What is the next step for a 17-year-old male patient with shortness of breath, chest pain radiating to the right shoulder, tachycardia, absent breath sounds on the right side, and a hyperresonant percussion note?

Management of Pneumothorax in a 17-Year-Old Male

STAT chest x-ray (CXR) is the next step in management for this patient presenting with clinical signs of pneumothorax.

Clinical Presentation Analysis

• The patient's presentation strongly suggests pneumothorax with classic findings of:
  • Shortness of breath and chest pain radiating to the right shoulder 1
  • Tachycardia (110 bpm) 1
  • Absent breath sounds on the right side 1
  • Hyperresonant percussion note 1, 2
  • Recent physical exertion (5-mile run) as a potential trigger 3

Diagnostic Approach

• STAT chest x-ray is the appropriate first diagnostic step to confirm pneumothorax before proceeding to treatment 1
• The American College of Cardiology/American Heart Association guidelines recommend chest radiography to evaluate potential pulmonary causes of chest pain 1
• While the clinical diagnosis is highly suggestive of pneumothorax, radiographic confirmation is necessary to:
  • Determine the size and extent of the pneumothorax 1, 3
  • Rule out other potential causes of the symptoms 1
  • Guide subsequent management decisions 1

Why Other Options Are Not Appropriate First Steps

• Arterial blood gas (ABG):

  • While useful for assessing oxygenation, ABG would not confirm the diagnosis or guide immediate management 1
  • The patient has normal vital signs except for tachycardia, suggesting adequate compensation at this time 3

• Chest CT pulmonary embolism (PE) protocol:

  • Not indicated as the first step when clinical findings strongly suggest pneumothorax 1
  • Would unnecessarily delay treatment and expose the patient to radiation 1

• Tube thoracostomy:

  • Should not be performed without radiographic confirmation of pneumothorax 1
  • The size of the pneumothorax needs to be determined first to guide appropriate management 1, 3

Management Following CXR Confirmation

• If pneumothorax is confirmed and significant:

  • Tube thoracostomy should be performed, with tube placement typically in the fourth/fifth intercostal space in the midaxillary line 1
  • For tension pneumothorax with hemodynamic compromise, needle decompression at the second intercostal space in the midclavicular line may be performed before chest tube placement 1

• If a small pneumothorax is identified:

  • Observation may be appropriate in selected cases 3
  • Supplemental oxygen should be provided as needed 1

Important Clinical Considerations

• Pneumothorax in young, tall males is often primary spontaneous pneumothorax, but can also be traumatic or exertion-induced 3, 4
• The hyperresonant percussion note is a key physical finding that strongly supports the diagnosis of pneumothorax 2, 5
• Portable ultrasound can be considered if immediately available, but should not delay obtaining a chest x-ray 1, 3
• Patients should be monitored closely for development of tension pneumothorax, which is a life-threatening emergency requiring immediate intervention 1, 6