EM Coach: Thoracic Disorders

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A previously healthy 21-year-old male presents with acute right sided chest pain and shortness of breath. He states it started several hours prior to arrival, and denies any trauma, leg swelling, or previous episode.

His vitals are HR 133, BP 85/60, RR 32, and SpO2 88% on room air. He is diaphoretic and appears in severe distress.

EM Coach: Thoracic Disorders _stem image


A chest X-ray is obtained. What is the most appropriate next step?

A. Bilateral chest tubes
B. Broad spectrum antibiotics
C. IV Lasix
D. Needle thoracostomy
E. Synchronized cardioversion

EM Coach: Thoracic Disorders_explanation image
This patient has a tension pneumothorax, based on the unstable vital signs in the setting of his right pneumothorax. Due to the life-threatening nature of this disease, patients need to be decompressed emergently. If not, they risk the pneumothorax becoming so large that preload is reduced, and cardiac arrest can occur. Needle decompression offers the easiest and fastest way to emergently decompress the pneumothorax. After the needle is placed, chest tube placement should follow.


The patient does not have an infection such as pneumonia based on the X-ray, thus antibiotics (Choice B) are not needed. Although pneumonia is diagnosed on CXR by a focal opacity, this CXR shows an opacity in a location not specific to a single lobe and surrounded by a lack of lung markings.

IV furosemide (Choice C) in this case is not appropriate since the patient does not have heart failure, but rather a pneumothorax causing his symptoms. Congestive heart failure typically presents with bilateral generalized opacities on the CXR, classically with “cephalization” of the vascular markings, i.e., accentuation of vascular markings rising to the upper portions of both lung fields.

A chest tube to the right side should be obtained after the needle thoracostomy, but he does not need bilateral chest tubes (Choice A) since the left side does not have any pathology on CXR.

Lastly, synchronized cardioversion (Choice E) can help with unstable tachydysrhythmia, not with a tension pneumothorax.



Of note, this is the X-ray that “should never have been seen” since tension pneumothorax is a clinical diagnosis – though this distinction is in the textbooks and not clinical practice. Ultrasound can be helpful in diagnosing a pneumothorax by looking for lung sliding. Be careful, however, since there can be false positive ultrasound exams in which there is no lung sliding, but it is not a pneumothorax, most notably if the patient previously had chest surgery.

Kosowsky JM, Kimberly HH. Chapter 67. Pleural disease. In: Walls RM, Hockberger RS, Gausche-Hill M, et al. Rosen’s Emergency Medicine: Concepts and Clinical Practice. 9th ed. Philadelphia: Elsevier; 2018.

1.   Pneumothorax In Pediatric Patients: Management Strategies To Improve Patient Outcomes; PEMP March 2017: https://www.ebmedicine.net/topics/cardiovascular/pediatric-pneumothorax

2.   Traumatic Pneumothorax: Updates in Diagnosis and Management in the Emergency Department – Trauma EXTRA Supplement   EMP Supplement April 2022: https://www.ebmedicine.net/topics/trauma/emergency-medicine-traumatic-pneumothorax

3.  Emergency Department Management of Eating Disorder Complications in Pediatric Patients; PEMP February 2020: https://www.ebmedicine.net/topics/psychiatric-behavioral/pediatric-eating-disorders

4. The Emergency Medicine Approach To The Evaluation And Treatment Of Pulmonary Embolism, December 2012: https://www.ebmedicine.net/topics/cardiovascular/pulmonary-embolism



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1 Comment


    1. Tuberculosis 2. Pleurodesis from Bleomycin are other causes of a non sliding pleura in the absence of a pneumothorax though lung markings should be easily visible to detect lung tissue and not diagnose the patient with a pneumothorax erroneously.

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