# how to properly ventilate patient with possible tension pneumo



## jshal (Jul 12, 2016)

would an EMT-B ventilate this patient using less force while squeezing the bag or would you just squeeze as normal? (ALS has not tubed them yet) are there things to look/listen for regarding tidal volume and artificial ventilations? 

anyone experience adverse effects from ventilating them normally?


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## Flying (Jul 12, 2016)

Hold on, why are we planning to ventilate this person?


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## Akulahawk (Jul 12, 2016)

I moved this thread to the BLS Discussion forum from the Scenario forum as the initial post is not a scenario but rather the beginning of a discussion about BLS ventilation of a tension pneumo patient.

Please continue the discussion!


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## jshal (Jul 12, 2016)

ok lets say he's unresponsive with slow, shallow restorations. diminished lung sounds on right side. i'll throw in a sucking chest wound if you want to make things extra interesting. (occlusive has been applied) 

would you ventilate normally or modify ventilations somehow while ALS in route to decompress chest etc.


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## Aprz (Jul 12, 2016)

I have never knowingly treated a patient with a tension pneumothorax.

Obviously going to ventilate a patient who has poor spontaneous respiration. They aren't breathing on their own, it is too shallow, or too slow. It is B in ABC. They will die if their breathing isn't corrected. In a tension pneumothorax, the other problem is an airway problem (only one lung working) and a circulation problem (obstructive shock with organs shifting and possibly hemorrhagic if traumatic). If the tension pneumothorax is from an open would, an occlusive dressing taped on three sides to make a one way valve might help. I personally see a pleural decompression as making a small intentional opening to make that valve.




jshal said:


> are there things to look/listen for regarding tidal volume and artificial ventilations?


Absolutely. It is mostly the same as things you'd look for in someone who is spontaneously breathing.

Skin signs
Rise and fall of the chest
Breath sounds
Keep an eye out for gastric distention
Diagnostics like EtCO2 and SpO2
Monitor HR and BP
Compliance/resistance felt when squeezing the bag
One that is specific to the BVM that I was taught, but haven't really appreciated in a patient without an advance airway is compliance or resistance felt while bag mask ventilating the patient. I probably haven't appreciated it due to a poorer seal between the bag and the patient's airway. That is you should feel some resistance squeezing the bag valve mask when the patient pressure in the lungs increase. For this reason, my primary indicator of relaxing the bag would be seeing some chest rise.

In a patient with a tension pneumothorax, you can expect the HR to elevate due hypoxia and hemorrhagic (if traumatic) and/or obstructive shock. You can expect a decreased BP due obstructive shock. Decreased SpO2 due to hypoxia. I would imagine a decreased EtCO2 due to shock and V/Q mismatch I think (one lung isn't usable / collapsed even though blood supply is still going to it). Don't expect perfect vital signs even post treatment, but can give you idea how the patient is responding to your treatment somewhat. Things like hyperventilating (a common issue) may increase SpO2 and HR while decrease BP and EtCO2. In late hypoxia, the patient may became bradycardic.


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## Hold My Beer (Jul 15, 2016)

If you identify the patient with having a tension punemo then assess his ABCs.  If they are not yet hypoxic then only apply high flow O2 with a non-rebreathing mask.  If the patient is getting worse with the O2 then you have to assist ventilation with a BVM.  When you are doing this be careful with the amount of force you are using.  Remember the patient now has up to 50% less tidal volume since they are operating with one good lung. Watch for minimal chest rise at about 10 ventilations per minute.  You should not expect to see the same amount of chest rise as you normally would due to one of the lungs has a huge leak and the other lung is fighting against increased resistance from the mediastinal shift.

If the patient has an open tension punemo like with your sucking chest wound then you have options.  The open wound is now basically your valve.  An open punemo is less likely to become a tension punemo because the pressure in the pleural space has a route to escape instead of compressing on the mediastinum.  Because you have rightfully occluded the chest wound the pressure now has nowhere to go. This can eventually cause a tension punemo.  To avoid this just lift up or briefly remove the dressing, "burp" the dressing, to allow the air pressure to escape and continue with your ventilations as normal.

Remember.  If you are going down the path of assisting the patient with a BVM then expect bad things to happen.  The tension punemo will reduce cardiac output but if the patient is HYPOXIC with poor skin signs then you must do something and tell that medic unit to step on it.  Also in this ( or any ) circumstance do not rely on a SpO2 reading to be accurate and your only tool for identifying hypoxia.


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## adam c (Jul 15, 2016)

Interesting proposition - the body has gone from negative pressure ventilation to positive pressure.


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## Martyn (Jul 16, 2016)

Sorry, but KISS rules here, surely...ventilate to provide adequate inflation of the 'non deflated' side, burp the occlusive as necessary and keep an eye open for cyanosis.



Aprz said:


> One that is specific to the BVM that I was taught, but haven't really appreciated in a patient without an advance airway is compliance or resistance felt while bag mask ventilating the patient.





adam c said:


> Interesting proposition - the body has gone from negative pressure ventilation to positive pressure.



As for the above two posts it's called assisted ventilations, were you not taught that?

One last thought, why make things seem so difficult?


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## Aprz (Jul 16, 2016)

I don't understand what you are trying to point out with my post. I was talking about my last pointer. Did you not like my choice of words with "bag mask ventilation" (I started using this phrase after seeing it in Manual of Emergency Airway 3rd Edition) or didn't understand what I was talking about when I talked about feeling the resistance of the bag when squeezing it? Assisted ventilation and talking about compliance/resistant you have squeezing the bag are two totally different things. I was saying that with a BLS airway, I usually do not feel or appreciate this resistance. I usually just watch for rise of the chest and then release the bag.

I'm a fake paramedic. Probably not even in EMs at all! It would make sense that I am uneduated in this BLS stuff. Except ECGs. I learned that stuff to make myself look real.


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## gotbeerz001 (Jul 16, 2016)

Aprz said:


> I'm a fake paramedic. Probably not even in EMs at all! It would make sense that I am uneduated in this BLS stuff. Except ECGs. I learned that stuff to make myself look real.


I think you're real. @Aprz


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## adam c (Jul 17, 2016)

Martyn said:


> it's called assisted ventilations, were you not taught that?



Since we started being picky, the "assisted ventilations" that you speak of, provide positive pressure, in that when you squeeze the bag, air is positively pushed into the airway. When the body breaths for itself, it sucks air in through negative ventilation - were you not taught that?


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## Martyn (Jul 17, 2016)

Yes I was...others it seems not lol


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## Martyn (Jul 17, 2016)

...and I would like to make a public apology to Aprz...sorry


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## Carlos Danger (Jul 17, 2016)

You ventilate a tension pneumo the same way you do anyone else, if using a BVM. 

It is logical to try using lower inflation pressures, but that is very hard to gauge with a BVM, especially if you don't mask people routinely, so I think it is likely that most folks would do more harm than good by trying to limit the inspiratory pressure. Once you have an advanced airway in place, it is much easier to use lower pressures and permissive hypercapnia. With a vent, you can of course just use a pressure mode set very low and long E-times. In these patients you worry less about etc02 than hemodynamics and oxygenation.


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## sack jears (Jul 17, 2016)

If breathing is inadequate then you have no choice but to ventilate, even though you risk increasing inthoracic pressure, further compressing organs. If you have a sucking wound then burping the dressing may allow you to be more aggressive with your ventilations. Ultimately this guy will need a chest dart but if they're hypoxic and breathing's inadequate then they gotta be bagged. I imagine that you would experience an increase in bag resistance if it was a closed tension pneumo because air couldn't escape their chest


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## bakertaylor28 (Feb 1, 2017)

The last TP I handled our MC orders were to avoid the BVM if possible with a TP case, and instead opt for high-flow O2 with a NRB. The notion is that with a TP Positive Pressure is an enemy and is to be avoided wherever POSSIBLE. (Though beyond a certain point, it will be impossible to avoid the BVM any longer without definitive treatment, because non-treated TP = impending cardiac arrest, pretty much.) This is where you need ALS because your going to have to get a chest tube in this guy relatively quickly to avoid an impending arrest.


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## Underoath87 (Feb 3, 2017)

bakertaylor28 said:


> This is where you need ALS because your going to have to get a chest tube in this guy relatively quickly to avoid an impending arrest.



You guys are doing chest tubes in the field?


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## NomadicMedic (Feb 3, 2017)

Underoath87 said:


> You guys are doing chest tubes in the field?



in his mind, yes.


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## E tank (Feb 3, 2017)

Underoath87 said:


> You guys are doing chest tubes in the field?


Maybe needle "thoracostomy"?


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## TransportJockey (Feb 3, 2017)

Underoath87 said:


> You guys are doing chest tubes in the field?


Some of us have  

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## SpecialK (Feb 3, 2017)

Basically, don't piss arse around and bloody well decompress it, with the understanding for a tension pneumothorax to be present the patient must have shock and this must be rapid and progressive, a "little of shortness of breath and tachycardia" doesn't equal tension pneumothorax.

Traditionally we've used been with a very long cannula but those days are over, bam, goneburger.  Finger or tube thoracostomy is where it is now at.  I've seen the HEMS Docs use a short chest tube with a one way valve of about six inches in length; do a traditional finger thoracostomy, insert it and sew it in with a few sutures.  The only downside to finger thoracostomy is it hurts, like a lot, but no major, use some SC 1% lignocaine plain and little bit ketamine and you'll be sweet.

As for ventilation? No difference really.


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## MikeC (Feb 12, 2017)

E tank said:


> Maybe needle "thoracostomy"?



Thoracostomy via ALS to relieve intrathoracic pressure on affected side. BVM indicated with low resp rate until that can be performed.


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