The correct answer is D. This patient has developed a tension pneumothorax, which is an emergency that requires immediate intervention with a needle on the side of the pneumothorax. He presented with a spontaneous pneumothorax, that progressed to a tension pneumothorax, and decompression to relieve the increased intrathoracic pressure is the first step in management. Young, thin men are at an increased risk for developing a spontaneous pneumothorax, and the exact cause is unknown.
Blood gases (choice A) are not the most important next step in management of this case. He requires a needle into the left 2nd intercostal space, which is a life-saving intervention in a patient with a tension pneumothorax. Blood gases may be drawn later on, after the needle and then the chest tube are inserted.
Endotracheal intubation (choice B) is the treatment for a flail chest, which presents with paradoxical chest wall motion, splinting, and crepitus of rib fragments. The patient in this case has a tension pneumothorax, not a flail chest.
A chest tube (choice C) is inserted after the needle is placed into the left 2nd intercostal space. By the time all of the required chest tube equipment is put together, a patient with a tension pneumothorax may die. Therefore, a needle insertion is the quickest life-saving procedure for this patient.
A chest x-ray (choice E) is not required to make the diagnosis of a tension pneumothorax. The diagnosis is clinical and a chest x-ray will only waste precious time.
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