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Review Question - QID 109455

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QID 109455 (Type "109455" in App Search)
A 27-year-old man presents to the emergency department following a motor vehicle accident. He was the unrestrained driver traveling at a high rate of speed prior to crashing into the back of a stopped semi truck. On arrival, he complains of shortness of breath and chest pain. He is alert and oriented and appears in acute distress. His temperature is 98.6°F (37.0°C), pulse is 120, blood pressure is 80/50 mmHg, respirations are 30/min, and pulse oximetry is 89% on room air. On exam, bruising is noted across the chest. Breath sounds are diminished over the left side of the chest. Jugular venous distention is noted. Which of the following is the most appropriate next step in management?
  • A

Blood transfusion

18%

8/44

Chest tube placement

2%

1/44

Chest radiograph

64%

28/44

Intravenous fluid administration

9%

4/44

Needle decompression

2%

1/44

  • A

Select Answer to see Preferred Response

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This patient with chest pain, shortness of breath, hypoxemia, diminished breath sounds and jugular venous distention likely has developed a tension pneumothorax. The most appropriate initial step in management for patients with suspected tension pneumothorax is needle decompression.

Tension pneumothorax most commonly develops in patients after trauma from a high energy mechanism of injury. Trauma results in a defect in the lung parenchyma that allows air to enter and accumulate in the pleural space. Accumulation of air leads to an increase in pressure in the pleural space. This pressure eventually leads to compression of the inferior vena cava and heart, which results in a decrease in venous return and cardiac output. By definition, patients with tension pneumothorax are hemodynamically unstable. Patients often report chest pain and shortness of breath, as with this patient. While chest radiograph would reveal the diagnosis of pneumothorax, it should not delay management of suspected tension pneumothorax. The most appropriate initial step in management is needle decompression with placement of a large bore catheter in either the second or third intercostal space at the midclavicular line, or the fourth or fifth intercostal space at the midaxillary line. Patients receiving needle decompression will eventually require placement of a large bore chest tube.

Roberts et. al review diagnosis and management of tension pneumothorax. They emphasize that tension pneumothorax should be diagnosed clinically, and recommend needle decompression as the most appropriate initial step in management.

Figure A shows an electrocardiogram demonstrating sinus tachycardia.

Incorrect Answers:
Answer 1: Blood transfusion is often indicated for patients with hypotension due to traumatic injury. However, this patient's history and presentation suggest tension pneumothorax as the cause of hypotension, and is best managed with immediate needle decompression.

Answer 2: Chest tube placement would eventually be indicated for this patient. However, the most appropriate immediate step is needle decompression to prevent further hemodynamic collapse.

Answer 3: Chest radiograph would likely demonstrate a large pneumothorax in this patient. However, tension pneumothorax is a clinical diagnosis. Intervention should not be delayed to obtain imaging studies to confirm the diagnosis.

Answer 4: Intravenous fluid administration is often indicated for patients with hypotension due to traumatic injury. However, this patient's history and presentation suggest tension pneumothorax as the cause of hypotension, and is best managed with immediate needle decompression.

Bullet Summary:
For patients with suspected tension pneumothorax, the most appropriate immediate step in management is needle decompression to prevent further hemodynamic collapse.

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