# chest decompression



## wdballer2431 (Mar 2, 2011)

What r u guys thoughts on penetrating trauma to the area of the 2nd/3rd intercoastal space with signs and symptoms of a tension. Best area to decompress. Also 3 or 4 sided occulsive dressing to the posterior with penetrating trauma to that area only. No exit wound on anterior chest. Most likely pt will be moved on long board. Thoughts??


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## Smash (Mar 2, 2011)

My thoughts? I think that the English language is in it's death throes. I appreciate that language evolves (or devolves apparently) but the idea with these message boards is to communicate questions, opinions, ideas, and just very occassionally, facts. If the message is lost because of poor grammar and spelling, or excessive use of obscure abbreviations and acronyms, then we may as well not bother. 

However, with regard to your questions: blunt finger dissection or needle decompression laterally for the tension pneumothorax. Anterior chest is not necessarily the best location for needle decompression anyway. 

I'm not sure what I should think about the rest of it. I'm wondering why one wouldn't dress a wound. I'm wondering why they need to be on a spineboard. Im wondering why it would matter anyway.  I'm wondering why there are so many question marks.  I'm wondering what I'm going to have for breakfast. 

Welcome to EMTLife.


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## Veneficus (Mar 2, 2011)

Smash said:


> My thoughts? I think that the English language is in it's death throes. I appreciate that language evolves (or devolves apparently) but the idea with these message boards is to communicate questions, opinions, ideas, and just very occassionally, facts. If the message is lost because of poor grammar and spelling, or excessive use of obscure abbreviations and acronyms, then we may as well not bother.
> 
> However, with regard to your questions: blunt finger dissection or needle decompression laterally for the tension pneumothorax. Anterior chest is not necessarily the best location for needle decompression anyway.
> 
> ...



But I like the anterior chest placement.


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## Shishkabob (Mar 2, 2011)

We were taught not only superior anterior chest placement, but also the axial area of the lower chest in school.  However, I don't know of an agency around here that allows needle thoracostomy to be done anywhere BUT the upper anterior aspect... apparently due to a time that a medic(s) pierced the spleen and/or liver and a receiving physician complained.


Granted I've never confirmed that story, but I havent seen any protocols of any agency in the area that allow axial placement.


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## Smash (Mar 2, 2011)

I like anterior too, but I have seen a number of VERY bad placements.  It seems to be common that people go too close to the sternum, skewering the internal mammary artery on an alarming number of patients.


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## wdballer2431 (Mar 2, 2011)

To Smash, I'mtyping on a phone. Don't see what's wrong with a few abbreviations. My question was having a gsw to the anterior chest with signs and symptoms if a tension pneumo. Would it be best to decompress as close to that area as possible?


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## wdballer2431 (Mar 2, 2011)

With that gsw being right in the area where u would typically decompress


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## Smash (Mar 2, 2011)

My reply still stands, blunt finger dissection or needle laterally.  You could make a hole beside the gunshot wound I guess.  Where the hole is doesn't really matter that much, both in terms of the hole that caused it and the hole that fixed it (hopefully)


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## usafmedic45 (Mar 2, 2011)

> My thoughts? I think that the English language is in it's death throes. I appreciate that language evolves (or devolves apparently) but the idea with these message boards is to communicate questions, opinions, ideas, and just very occassionally, facts. If the message is lost because of poor grammar and spelling, or excessive use of obscure abbreviations and acronyms, then we may as well not bother.



Amen.



> apparently due to a time that a medic(s) pierced the spleen and/or liver and a receiving physician complained.



As opposed to hitting the heart, lung, or aorta....



> To Smash, I'mtyping on a phone.



So?



> Don't see what's wrong with a few abbreviations.



You mean besides the fact that it makes you look like you've been pithed?  It's not just the abbreviations.  The poor syntax and grammar also gives you less than a polished appearance.



> Would it be best to decompress as close to that area as possible?


You do know what happens with air or fluid in the pleural cavity, right?  

To answer your question, needle decompression should be only used if the patient is in extremis.  It's overused by excessively eager paramedics.


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## Shishkabob (Mar 2, 2011)

usafmedic45 said:


> As opposed to hitting the heart, lung, or aorta....



Preaching to the choir...


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## fast65 (Mar 2, 2011)

I love the fact that grammar lessons always come first on this forum 

As for the OP, everyone else has pretty much already answered your question...why not make a hole next to the GSW?


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## lightsandsirens5 (Mar 2, 2011)

Smash said:


> My thoughts? I think that the English language is in it's death throes. I appreciate that language evolves (or devolves apparently) but the idea with these message boards is to communicate questions, opinions, ideas, and just very occassionally, facts. If the message is lost because of poor grammar and spelling, or excessive use of obscure abbreviations and acronyms, then we may as well not bother.



I love you.


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## Smash (Mar 2, 2011)

lightsandsirens5 said:


> I love you.



:wub:


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## 18G (Mar 7, 2011)

As far as the comments on the abbreviations, etc... I think they are out of line. People need to understand that the generation of today was brought up with the Internet, texting, hand-held devices, etc. This is all very natural to them and is as common to them as a pencil and paper is to you. It is what it is and  they aren't gonna change for you. I understood the OP's questions perfectly. 

As the OP stated, he was typing on a hand-held device where abbreviations make it much easier to get your msg out. If you don't understand the abbreviations then I would recommend you come up to speed. 

Now to the actual question.... when my class was practicing the chest decompression on a cadaver, our medical director showed us the typical anterior (2nd intercostal) and axillary placement. He said that as long as it is performed in the apice of the lung you don't have to be precise with it being 2nd intercostal... if its 3rd or 4th its all good as long as u observe correct procedure. 

If you cant or dont feel comfortable with anterior placement due to trauma to the anterior chest then I would go for axillary placement. If its a tension then it needs decompressed now. So regardless if its anterior or axillary, it needs done. Of course follow ur protocols and seek medical direction if need be... my protocols do not address location to decompress.


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## Veneficus (Mar 7, 2011)

18G said:


> As far as the comments on the abbreviations, etc... I think they are out of line. People need to understand that the generation of today was brought up with the Internet, texting, hand-held devices, etc. This is all very natural to them and is as common to them as a pencil and paper is to you. It is what it is and  they aren't gonna change for you. I understood the OP's questions perfectly.



I agree with your statement, but I would just like to point out that right or wrong, fair or biased, in every English speaking country and a few  that aren't, judge a person's intelligence and ability by their proficency with the language. 

Poor use of the language can cost opportunities and close doors. Especially when many of the decision makers are still older than I am and in their values, proper language is a must. 

Competition is tough, why take any chances that could eliminate you?



18G said:


> If you cant or dont feel comfortable with anterior placement due to trauma to the anterior chest then I would go for axillary placement. If its a tension then it needs decompressed now. So regardless if its anterior or axillary, it needs done. Of course follow ur protocols and seek medical direction if need be... my protocols do not address location to decompress.



In massive pneumo, tension or not, one needle will not be enough, so demanding one specific placement seems like a poor idea.


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## Firemanfred55 (Mar 7, 2011)

BLS before ALS, occlusive dressing tape on three sides. If you notice tracheal deviation burp it. If that doesn’t work than go ALS.


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## JPINFV (Mar 7, 2011)

18G said:


> As far as the comments on the abbreviations, etc... I think they are out of line. People need to understand that the generation of today was brought up with the Internet, texting, hand-held devices, etc. This is all very natural to them and is as common to them as a pencil and paper is to you. It is what it is and  they aren't gonna change for you. I understood the OP's questions perfectly.



As someone who grew up with the internet (if you remember 14.4 modems as a kid, then you fall into this group), I call BS. When you're communicating on a professional forum open to the public, what and how you write is a reflection both on yourself and the profession you're representing. 



> As the OP stated, he was typing on a hand-held device where abbreviations make it much easier to get your msg out. If you don't understand the abbreviations then I would recommend you come up to speed.


Strange, my phone is an old flip phone with a standard 12 key touch pad. When I text (I rarely do), I find it no problem to construct grammatically correct sentences with punctuation and full words in a rapid manner. It's not that hard with 12 keys, I can't imagine it's harder with a full keypad smart phone.


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## Veneficus (Mar 7, 2011)

Firemanfred55 said:


> BLS before ALS, occlusive dressing tape on three sides. If you notice tracheal deviation burp it. If that doesn’t work than go ALS.



Can you please tell me the purpose of this statement?

It looks like a reply to my statement that 1 needle is not going to be enough. 

In order to treat a significant pneumo definitively, it requires a chest tube, sometimes 2. The common size used is at least 28 french. Which if you convert to Metric is 9.3mm. A 14g catheter is 1.6mm. 

That means in order to get the same effect you would need (6) 14g needles because there is no way to insert 5.8 of them. If you were to use a larger french tube like a 32 it would require even more.

Since we know it takes less skill and less time to insert 6 needles into somebody's chest than it does to insert a chest tube for most providers, multiple needles is the choice in the prehospital setting, unless you have an extremely skilled provider putting in the tube. (I have seen senior surgeons do it in about 2 minutes.)

I have also witnessed the placement of a total of (5) 14g needles to the anterior chest in order to obtain clinically significant relief of bilateral pneumos in the field.


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## Firemanfred55 (Mar 7, 2011)

Veneficus said:


> Can you please tell me the purpose of this statement?
> 
> It looks like a reply to my statement that 1 needle is not going to be enough.
> 
> ...


My response was to the initial question. As far as chest tubes in the field, outside of flight medics I haven’t seen that happen.   When it comes to multiple 14 or 18g needles I’m fully aware of that.
So relaxes o wise one.


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## 18G (Mar 7, 2011)

Tracheal deviation is a late sign and one that is difficult to note in the field especially with a cervical collar in place. There are signs that appear much earlier and are more apparent then tracheal deviation.

I would not rely on trach deviation when deciding to lift the occulsive dressing.


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## usalsfyre (Mar 7, 2011)

Firemanfred55 said:


> BLS before ALS, occlusive dressing tape on three sides. If you notice tracheal deviation burp it. If that doesnt work than go ALS.



If I'm thinking tension pneumo, I'm probably not going to waste time burping a dressing


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## usalsfyre (Mar 7, 2011)

To the non-US providers (especially down-under), are all of your providers doing open thoracotomies or just the HEMS doctors?


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## usafmedic45 (Mar 7, 2011)

> To the non-US providers (especially down-under), are all of your providers doing open thoracotomies or just the HEMS doctors?



You mean thoraco_stomies_?  Right?  I don't know of anyone that allows a non-physician to do a field thorac_otomies_ (outside of some really sporty SF medical personnel)


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## usalsfyre (Mar 7, 2011)

usafmedic45 said:


> You mean thoraco_stomies_?  Right?  I don't know of anyone that allows a non-physician to do a field thorac_otomies_ (outside of some really sporty SF medical personnel)



Yep, thoracostomy is what I meant, dang my ADHD.

An open thoracotomy in the field would be uhhh, impressive to say the least...


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## usafmedic45 (Mar 7, 2011)

> An open thoracotomy in the field would be uhhh, impressive to say the least...



The location is secondary.  It's not the location that matters or the technical ability to do the thoracotomy itself, it's the judgment that it takes to make the decision whether to do the procedure and the skill and knowledge to deal with what you might find upon opening up the chest.  As one of my trauma surgeon friends put it, "Thoracotomies are like discussing your girlfriend's prowess in bed in front of her father.  Only do either if you really want to deal with the cluster:censored::censored::censored::censored: that might ensue."


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## MrBrown (Mar 7, 2011)

usalsfyre said:


> To the non-US providers (especially down-under), are all of your providers doing open thoracotomies or just the HEMS doctors?



Our Intensive Care Paramedics do needle thoracostomy (Turkel chest decompression) whereas the HEMS Doctors (in AU) can do an open thoracotomy.

Same with HEMS in London, they have published some research on it.


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## Veneficus (Mar 8, 2011)

18G said:


> Tracheal deviation is a late sign and one that is difficult to note in the field especially with a cervical collar in place. There are signs that appear much earlier and are more apparent then tracheal deviation.
> 
> I would not rely on trach deviation when deciding to lift the occulsive dressing.



I would like to dispell this rmor immediately as it is one of my pet peeves.

Gross tracheal deviation is a late sign.

Tracheal deviation is defined as movement of 3mm or more from the line between the symphisis of the mandible and the jugular notch. It is not a late sign, it is just one that has to be actively searched for by actually attempting to measure it.

I agree it is not a finding suitable for field work.


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## wdballer2431 (Mar 9, 2011)

I agree with the trachael deviation being a late sign. Better signs to look for would be tachypnea, absent lung sounds, and hypotention due to pressure in the plueral cavity causing a decrease in CO. Once again, sorry to anyone I offended with abbreviations, it is a forum not a job resume. I appreciate everyones opinions and feedback on treatment


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## Aidey (Mar 9, 2011)

wdballer2431 said:


> I agree with the trachael deviation being a late sign. Better signs to look for would be tachypnea, absent lung sounds, *and hypotention due to pressure in the plueral cavity causing a decrease in CO*. Once again, sorry to anyone I offended with abbreviations, it is a forum not a job resume. I appreciate everyones opinions and feedback on treatment




Huh?

Problem number 2 with abbreviations. Not everyone uses the same ones.


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## STXmedic (Mar 9, 2011)

wdballer2431 said:


> I agree with the trachael deviation being a late sign. Better signs to look for would be tachypnea, absent lung sounds, and hypotention due to pressure in the plueral cavity causing a decrease in CO. Once again, sorry to anyone I offended with abbreviations, it is a forum not a job resume. I appreciate everyones opinions and feedback on treatment



I like how you use the abbreviation for ease and quickness of writing, yet you then proceed to type out an entire sentence justifying it... Kind of defeats the purpose, huh?  Unless cardiac output is just too complicated to spell......


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## abckidsmom (Mar 9, 2011)

Aidey said:


> Huh?
> 
> Problem number 2 with abbreviations. Not everyone uses the same ones.




Cardiac Output.  It's pretty standard, especially when viewed in context of the conversation.

Those are the signs I look for as well.  If I'm worried about a tension pneumo, the patient is typically supine on a backboard.  No need to cause further discomfort to a dyspneic patient by digging in to palpate their trachea.

If I believe a person has a tension pneumo and is unconscious, I might palpate for a learning experience, or a "gee that's neat" kind of thing, but I don't believe it's a helpful enough sign to cause that added anxiety in a conscious patient.


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## wdballer2431 (Mar 9, 2011)

PoeticInjustice said:


> I like how you use the abbreviation for ease and quickness of writing, yet you then proceed to type out an entire sentence justifying it... Kind of defeats the purpose, huh?  Unless cardiac output is just too complicated to spell......



Like abckidsmom wrote, CO is a very standard abbreviation, especially in the context of how I used it. Maybe we shouldnt use Bp or Hr because those might be too complex for everyone to understand. Medicine has endless amounts of abbreivations, so stop harping on it when I write one.


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## STXmedic (Mar 9, 2011)

wdballer2431 said:


> Like abckidsmom wrote, CO is a very standard abbreviation, especially in the context of how I used it. Maybe we shouldnt use Bp or Hr because those might be too complex for everyone to understand. Medicine has endless amounts of abbreivations, so stop harping on it when I write one.



I'm not saying it's not. I knew exactly what you were referring to as soon as I read it. CO is absolutely an accepted abbreviation for cardiac output, especially in the context it was used. I use abbreviations all the time, and am guilty of sometimes even over-using them in my reports  I just found it funny, and slightly redundant, that you used an abbreviation (which is generally used to save space or write quickly) and then followed it up with an explanation/justification of it's use. Again, kind of defeats the purpose


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## Firemanfred55 (Mar 9, 2011)

usalsfyre said:


> If I'm thinking tension pneumo, I'm probably not going to waste time burping a dressing



gsw cover, burb,then ALS


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## Veneficus (Mar 9, 2011)

usalsfyre said:


> If I'm thinking tension pneumo, I'm probably not going to waste time burping a dressing



I must second this statement. 

Treat it and move on.


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## usalsfyre (Mar 9, 2011)

Firemanfred55 said:


> gsw cover, burb,then ALS



I'm probably going to cover with an occlusive taped on four sides, and needle PRN.


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## Smash (Mar 9, 2011)

Defib pads make great occlusive dressings for bigger/messier holes, just be sure to explain why they are in a strange place.  Never even heard of "burping" the dressing; I can't imagine that it is any use, and I would be getting out my pneumocaths anyway.  So I'll third usalsfyre's statement.


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## JPINFV (Mar 9, 2011)

Firemanfred55 said:


> gsw cover, burb,then ALS



Repeating yourself does not change anything...

Also, make sure to remind the physician to remember his "BLS" when he goes to put in a chest tube before burping the dressing. Please report back when you do.


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## usalsfyre (Mar 9, 2011)

Also worth repeating for the newer providers you need to be hypervigilant for signs of tension pneumo and ready to needle the chest anytime you provide PPV to a chest injury.


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## M3dicDO (Mar 9, 2011)

JPINFV said:


> Also, make sure to remind the physician to remember his "BLS" when he goes to put in a chest tube before burping the dressing. Please report back when you do.



LMFAO!:lol:


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## Melbourne MICA (Mar 9, 2011)

Smash said:


> Defib pads make great occlusive dressings for bigger/messier holes, just be sure to explain why they are in a strange place.  Never even heard of "burping" the dressing; I can't imagine that it is any use, and I would be getting out my pneumocaths anyway.  So I'll third usalsfyre's statement.



I love the idea of defib pads as big sticky dressings. Nice one smash.

As for decompression's - needle thoracostomy as described by others. Anterior chest placement as also indicated by others. We have also had instances of medial placement but also a few who don't slant the stilette towards the vertebrae - ie they go down too straight and miss altogether. One of my colleagues did exactly that just the other week - made for an interesting Xray. 

Still, if both officers check the placement and mark it correctly, it is hard to see why any of us stick that bloody great sharp pointy thing in the wrong spot given all those goodies lie in wait just below.

Still you know you are alive (as you can feel your own sphincter puckering) when you deliberately stab someone in the chest.

All good fun. A seriously useful procedure when its done properly.

MM


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## Mex EMT-I (Apr 15, 2011)

Hello.

As a non native english speaker could someone give me a hand and explain to me the term:

"burping the dressing"

It really caught my attention and i don´t know what you reffer to when you speak of it.

Thanks a lot.


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## Shishkabob (Apr 15, 2011)

It means releasing one of the sides of the dressing to allow the pressure to be relieved.


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