Jugular distension

[Gurby]

Or how about this:

If this was my patient I would consider a needle decompression, but I would feel bad about it and call medical control first. Medical control would likely tell me to hold off, drive fast, but be ready to pop a needle in if patient condition changes.

Why do you suppose I feel bad about it, and why would medical control probably tell me to not decompress?

 

[STXmedic]

Or how about this:

If this was my patient I would consider a needle decompression, but I would feel bad about it and call medical control first. Medical control would likely tell me to hold off, drive fast, but be ready to pop a needle in if patient condition changes.

Why do you suppose I feel bad about it, and why would medical control probably tell me to not decompress?

Your Med control is a pansy.

To be fair, if the patient presented as described he likely would not have a BP of 110/something.

 

[Gurby]

Your Med control is a pansy.

To be fair, if the patient presented as described he likely would not have a BP of 110/something.

That's what I was getting at with "part of the patient description is wrong" - this would be a slam dunk needle decompression except that patient's blood pressure is seemingly stable. Maybe med control would ask me to re-check the blood pressure, because the picture doesn't seem to make sense. I doubt you could build up enough pressure to cause tracheal deviation without also causing significant hemodynamic compromise.

I suppose this is outside of the scope of OP's question anyways. I just wanted to make him/her think a bit more about what a pneumothorax is, what a tension pneumo is, what issues can come from it and the pathophysiology behind it.

 

[Austin carawan]

That was word for word. I'm not too sure then... Ohhh! Hypoperfusion Jim!?!?

 

[Austin carawan]

Please bare with me, as online schooling truly leaves several dark spots, would you expect to see a low blood pressure?

 

[Austin carawan]

Or would syst. And diastolic grow closer together?

 

[STXmedic]

So a tension pneumo causes a decreased preload. If the preload decreases, what would you expect to happen to the blood pressure? (Hint: think a hose a spray nozzle. If you king the hose, what happens to the nozzle)

 

[Gurby]

So a tension pneumo causes a decreased preload. If the preload decreases, what would you expect to happen to the blood pressure? (Hint: think a hose a spray nozzle. If you king the hose, what happens to the nozzle)

I wonder if OP can explain why/how tension pneumo reduces preload (basically the amount of blood in the heart just before it contracts)?

 

[Flying]

Save for exceptional classes and instructors, preload just isn't a thing at the EMT level guys.

 

[Austin carawan]

Ohh, so basically the heart cannot fill up with blood efficiently therefore causing it to pump less blood out. Low bp. Kind of like vasodilation except but vice versa? Ie instead of arteries expanding you have less fluid? You guys are a great help, emailing the instructor only leads me to believe I didn't read well enough, thank you all

 

[Flying]

Ohh, so basically the heart cannot fill up with blood efficiently therefore causing it to pump less blood out. Low bp. Kind of like vasodilation except but vice versa? Ie instead of arteries expanding you have less fluid? You guys are a great help, emailing the instructor only leads me to believe I didn't read well enough, thank you all

A better way to describe it is that the heart is being smothered. If you press on all sides of the heart at once (which is what the air pressure is doing) you will end up with poor filling of blood and poor ejection of blood.

Instead of a hand, you have air pressure that isn't supposed to be in the thoracic cavity. You can probably figure out why you get JVD and reduced pressure.

Think of reasons this might happen in the first place and how a pneumothorax would evolve into a tension pneumo.

 

[Austin carawan]

i understand, would the lack of circulation be of greater importance than the air in the pleural space? Or remove the air and the heart problem fixes itself?

A better way to describe it is that the heart is being smothered. If you press on all sides of the heart at once (which is what the air pressure is doing) you will end up with poor filling of blood and poor ejection of blood.

Instead of a hand, you have air pressure that isn't supposed to be in the thoracic cavity. You can probably figure out why you get JVD and reduced pressure.

 

[Gurby]

A better way to describe it is that the heart is being smothered. If you press on all sides of the heart at once (which is what the air pressure is doing) you will end up with poor filling of blood and poor ejection of blood.

I'm not sure if it's actually pressure on the vena cava that does it, or if it's pressure exerted directly on the heart. The vein is probably easier to compress, so I'd imagine that happens first. Same idea either way.

On the topic of physical findings, at least in my experience, you are not actually very likely to see tracheal deviation or JVD (but it's good to recognize those signs for the test, no doubt). You are more likely to see subcutaneous emphysema: air going elsewhere in the body into places it shouldn't go, causing what looks like swelling:

Actually it looks like there might be some TD in this next one. Cool!

 

[STXmedic]

Save for exceptional classes and instructors, preload just isn't a thing at the EMT level guys.

Both programs I've taught at, we've taught basics about the concepts hemodynamics, including preload and after load. But that's only two programs I suppose.

Ohh, so basically the heart cannot fill up with blood efficiently therefore causing it to pump less blood out. Low bp. Kind of like vasodilation except but vice versa? Ie instead of arteries expanding you have less fluid? You guys are a great help, emailing the instructor only leads me to believe I didn't read well enough, thank you all

Yes and no. You've got the idea right. They will be hypotensive because their heart can't fill as much. Less in = less out. Especially when you factor in the Frank-Starling law (that is one you likely didn't cover). It also doesn't necessarily "push on all sides at once". That's more descriptive of cardiac tamponade. What the tension pneumo is doing is displacing the heart to the side- away from the injury. Now going back to the hose analogy, what supplies the preload to the heart?

 

[Flying]

I'm not sure if it's actually pressure on the vena cava that does it, or if it's pressure exerted directly on the heart. The vein is probably easier to compress, so I'd imagine that happens first. Same idea either way.

From what I understood, it doesn't really matter what is being compressed, just that thoracic pressure works against the entire system additively/subtractively. Probably an oversimplification.

 

[Austin carawan]

The venue cavae!

Both programs I've taught at, we've taught basics about the concepts hemodynamics, including preload and after load. But that's only two programs I suppose.



Yes and no. You've got the idea right. They will be hypotensive because their heart can't fill as much. Less in = less out. Especially when you factor in the Frank-Starling law (that is one you likely didn't cover). It also doesn't necessarily "push on all sides at once". That's more descriptive of cardiac tamponade. What the tension pneumo is doing is displacing the heart to the side- away from the injury. Now going back to the hose analogy, what supplies the preload to the heart?

 

[STXmedic]

The venue cavae!

Exactly. So the heart/mediastinum gets displaced away from the injury due to pressure. The vena cava have some give, but not a ton. As the heart shifts, they start to shift with it and "flatten". Flatten the garden hose and you see what's now giving the heart it's preload. Significantly less flow, yeah?

 

[Gurby]

From what I understood, it doesn't really matter what is being compressed, just that thoracic pressure works against the entire system additively/subtractively. Probably an oversimplification.

Lots of factors at work I guess. Increased pressure alone will drop preload, as seen with CPAP.

 

[Austin carawan]

Yea definitely! So is you primary concern, circulation or the air in pleural space?
My thoughts are, fix the air pressure, and the heart will find itself back where it should be. Is that incorrect?

Exactly. So the heart/mediastinum gets displaced away from the injury due to pressure. The vena cava have some give, but not a ton. As the heart shifts, they start to shift with it and "flatten". Flatten the garden hose and you see what's now giving the heart it's preload. Significantly less flow, yeah?

 

[STXmedic]

Lots of factors at work I guess. Increased pressure alone will drop preload, as seen with CPAP.

Yeah, very true. CPAP is causing positive pressure and hyperinflation in both pleural spaces, so that would be a little more descriptive of pressure from all sides. The pressure also works on baroreceptors.