A child presented with respiratory distress, was brought to emergency with bag and mask ventilation. Now he is intubated. Chest x-ray shows right sided deviation of mediastinum with scaphoid abdomen. His pulse Impulse has shifted to the right. What is the next step?

The findings (mediastinal shift to right, scaphoid abdomen, pulse impulse shifted right) in an intubated child indicate left-sided tension pneumothorax or massive gastric distension from air trapping. Placing a nasogastric tube to decompress the stomach is the immediate next step. Removing ETT is unsafe, surgery is premature, and chest tube is for pneumothorax (but rule out gastric issue first).