tension pneumo

[bw1776]

Hey guys.

I've asked guys I work who are some really good medics but they kinda stick with what protocols say and not what would actually work well given certain situations.

I've worked GSWs and stabbings with sucking chest wounds and tension pneumothorax. The 3 sided dressing or chest seals sound great but between diaphorysis, the pt moving, and things bumping around, they don't stay on or work the way they should. I like the idea of using a defib pad to totally occlude it and burping it. Also, needle decomp with a finger cut off of a med glove used as a one way valve (which is what we have) doesn't work very good either. So if I was sticking with totally occlusive and burping it, how often do you guys think it should be burped? I know you read the pt but I don't want to wait for a pneumo to develop either.

I'm talking about if you were nowhere and a couple hours from higher care, what would you guys do or come up with. Protocol free answer.

Thanks guys.

[bw1776]

So wait til a pt is decompensating...that's the answer everybody gives I get it. If thats the only way you know when to burp it, that's fine but I don't like the idea of my pt to start circling the drain every time before I'm able to help him.

The HALO is a good option but I don't get to pick what we carry. Defib pad works the same way, no problems there.

[RichL025]

If you are truly a "couple of hours" out from definitive medical care, then you had better be able to put in a chest tube.

I have lost count of the number of angiocaths EMS has used to "needle" the chest, and then a subsequent CT scan proves they were never within a centimeter of the pleural cavity.... And every time I am solemly assured they got a rush of air...

[Surgicalcric]

Cookbook medicine...

Originally Posted by bw1776

So wait til a pt is decompensating...that's the answer everybody gives I get it. If thats the only way you know when to burp it, that's fine but I don't like the idea of my pt to start circling the drain every time before I'm able to help him...

So you are looking to treat an algorithm instead of the patient? There is not a magic time standard that can be used to determine when someone may/may not have developed a tension pneumo. That is determined according to MOI and symptoms/signs the patient presents with.

Have you tried basing your treatment off respiratory effort and sufficiency instead of looking for an easy answer? SAO2 and ETCO2 measurements? Comparative decrease in rise/fall of the chest? Patient complaint of increased respiratory difficulty, cant catch breath? I could go on... It shouldn't take the patient presenting with JVD or mediastinal shift (very late signs) for you to know there is an issue/the patient is having difficulty.

What more do you need?

[Surgicalcric]

Originally Posted by RichL025

If you are truly a "couple of hours" out from definitive medical care, then you had better be able to put in a chest tube.

I have lost count of the number of angiocaths EMS has used to "needle" the chest, and then a subsequent CT scan proves they were never within a centimeter of the pleural cavity.... And every time I am solemly assured they got a rush of air...

Are they using 14ga x 3.25" long caths or the standard 14ga x 1.88" long? I have never had an issue with our barrel chested guys with the 3.25" ones.

[Trapper John]

I'm going with occlusive dressing and a chest tube with a butterfly valve made from surgical gloves every time. Seems like SOP to me.

[RichL025]

Originally Posted by Surgicalcric

Are they using 14ga x 3.25" long caths or the standard 14ga x 1.88" long? I have never had an issue with our barrel chested guys with the 3.25" ones.

Don't know - I need to pin them down on that. I'm usually pretty busy when they wheel in the patient, and if the portable chest is OK and they are breathing acceptably, I don't worry about what they stuck in the chest until I'm in the scanner. EMS has usually left by that time....

[craigepo]

Spousal unit alpha says if you're truly a couple hours out, you had better be carrying some chest tubes.

[RichL025]

You'd better be carrying a longer catheter....

Mil Med. 2007 Dec;172(12):1260-3.
Chest wall thickness in military personnel: implications for needle thoracentesis in tension pneumothorax.
Harcke HT1, Pearse LA, Levy AD, Getz JM, Robinson SR.
Author information
Abstract

Needle thoracentesis is an emergency procedure to relieve tension pneumothorax. Published recommendations suggest use of angiocatheters or needles in the 5-cm range for emergency treatment. Multidetector computed tomography scans from 100 virtual autopsy cases were used to determine chest wall thickness in deployed male military personnel. Measurement was made in the second right intercostal space at the midclavicular line. The mean horizontal thickness was 5.36 cm (SD = 1.19 cm) with angled (perpendicular) thickness slightly less with a mean of 4.86 cm (SD 1.10 cm). Thickness was generally greater than previously reported. An 8-cm angiocatheter would have reached the pleural space in 99% of subjects in this series. Recommended procedures for needle thoracentesis to relieve tension pneumothorax should be adapted to reflect use of an angiocatheter or needle of sufficient length.

EDIT: If you really need to needle decompress someone, place the needle in the 5th ICS MAL, NOT where you were taught at the 2nd ICS MCL.....

[Koldsteel]

What do you use for a valve on the end of the chest tube once inserted ?

And why is 2nd ICS MCL a poor insertion point ? Ive decompressed a few at that location without a problem.

[Trapper John]

Originally Posted by Koldsteel

What do you use for a valve on the end of the chest tube once inserted ?

Surgical gloves make an effective butterfly valve: Cut off the first or second digit of the glove. Place the open end around the chest tube opening, cut the closed end, voila - butterfly valve.

[RichL025]

Originally Posted by Koldsteel

What do you use for a valve on the end of the chest tube once inserted ?

And why is 2nd ICS MCL a poor insertion point ? Ive decompressed a few at that location without a problem.

1. Heimlich valve or equivalent.

2. Shorter distance from skin to pleural space (although there is one study out there that contradicts that)

Rich