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HardRespiratoryTension pneumothoraxuk-plab-1

A 34-year-old man presents with sudden onset right-sided pleuritic chest pain and increasing breathlessness after a coughing fit. He is tall and thin with no past medical history. He is tachycardic at 120 beats per minute and hypotensive at 85/50 mmHg. On examination there is tracheal deviation to the left, absent breath sounds on the right and a hyper-resonant right hemithorax. What is the single most appropriate immediate management step?

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