Review Question - QID 214903

Tension pneumothorax is an emergency and clinical diagnosis that requires immediate needle thoracostomy.

This patient has developed a tension pneumothorax, which is a life-threatening condition and surgical emergency. It develops when tissue injury allows air to enter the pleural space, but a flap-valve mechanism prevents air from escaping. The air trapped in the pleural space displaces mediastinal structure to the opposite side, impairs venous return, and subsequently decreases cardiac output. Clinically, it presents as rapid onset of severe shortness of breath or respiratory distress, tachycardia, tachypnea, and hypotension, while physical exam may show distention of neck veins due to SVC compression, absence of breath sounds and hyperresonance to percussion on the affected side, and tracheal deviation to the opposite side. Treatment should be initiated immediately with a needle thoracostomy for pleural cavity decompression without waiting for x-ray confirmation of the diagnosis, followed up with a tube thoracostomy with underwater seal.

Incorrect Answer:
Answer 1: Arterial blood gas analysis – An ABG would provide information about the severity of respiratory compromise, but waiting for this result is inappropriate in this case of emergency. Needle or tube thoracostomy is the most appropriate first step in management.

Answer 2: Intravenous fluids – Fluid resuscitation is an appropriate treatment for shock. While shock may present with similar hypotension, tachycardia, and sudden clinical deterioration, it is less likely than tension pneumothorax in this case.

Answer 4: Pericardiocentesis – Pericardiocentesis is the emergent treatment for cardiac tamponade, a condition in which fluid fills the pericardial sac. It is characterized by hypotension, tachycardia, muffled heart sounds, dilated neck veins, and insufficient response to fluid therapy. Tension pneumothorax may mimic cardiac tamponade with findings of hypotension and distended neck veins, but the unilateral absent breath sounds and tracheal deviation in this case make tension pneumothorax the more likely diagnosis.

Answer 5: Stat chest x-ray – Findings on x-ray for a tension pneumothorax include increased lucency on the affected side of the chest and deviation of the trachea and mediastinum away from the affected side. As this is an emergency condition, treatment should not be delayed by waiting for radiographic confirmation.

Bullet Summary:
Tension pneumothorax is an emergency and clinical diagnosis that requires immediate needle thoracostomy.