In tension pneumothorax with clinical instability, what is the initial management step?

• A. Needle decompression
• B. Chest tube
• C. Intubation
• D. Observation

Answer: (A)

In a tension pneumothorax with clinical instability, the priority is to rapidly relieve the trapped air and restore hemodynamics. Needle decompression delivers immediate relief by allowing air to escape and decompressing the mediastinal structures, which can quickly improve venous return and blood pressure in an unstable patient. After stabilization, chest tube thoracostomy provides definitive, ongoing evacuation of the pneumothorax. Intubation or positive-pressure ventilation may be necessary for airway management, but it can worsen the tension if decompression hasn’t occurred yet, so it is not the first step in this scenario. Observation is inappropriate because ongoing pressure can lead to rapid deterioration.