Question

A 26-year-old man who has AIDS presents with rapidly progressing dyspnea. The symptoms became apparent following a diagnostic thoracentesis for a left-sided pleural effusion; you suspect the effusion is caused by mycobacterium. The patient reports left-side chest pain and difficulty in breathing. On examination, he is in respiratory distress; temperature is 38, RR is 39, and BP is 70/40 mm Hg. He has decreased breath sounds in his left lung field, and the percussion note is more resonant. What is the most appropriate course of action?

1. Administer 100% oxygen by mask
2. Sedate and endotracheally intubate
3. Perform needle decompression
4. Insert an underwater sealed chest tube
5. Order an urgent chest X-ray

Answer 1

The most immediate and appropriate course of action for the 26-year-old man presenting with signs of a tension pneumothorax is to perform needle decompression to relieve the pressure and stabilize the patient.

Step-by-step explanation:

The 26-year-old man presenting with rapidly progressing dyspnea following a diagnostic thoracentesis and suspect pleural effusion caused by mycobacterium shows signs of respiratory distress, notably tachypnea, hypotension, decreased breath sounds on one side, and a more resonant percussion note.

These symptoms may indicate a tension pneumothorax, a life-threatening condition that occurs when air collects in the pleural space and cannot escape, leading to collapsed lung and mediastinal shift.

The most appropriate immediate course of action is to perform needle decompression to relieve the pressure in the chest.

This emergency procedure will allow trapped air to escape and should stabilize the patient before further definitive treatment like inserting an underwater sealed chest tube can be performed.

Administering 100% oxygen and considering further interventions such as sedation and endotracheal intubation might be necessary afterwards, depending on the patient's response and ongoing respiratory status.

Answer 2

The man showing symptoms of tension pneumothorax following thoracentesis should immediately undergo needle decompression, followed by the insertion of a chest tube, with an urgent chest X-ray to confirm diagnosis (option 3,4 and 5).

Step-by-step explanation:

The 26-year-old man with AIDS presenting with rapidly progressing dyspnea, left-sided chest pain, and signs of respiratory distress following a diagnostic thoracentesis likely has a tension pneumothorax due to the sudden onset of symptoms after the procedure and the signs of decreased blood pressure, tachypnea, and the hyperresonant percussion note.

The most appropriate immediate course of action is to perform needle decompression to relieve the pressure on the affected side of the chest. This should be followed promptly by the insertion of an underwater sealed chest tube to allow for continued evacuation of air from the pleural space and help re-expand the lung.

Oxygen administration and intubation may be necessary as part of ongoing management but are not the immediate treatments for suspected tension pneumothorax. An urgent chest X-ray should be obtained as soon as possible after the initial emergency treatment to confirm diagnosis and placement of the chest tube.

Hence, the answer is option 3,4 and 5.