratory support, but he is currently maintaining his airway; making intubation precede treatment of the suspected obstructive cause delays decompression. C would be reasonable in a sufficiently stable patient requiring diagnostic clarification, but not in this shocked, severely hypoxaemic patient. E similarly uses a potentially useful bedside adjunct, but makes ultrasound confirmation a prerequisite to treating a clinically suspected life-threatening tension pneumothorax. ([nice.org.uk](https://www.nice.org.uk/guidance/ng39/chapter/Recommendations))

Reference: Major trauma: assessment and initial management (NG39), recommendations 1.4.1–1.4.2 (17 February 2016) — https://www.nice.org.uk/guidance/ng39/chapter/Recommendations