Management of Tension Pneumothorax
The most appropriate management is C. Needle decompression followed immediately by D. Thoracostomy chest tube—needle decompression is the critical first step to prevent imminent death, but definitive treatment requires chest tube placement. 1, 2, 3
Immediate Life-Saving Intervention
This patient has tension pneumothorax—a true medical emergency where death occurs within minutes without immediate decompression. 2, 3 The clinical picture is diagnostic:
- Decreased breath sounds on the right lung 3
- Tracheal shift to the left (away from the affected side) 2
- Post-MVA trauma mechanism 1
Perform needle decompression FIRST at the 2nd intercostal space, midclavicular line using a minimum 7-8 cm needle (No. 14 gauge). 1, 2, 3 This converts the immediately life-threatening tension pneumothorax into a simple pneumothorax. 3
Critical Technical Points for Needle Decompression
- Use a needle at least 7-8 cm in length—the standard 4.5 cm needle fails in 32.84% of cases because chest wall thickness exceeds 3 cm in 57% of trauma patients. 1, 4, 5
- For every 1 cm increase in needle length, failure rate decreases by approximately 7.76 percentage points. 1
- The needle is only a temporizing measure—leave it in place until the chest tube is functioning. 1, 2
Definitive Management
Follow immediately with tube thoracostomy (chest tube) at the 4th-5th intercostal space, midaxillary line. 2, 3, 6
- Use a 24-28F large-bore chest tube for unstable trauma patients with ongoing air leak. 1, 6
- Connect to underwater seal drainage system. 1
- Confirm bubbling in the underwater seal before removing the decompression needle—this verifies proper chest tube function. 1, 2
- Apply suction (approximately 20 cmH₂O) if the lung fails to re-expand with water seal alone. 1, 6
Why Other Options Are Incorrect
A. Fluid resuscitation alone will not address the mechanical problem of air under pressure compressing the heart and great vessels—the patient will die from obstructive shock despite adequate fluid volume. 2, 3
B. Assisted ventilation is contraindicated and dangerous—positive pressure ventilation will worsen the tension pneumothorax by forcing more air into the pleural space through the one-way valve mechanism. 7, 8
Critical Pitfalls to Avoid
- Never delay decompression for imaging confirmation—tension pneumothorax is a purely clinical diagnosis, and waiting for chest X-ray confirmation causes preventable death. 2, 3
- Do not use needles shorter than 7 cm—they fail to reach the pleural space in 50% of trauma patients. 1, 4, 5
- Do not stop at needle decompression alone—26% of needles demonstrate mechanical failure (kinking, obstruction, dislodgment) within 5 minutes, and 58% overall fail to adequately relieve tension physiology. 8
- Patients on positive pressure ventilation always require tube thoracostomy as the positive pressure maintains the air leak. 1