A young man presents to the emergency department with shortness of breath and chest pain. His HR is 120 , BP is 80/50, JVP elevated and trachea shifted to left. His oxygen saturation is 70% in spite of supplemental oxygen. What is the next step of management?
Ans: A (Insert a large bore needle on right side) Ref: Harrison's Textbook of Internal Medicine, 17th ed. chapter 257Explanation:The answer is insert a large bore needle on the right side.The clinical features are indicative of tension pneumothorax.Presence of chest pain, shortness of breath, oxygen saturation not improving with supplemental oxygenation with tracheal shift to opposite side raises the possibility of a tension pneumothorax or a massive pleural effusion.In a case of massive pleural effusion the symptoms are gradual and not acute.Immediate management would be to insert a large bore needle on the right side.Tension PneumothoraxIn tension pneumothorax, the pressure in the pleural space is positive throughout the respiratory cycle.The positive pleural pressure is life-threatening both because ventilation is severely compromised and because the positive pressure is transmitted to the mediastinum, which results in decreased venous return to the heart and reduced cardiac output.Tension pneumothorax must be treated as a medical emergency.Clinical featureso Chest paino Shortness of breatho Cyanosiso Unilateral chest expansion - No or little movement on the involved sideo Dimished breath sounds on affected sideo Decreased tactile fremituso Hyperresonance to percussiono Tracheal & mediatstinai shift to opposite sideo Spo2 not improving with oxygeno Tachycardiao Pulsus paradoxuso Hypotensiono Elevated JVP.Managemento If the tension in the pleural space is not relieved immediately, the patient is likely to die from inadequate cardiac output or marked hypoxemia,o To relieve the tension by insertion of an intercostal tube (tube thoracostomy).o If an intercostal tube is not readily available a large- bore needle can be inserted into the pleural space through the second anterior intercostal space,o The needle should be left in place until a thoracostomy tube can be inserted.
Insert a large bore needle on right side
Insert a large bore needle on left side
Arrange for an urgent chest xray and meanwhile give high doses of inhaled oxygen
Emergency tracheostomy to secure airway
Pleural Effusion & Pneumothorax