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I have read where tracheal deviation is actually visible but missed during physical exam because the trachea is deviated only by a few mm.I would not personally decompress without signs of significant air hunger and hypoxia. On both occasions I have witnessed an actual developing tension pneumothorax there was jugular venous engorgement, asymmetrical chest (best viewed from the feet looking toward the head), absent breath sounds on the affected side, hyperresonance to percussion, and subcutaneous emphysema. Notably absent from the physical exam was tracheal deviation although it was clearly visible on CXR -- don't necessarily expect to see it because the "turn" can happen below the sternal notch. I have reviewed a lot of reports over the years where the chest was "decompressed" but the physical exam did not warrant it. Just because it happens a lot does not mean it was indicated. I agree with others who suggest the more likely diagnosis is hemothorax although I understand why you were concerned with a dropping blood pressure.