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Stab wound to the chest
A 30-year-old man is brought in with a stab wound to the left chest. He is breathless, BP 78/40 mm Hg, his neck veins are distended, breath sounds are absent on the left with hyperresonance, and the trachea is deviated to the right.
Step 1 of 4
What is the most appropriate immediate step?
Correct answer: D
This is a tension pneumothorax — a clinical diagnosis. Decompress immediately and then place a chest tube, without waiting for imaging (see pleural cavity).
Show answer
D
This is a tension pneumothorax — a clinical diagnosis. Decompress immediately and then place a chest tube, without waiting for imaging (see pleural cavity).
Step 2 of 4
Where does current ATLS guidance favor needle decompression in adults?
Correct answer: D
Current ATLS guidance for adults favors the 4th/5th intercostal space in the anterior to mid-axillary line; the 2nd intercostal space in the midclavicular line is the older site.
Show answer
D
Current ATLS guidance for adults favors the 4th/5th intercostal space in the anterior to mid-axillary line; the 2nd intercostal space in the midclavicular line is the older site.
Step 3 of 4
Which boundaries define the "triangle of safety" for the chest tube?
Correct answer: A
The triangle of safety: the lateral border of pectoralis major, the anterior border of latissimus dorsi, a horizontal line at the nipple (about the 5th intercostal space), with its apex below the axilla.
Show answer
A
The triangle of safety: the lateral border of pectoralis major, the anterior border of latissimus dorsi, a horizontal line at the nipple (about the 5th intercostal space), with its apex below the axilla.
Step 4 of 4
Why is the needle or tube passed over the upper border of a rib?
Correct answer: C
The intercostal neurovascular bundle runs in the costal groove along the inferior border of each rib, so passing just over the superior border of the rib below avoids it (see intercostal space).
Show answer
C
The intercostal neurovascular bundle runs in the costal groove along the inferior border of each rib, so passing just over the superior border of the rib below avoids it (see intercostal space).
Key points
- Hypotension + JVD + absent breath sounds + tracheal deviation away → decompress now.
- Adults: 4th/5th intercostal space, anterior to the mid-axillary line.
- Go over the top of the rib — the bundle runs under each rib.
Study: Pleural cavity, Intercostal space, Pectoralis major, Latissimus dorsi