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Traumatic tension pneumothorax — MRCEM SBA MCQ

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EasyResuscitation and critical illnessTraumatic tension pneumothoraxMRCEM SBA

A 42-year-old woman is brought to the emergency department after falling from scaffolding. She is conscious and speaking, but increasingly breathless despite high-concentration oxygen. Her SpO₂ is 85%, heart rate 132/min and blood pressure 78/46 mmHg. The left chest is hyper-resonant with markedly reduced breath sounds; no major external haemorrhage is apparent. A clinician skilled in open thoracostomy is at the bedside. What is the most appropriate next management sequence?

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

The unilateral hyper-resonance and markedly reduced breath sounds after blunt chest trauma indicate a suspected left tension pneumothorax. Profound hypotension and severe hypoxaemia make decompression the immediate priority. NICE advises decompression before imaging when suspected tension pneumothorax is accompanied by haemodynamic instability or severe respiratory compromise. In hospital, its recommended sequence is open thoracostomy followed by a chest drain. **A** is therefore the best answer. ([nice.org.uk](https://www.nice.org.uk/guidance/ng39/chapter/Recommendations)) **B** is attractive because needle decompression is an established emergency intervention, but it is not NICE’s recommended hospital technique here; it may be appropriate when urgent decompression is needed and open-thoracostomy expertise is unavailable. **C** and **D** offer useful ways to assess chest injury in a patient stable enough for imaging, but neither should delay decompression in this patient. **E** is tempting given her hypoxaemia, yet she is still speaking and has a suspected obstructive cause of shock requiring immediate relief. Airway intervention may subsequently be necessary, but it should not take precedence over decompression on these facts. ([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 — recommendation 1.3.5 (17 February 2016) — https://www.nice.org.uk/guidance/ng39/chapter/Recommendations