A 31-year-old male was shot in the chest. He is anxious with distended neck veins and absent breath sounds on the right. What is the most appropriate action?

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A tension pneumothorax from a chest wound is suggested by distended neck veins and no breath sounds on the affected side. The life-saving move is to relieve the pressure in the pleural space. Pleural decompression directly eliminates the automatic air buildup that is squashing the lung and impeding venous return to the heart, allowing the lung to re-expand and improving cardiac output. In the field, this is done quickly with needle decompression on the affected side, often followed by a chest tube for definitive drainage.

CPR isn’t the immediate step here because circulation is not the primary failure; the problem is the pressure trapping air in the chest. Giving fentanyl doesn’t treat the underlying issue and could worsen breathing or blood pressure. Placing a chest tube on the opposite side would not relieve the tension on the injured side.