View Full Version : Remind me again please
When do you use a needle decompression and when do you use a chest tube? Memory says that they are both used to releave air trapped in the chest cavity between the lungs and the ribs. So it seems to me that the chest tube can remove air faster then the needle. I am sure I am missing something, just don't know what or I am just completely wrong.
What, did you go and piss off your team's 18D again, so he won't tell you? ;)
The entire Battalion is out of state training and unavailable while I await the birth of my first child.
Roguish Lawyer
03-01-2005, 20:29
The entire Battalion is out of state training and unavailable while I await the birth of my first child.
Congrats, Para! Enjoy the time you can spend with the kid -- they grow up fast.
NousDefionsDoc
03-01-2005, 20:47
Excellent question! :munchin
The Reaper
03-01-2005, 21:51
The entire Battalion is out of state training and unavailable while I await the birth of my first child.
Early congrats!
TR
Sacamuelas
03-01-2005, 22:26
A needle is used for a VERY quick decompression in a critical situation and could be used as a emergency diagnostic confirmation during a field type situation when no chest xray is available and before you cut in a chest tube. You literally hear the air release once your gain access to that pleural space and in my VERY limited experience get very quick and affirmative results with the patient if you were (a) successful and (b) it was needed and they actually had a tension pneumo. LOL
I've been at the table and assisted while my son was needled twice to relieve a tension pneumo with critical symptoms of pronounced tracheal shift, diminished breath sounds, very low 02 sats even while being ventilated on 100% 02, bradycardia, yet plenty of blood volume (he did not display JVD but if the patient does have JVD- it does alert you that there is not a volume deficiency causing the shock and helps diagnose TP) while a chest tube setup was obtained. Chest tube w/suction unit was the permanent treatment for his condition.
NOTE: Please wait for SwatSurgeon or DocT to chime in on this. They are trauma surgeons and true experts. :cool:
swatsurgeon
03-02-2005, 08:01
Saca is correct...let me add one thing....tracheal deviation, low blood pressure are 'later' signs of tension PTX. If the patient has the signs or symptoms that make you even THINK that the patient has a PTX, just decompress it.....this is the VAIL RULE #1: if you think it, do it...when it comes to decompression or intubation. The worst they do is now buy a chest tube.
The free and open space created by the needle, decompresses the tension component but can give a simple PTX that can compromise some people....hence why I like those little one way valves I showed in another thread. Air gets out and can't rush back in.
If someone gets needle decompressed and decompensates, intubation or just providing positive pressure ventilation will expand the lung but damn, we breath by negative pressure ventilation without assistance.
Chest tubes are not a front line item, but a 10 or 12 gauge wire wrapped needle and a one way valve is just as good as a chest tube IMHO
Just use search: for fish tank valve and the thread will be there, I can't link it for some reason
http://www.professionalsoldiers.com/forums/showthread.php?t=4000&highlight=fish+tank+valve
I saw the link, which is what started this all. I believe NDD linked it on the survival kit thread which started me working on my survival kit matrix for the next trip across the ocean. The medical stats I heard was that 70% of deaths came from blood loss, 50% from extremities and 20% from non-extremities. Another 20% from air in the chest cavity and 5% from closed air-ways. Thus, create a plan to handle that 95%.
swatsurgeon
03-02-2005, 10:42
Para,
your stats are about right....airway/breathing and bleeding are ~85-90%....so tourniquet, traumadex, wire wrapped needle and fish tank valve and you are ready.....never leave home without them. Also, bring antibiotics!! (find that thread also)
Thursday
03-04-2005, 02:52
Saca is correct...let me add one thing....tracheal deviation, low blood pressure are 'later' signs of tension PTX.
This is definately correct. We just finished up learning all flavors of PTX ( hemo, tension, closed, open ) in class.
Tracheal deviation is an extremely late sign that will indicate that the effected lung has shifted at least 6 to 8 inches. If a medic simply waits to diagnose a TPTX by tracheal deviation, that pt. will most likely die if they are not decompressed immediately. Even JVD is a late sign, indicating a failing right side of the chest, producing excess fluid backup in the Vena Cava.
I do have a question about chest tubes though, seeing as though we dont do them in the civilian EMS field. I know that a needle decompression is in the 2nd intercostal, where would a chest tube be inserted? Is it more medial, in the 2nd?
swatsurgeon
03-04-2005, 08:33
chest tubes in the field can be placed in 2 areas IMHO. For air and maybe blood, can place it anteriorly, 2nd or 3rd space, mid-clavicular line but it has to be a smaller tube (12F-20F). For large hemothorax +/- air, anterior axillary line, 5th space, 28-36F tube.
TitratetoEffect
03-06-2005, 10:37
Just wanted to add my .02cents to this very important conversation. According to TCCC (hence a tactical combat situation) you only need only two S/S to perform a needle decompression. 1. Mechanism of injury and 2. difficulty breathing are enough signs to initiate. Another S/S to look for is unilateral rise and fall of the chest if possible. In a combat situation it will be very difficult to determine increased tympani with percussion or decreased breath sounds with auscultation. And, as stated before tracheal deviation and JVD are late signs which may indicate a progression to deadly Vetricular Rhythms and cardiac collapse from cardiac compression.
Phil
NousDefionsDoc
03-06-2005, 11:00
chest tubes in the field can be placed in 2 areas IMHO. For air and maybe blood, can place it anteriorly, 2nd or 3rd space, mid-clavicular line but it has to be a smaller tube (12F-20F). For large hemothorax +/- air, anterior axillary line, 5th space, 28-36F tube.
Why would you use the smaller tube at all? With a GSW, would you not assume hemo, even if eventually, and take preventative measures prior? I don't see the downside of going with the larger tube in every case. I probably wouldn't carry the smaller tube.
swatsurgeon
03-06-2005, 13:47
NDD,
I agree with the larger tube for penetrating trauma...first off, chest tubes have little to no place in the field, yes in an aid station or FAST area, but not under fire. The smaller tube is under ideal conditions with a 'pure' pneumothorax, popped bleb, stab wound, etc. For the typical need for a battle field chest decompression, stick with a needle.
NousDefionsDoc
03-06-2005, 17:49
NDD,
I agree with the larger tube for penetrating trauma...first off, chest tubes have little to no place in the field, yes in an aid station or FAST area, but not under fire. The smaller tube is under ideal conditions with a 'pure' pneumothorax, popped bleb, stab wound, etc. For the typical need for a battle field chest decompression, stick with a needle.
Cool. Thanks.
How often do you think needles actually enter the chest cavity?
I think most placed by EMS at least tend to stay in the muscle and never break the pleura which is why we have stopped routinely placing tubes and getting xrays to verify unless the patient is unstable. Often the catheter is simply not long enough in a heavy or muscular patient.
t.
TerribleTobyt
03-06-2005, 19:21
ISTR from the lecture a large bore needle into the 7th ICS, mid-axillary line. Palpate the space, slide needle OVER the 7th rib (vice under the 6th rib). If done properly, the patient should express instant relief.
Is that correct, or am I remembering it wrong??
Toby-a chance to cut'sa chance to cure!!!!!! :D
swatsurgeon
03-07-2005, 06:21
the only needles we now have available are 5 cm (2.5 inches) which 'should' be long enough to penetrate the pleura. Doc T is referring to 2 articles from the 90's that showed >65% of all chest decompression needles never made it into the pleural space to decompress the pneumothorax. These needles were the standard 1 1/4 inch IV starter needles....hence why the recommendation for a 2 1/2 inch needle. Some places have gone to a longer HARPOON 5 inch needle but under stressful circumstances this thing is a weapon and can lacerate lung,heart (if put too low) and do more harm than good potentially. The other issue remains that unprotected plastic catheters can bend and kink and the pneumothorax can re-accumulate....
which is why I recommend, and carry, the wire wrapped needles...can tie them into a knot and they retain their lumen. Yes, they are expensive but aren't you worth it?! The bad guy can get the old kind; the soldier, SWAT officer gets the wire wrapped from me.
Question,
I just went throught the PHTLS course up here and one of the instructors said that the placement of a chest tube touches/penetrates one of the 4 (5?) painful "P's", the plura. He had the proceedure once and said that he levitated off the table while trying to whack the Dr. who was placing the tube. Why is the puncture of the plura so painful, and what are the other Painful P's?
Thanks,
Maya