A 25-year-old male is brought to the emergency department after a high-speed motorbike accident. He is unresponsive, has a GCS of 6, and his oxygen saturation is dropping despite high-flow oxygen. His trachea is deviated to the left, and there are no breath sounds on the right side. What is the most appropriate immediate management? A) Urgent endotracheal intubation B) Immediate needle thoracostomy in the right second intercostal space C) Chest X-ray to confirm pneumothorax D) Insert a chest drain in the right fifth intercostal space E) IV fluids and wait for improvement Correct Answer: B) Immediate needle thoracostomy in the right second intercostal space Explanation: This is a tension pneumothorax → tracheal deviation, absent breath sounds, respiratory distress. Immediate needle decompression is the priority → Right second intercostal space, midclavicular line. Chest drain follows after decompression. A) Urgent endotracheal intubation → Incorrect. First, relieve the tension pneumothorax. C) Chest X-ray → Incorrect. This is a clinical diagnosis—do not delay treatment. D) Insert a chest drain → Incorrect. Needle decompression comes first in tension pneumothorax. E) IV fluids and wait → Incorrect. This is a life-threatening emergency. Key Tips for PLAB 1: ✅ Tension pneumothorax = Immediate needle thoracostomy (no waiting for X-ray) ✅ Classic signs: Tracheal deviation away, absent breath sounds, respiratory distress ✅ Chest drain follows needle decompression
