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Suspected traumatic tension pneumothorax — MRCEM SBA MCQ

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HardRespiratory emergenciesSuspected traumatic tension pneumothoraxMRCEM SBA

A 46-year-old man is brought to the emergency department after falling from scaffolding onto his left side. He is breathing spontaneously. Initial eFAST does not demonstrate a pneumothorax, although subcutaneous emphysema obscures much of the left anterior chest view. While awaiting a portable chest radiograph, he becomes markedly breathless. His blood pressure falls from 118/74 to 76/44 mmHg and his SpO₂ falls to 83% despite oxygen via a reservoir mask. Air entry is markedly reduced on the left, with hyperresonance to percussion. A clinician skilled in open thoracostomy is at the bedside. What is the most appropriate next pleural management sequence?

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

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Correct answer: B — Perform open thoracostomy immediately, then insert a chest drain.

The abrupt hypotension and severe hypoxaemia after left-sided chest trauma, together with markedly reduced left air entry and hyperresonance, warrant immediate treatment for suspected tension pneumothorax. The earlier eFAST does not exclude pneumothorax, particularly when subcutaneous emphysema limited the view. NICE recommends decompression before imaging when suspected tension pneumothorax is accompanied by haemodynamic instability or severe respiratory compromise. In hospital, the recommended sequence is open thoracostomy followed by a chest drain. The available expertise makes **B** the best answer. ([nice.org.uk](https://www.nice.org.uk/guidance/ng39/chapter/recommendations)) **A** offers rapid decompression, but needle decompression is not the preferred approach when open thoracostomy expertise is immediately available. **C** delays treatment for radiographic confirmation despite shock. **D** similarly delays decompression to repeat a test that cannot reliably exclude pneumothorax here. **E** requires transfer and further delay; CT is appropriate for selected patients with chest trauma who are haemodynamically normal or responding to resuscitation, not as a prerequisite to treating this deterioration. Following decompression and drain insertion, he requires continued trauma resuscitation and monitoring for recurrence. ([nice.org.uk](https://www.nice.org.uk/guidance/ng39/chapter/recommendations))

Reference: NICE NG39: Major trauma: assessment and initial management — Recommendations (17 February 2016) — https://www.nice.org.uk/guidance/ng39/chapter/recommendations NICE NG39: Major trauma: assessment and initial management — Chest decompression of tension pneumothorax (17 February 2016) — https://www.nice.org.uk/guidance/ng39/chapter/recommendations NICE NG39: Major trauma: assessment and initial management — Imaging to assess chest trauma (17 February 2016) — https://www.nice.org.uk/guidance/ng39/chapter/recommendations