Question:medium
A patient presented with RTA (Road Traffic Accident) leading to breathlessness and decreased air entry into the right lung and the patient is hypotensive. What is the next step?
A patient presented with RTA (Road Traffic Accident) leading to breathlessness and decreased air entry into the right lung and the patient is hypotensive. What is the next step?
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Breathlessness with absent breath sounds and hypotension after trauma points to tension pneumothorax requiring emergency needle decompression.
Updated On: Jun 23, 2026
- Needle inserted at 2nd ICS in MCL
- Needle inserted at 5th ICS in mid axillary
- Fluid resuscitation using wide bore cannula
- Wide bore needle decompression
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The Correct Option is B
Solution and Explanation
The clinical scenario -- RTA + breathlessness + decreased air entry on right + hypotension -- is the classic presentation of tension pneumothorax. Air accumulates in the pleural space and cannot escape, causing progressive mediastinal shift, compression of the contralateral lung, and obstructive shock (hypotension). On bedside assessment, ultrasound (FAST) shows the Seashore sign in B-mode and Stratosphere sign in M-mode confirming pneumothorax. Management is emergency needle thoracocentesis (needle decompression). Insertion site as per updated ATLS guidelines: 4th/5th ICS at the mid-axillary line (MAL) in adults (previously 2nd ICS MCL -- still used in children). The MAL site is preferred in adults because chest wall thickness at 2nd ICS MCL may prevent a standard 14G cannula from reaching the pleural space, whereas the axillary wall is reliably thinner ($<4$ cm in most adults). Following needle decompression, a chest drain (tube thoracostomy) is inserted definitively at the same site. Fluid resuscitation cannot correct obstructive shock until the mechanical cause is relieved. \[\boxed{\text{Needle at 5th ICS in mid-axillary line}}\]
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