This case demonstrates the importance of quickly identifying a pediatric patient in acute respiratory distress secondary to pneumothorax and highlights the emergent management of these patients. The 16-year-old male patient presented to the emergency department (ED) with a chief complaint of right-sided rib pain and shortness of breath that began acutely after an all-terrain vehicle (ATV) accident. The patient was in respiratory distress upon presentation and had diminished right-sided breath sounds. A portable chest X-ray demonstrated pneumothorax with significant mediastinal leftward shift. Needle decompression of the right chest wall was performed and right sided thoracostomy was placed. It is important to maintain a high index of suspicion for tension pneumothorax in pediatric trauma patients with respiratory distress, even when hemodynamically stable. This case report discusses proper management of traumatic tension pneumothorax and discusses current recommendations for needle decompression and thoracostomy.TopicsTension pneumothorax, pediatrics, respiratory distress, portable chest x-ray, ultrasound.