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Suspected traumatic tension pneumothorax — MRCEM SBA MCQ

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EasyTraumaSuspected traumatic tension pneumothoraxMRCEM SBA

A 34-year-old man arrives at a major trauma centre after falling from scaffolding. He is speaking, but is increasingly breathless despite high-flow oxygen. His oxygen saturation is 86%, heart rate 138 beats/min and blood pressure 78/46 mmHg. There is bruising over the left chest, with markedly reduced breath sounds and hyperresonance on that side. No significant external bleeding is evident. A clinician trained in open thoracostomy is at the bedside. What is the most appropriate immediate management plan?

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Correct answer: B — Perform open thoracostomy followed by chest drain insertion, without prior imaging.

The unilateral loss of breath sounds and hyperresonance after chest trauma suggest a pneumothorax. The accompanying profound hypoxaemia and hypotension make a tension pneumothorax the immediate working diagnosis. This is a clinical decision: decompression must not wait for imaging. For tension pneumothorax in hospital, NICE recommends open thoracostomy followed by a chest drain; an appropriately trained clinician is already present. ([nice.org.uk](https://www.nice.org.uk/guidance/ng39/chapter/Recommendations)) A is attractive because eFAST can assist assessment of chest trauma, but obtaining it first would delay treatment in this unstable patient. C offers immediate decompression and may be considered where open thoracostomy expertise is unavailable; it is not the best plan when that expertise is at the bedside. D delays decompression for radiographic confirmation, despite the combination of suspected tension pneumothorax and haemodynamic instability. E imposes a still greater imaging delay and is inappropriate before treating this immediately life-threatening condition. Imaging can follow decompression once the patient has been reassessed. ([nice.org.uk](https://www.nice.org.uk/guidance/ng39/chapter/Recommendations))

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