# A 45-year-old construction worker is brought to the emergency department after falling from scaffolding and landing on his left side. He reports severe left-sided chest pain and difficulty breathing. What is the nurse's immediate priority action?

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> subject: Adult Health

## 문제

A 45-year-old construction worker is brought to the emergency department after falling from scaffolding and landing on his left side. He reports severe left-sided chest pain and difficulty breathing. What is the nurse's immediate priority action?

Assessment reveals decreased breath sounds on the left side, tracheal deviation to the right, and jugular vein distention. His vital signs are: BP 90/60 mmHg, HR 120 bpm, RR 28/min, O2 sat 88% on room air.

## 보기

1. Administer high-flow oxygen via non-rebreather mask
2. Prepare for immediate needle decompression or chest tube insertion **✔ 정답**
3. Obtain a chest X-ray to confirm the diagnosis
4. Insert two large-bore IV lines for fluid resuscitation

**정답: 2**

## 해설

Immediate needle decompression or chest tube insertion is priority for tension pneumothorax with signs like tracheal deviation and hypotension. Delaying for diagnostics can lead to cardiac arrest.

## 심화 해설

Clinical Presentation and Pathophysiology

This patient’s presentation is a classic picture of a tension pneumothorax. The mechanism of injury—a fall with blunt trauma to the left chest—can cause a rib fracture or parenchymal lung injury, creating a one-way valve effect. Air enters the pleural space during inspiration but cannot exit during expiration. As intrapleural pressure rises, the affected lung collapses completely. The accumulating pressure then pushes the mediastinum toward the opposite side. This shift explains the assessment findings: tracheal deviation to the right (away from the affected left side), distended neck veins from impaired venous return, and absent breath sounds on the left. The vital signs—BP 90/60 mmHg, HR 120 bpm, RR 28/min, and O2 sat 88%—reflect obstructive shock and severe hypoxemia. The mediastinal shift kinks the great vessels, reducing cardiac preload and cardiac output, which is a life-threatening emergency [1].

Priority Action Analysis

In a tension pneumothorax, the immediate threat is the trapped air under pressure causing cardiovascular collapse. The definitive emergency treatment is rapid decompression of the pleural space to relieve the pressure on the heart and great vessels. The cited protocol explicitly states that for unstable patients with life-threatening respiratory distress and hemodynamic instability, the priority is emergency decompression [1]. While the other options are components of care, they do not address the root cause of the obstructive shock.

*   Option 1 (Administer high-flow oxygen): Oxygenation is critical, but it will not resolve the mechanical compression of the heart and mediastinal shift. The protocol lists supplemental oxygen as a supportive measure, but decompression is the priority for an unstable patient [1].

*   Option 3 (Obtain a chest X-ray): A tension pneumothorax is a clinical diagnosis. Waiting for radiographic confirmation in a patient with tracheal deviation and hypotension delays a life-saving procedure. The protocol emphasizes rapid diagnosis based on clinical signs, not imaging, for unstable patients [1].

*   Option 4 (Insert two large-bore IV lines): Fluid resuscitation is a supportive measure for hypotension. However, in obstructive shock from a tension pneumothorax, the primary problem is not hypovolemia but impaired venous return due to increased intrathoracic pressure. Giving fluids without first relieving the obstruction will be ineffective and delays definitive care.

Therefore, the nurse’s immediate priority is to prepare for needle decompression or assist with chest tube insertion. This directly converts the tension pneumothorax to a simple pneumothorax, relieving the mediastinal shift and restoring cardiac output. The protocol confirms that emergency decompression is the required action for unstable patients before urgent transfer for definitive management [1].References (research sources)

- [1]International Pain and Spine Intervention Society Emergency Protocols: Pneumothorax.Research articleWasserman RA, Meral RM, Joshi M. (2026) · DOI: 10.1016/j.inpm.2026.100779

## 임상 시나리오

Tension Pneumothorax DecompressionImmediate Priority for Unstable Trauma Patient
For a patient with chest trauma, tracheal deviation, absent breath sounds, and hypotension (BP 90/60 mmHg), suspect tension pneumothorax. The immediate priority is needle decompression to relieve pressure on the heart and great vessels.

Perform needle decompression at the 2nd intercostal space, midclavicular line on the affected side, followed by chest tube insertion. Do not delay for imaging such as a chest X-ray in an unstable patient.

CautionAdministering high-flow oxygen or IV fluids without decompression does not correct the underlying obstructive shock and can delay definitive, life-saving treatment.

## 핵심 개념

- **Tension Pneumothorax** — A life-threatening condition where air trapped in the pleural space under pressure shifts the mediastinum, compressing the heart and great vessels, leading to obstructive shock.
- **Mediastinal Shift** — Deviation of the trachea and heart from midline toward the unaffected side due to high pressure in the opposite pleural space.
- **Needle Decompression** — Emergency procedure inserting a large-bore needle into the 2nd intercostal space at the midclavicular line to release trapped air from the pleural space.
- **Obstructive Shock** — A state of shock caused by a physical obstruction to blood flow; in tension pneumothorax, increased intrathoracic pressure reduces venous return and cardiac output.
- **Jugular Vein Distention (JVD)** — Visible bulging of neck veins indicating increased central venous pressure, often due to impaired venous return to the heart.

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