Traumatic tension pneumothorax during positive-pressure ventilation — MRCEM SBA MCQ

Correct answer: B — Perform open thoracostomy followed by chest drain insertion before further imaging.

The abrupt combination of hypotension, hypoxaemia, rising airway pressure and new unilateral loss of breath sounds during positive-pressure ventilation makes tension pneumothorax the immediate working diagnosis. The earlier radiograph does not exclude a pneumothorax developing subsequently. Unchanged tube depth and preserved right-sided breath sounds make endobronchial tube migration less persuasive as the explanation. This patient has both haemodynamic instability and severe respiratory compromise, so decompression must precede imaging. In hospital, NICE recommends open thoracostomy followed by a chest drain for tension pneumothorax. A is tempting because needle decompression can provide emergency access to the pleural space, but it is not the recommended hospital approach when skilled open thoracostomy is immediately available. C and D offer rapid bedside assessments; either may help evaluate chest trauma when the patient can tolerate assessment, but neither should delay treatment of suspected tension pneumothorax in this deteriorating patient. E is appropriate to consider for selected adults with suspected chest trauma who are haemodynamically normal or responding to resuscitation without severe respiratory compromise, not for a patient who needs immediate decompression. Further imaging and assessment of associated injuries can follow stabilisation.

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 1.4.4–1.4.5 (17 February 2016) — https://www.nice.org.uk/guidance/ng39/chapter/Recommendations