# Needle vs Finger Thoracostomy in the Wilderness



## Summit (Jun 29, 2018)

Thoracostomy for tension ptx... the evidence and debate is out there:

Needles not penetrating, needle complications, needle collapse/occlusion vs simple complications...

https://www.ems1.com/ems-products/m...-the-chest-Evolution-in-needle-decompression/
https://www.ncbi.nlm.nih.gov/pubmed/26807605
https://www.jems.com/articles/print...simple-thoracostomy-moving-beyond-needle.html
https://emcrit.org/emcrit/needle-finger-thoracostomy/
https://adventuredoc.wordpress.com/2013/01/01/finger-thoracostomy-and-pneumothorax/
http://www.scancrit.com/2012/07/31/tension-pneumothorax-needle-knif/

*What does your agency use? *

*Simple?* Scalpel and forceps?
*Needle?* 14ga 2" IV? 10ga 3.25" angio? Cook? Turkel? Enhanced Ptx Needle? PneumoFix?
*Tube?* Are you placing chest tubes?

While I have only used angios and assisted with CTs, I've practiced simple, CT, and angio on cadaver. The Turkel strikes me as the best tool, just not for the wilderness (maybe for organized rescue if packaged differently). Enhanced Ptx seems like an improvement over a normal 10ga angio for the side of a trail...






*Do you maintain this capability in your personal kit for friends and family?*

Life-or-death, antiseptic, a sharp knife and a glove does accomplish the brutally simple procedure that is a simple.

Share your thoughts, experience, and perspective


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## Peak (Jun 29, 2018)

My thoughts are that in the wilderness I don't pack a CT drain, and even if I did I would be limited by the battery power on the suction unit that we have. As an adjunct to immediate transport it may have some validity but with any extended scene time may become a bigger problem than a benefit. 

Finger thoracostomy is very effective however you need to have a positive pressure airway or figure out how to make an effective one way chest seal, the latter of which is easier said than done. In a dirty wilderness environment it is also huge vector for infectious disease, even if performed under aseptic technique. 

Needle decompression, whether performed with an angio, butterfly, or any of the other marketed products do have a lot of limitation. While many providers in the ED, OR, and critical care are transitioning towards pigtails these are generally for simple pneumothorax. These pigtail catheters do not perform well with hemothorax. In my experience the needle devices only exacerbate the same problem. Of course the body habitus of our larger patients may also prevent correct placement of a needle device, especially if using 1.75" 14s. 

In the prehospital enviorment I have only ever used needle type devices. For neonates I use a 23 guage butterfly with a sryinge or 24 guage angio with a stopcock, infants I use a 22, toddlers get a 20, and everyone else earns a 14 guage. Most of my needle decompression have been on thinner patients so I haven't had as much of an issue with obesity, the number one issue is from the angio getting clotted off by a hemothorax, I just place another one next to it. In a trauma arrest I can see benefit to thoracostomy, but then the debate becomes how much you are going to carrying into a true wilderness environment.


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## VFlutter (Jun 29, 2018)

Needle decompression is our primary treatment. We are allowed to "assist" with Chest Tubes, realistically placing them ourselves with MD permission, but do not carry them.

The 10g 3.25 NAR needles work great and do not clot off as quickly as the 14g. If they do, just place another and go Lateral. I have done many needle compressions in the field, just sure you have the appropriate needles and the correct landmarks and you are fine. If you are in a truly austere environment you can reuse the needle (not catheter) multiple times.  

I do carry decompression needles in my kits since I carry a gun and go to the range a lot. Also do have a scalpel in my main kit but don't plan on doing a thorocostomy on anyone.

Finger thoracostomies are great in the peri-arrest/arrest patient however not sure i'd use it as my primary treatment. And you better be confident it is a pneumo and not a hemopneumo or you may cause more harm than good. At least you can cap a needle.


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## Tigger (Jun 30, 2018)

3.25" 10ga catheter here. There was some talk about finger thoracotomies but that's pretty far down the waiver list. We keep six in the ambulance so even if it does clot off, there's another. I keep some in my own bags too, there are few things you can really help a seriously injured backcountry enthusiast, a tension pneumo is one. All the better that our medical director encourages that sort of thing.


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## Summit (Jun 30, 2018)

For my personal bag, I have a pair of 10ga 3.25" as I spend most of my time outside doing things that involve gravity, speed, rocks, and trees, and, as @Tigger points out, "there are few things you can really help a seriously injured backcountry enthusiast, a tension pneumo is one."



Peak said:


> Finger thoracostomy is very effective however you need to have a positive pressure airway or figure out how to make an effective one way chest seal, the latter of which is easier said than done. In a dirty wilderness environment it is also huge vector for infectious disease, even if performed under aseptic technique.


I think a seal is quite doable. The massive infection risk is a huge potential problem. It is almost guaranteed since in an extended extrication, it will likely be necessary to open up that seal and stick your finger back in there to re-release/drain and most of us don't have have stacks of sterile gloves and chloarprep on the trail.  Of course, an empyema is not as bad as death... but the question is what is the best intervention? I don't think it is a finger thora in the wilderness unless it is all you have and they are peri-arrest.



> Needle decompression, whether performed with an angio, butterfly, or any of the other marketed products do have a lot of limitation. ... These pigtail catheters do not perform well with hemothorax.


Indeed, even with a syringe and a 10ga 3.25", you can't really expect to effectively drain a hemothorax much, or at all, depending on location of the needle and the bleed, plus the age of the injury (a little clotting may mean you get nothing). These people need a properly placed tube thoracostomy and a pleurevac, something they can't get in the wilderness.

But who do we consider an invasive chest procedure on in the wilderness? Tension. That's it. They have to be in extremis to warrant it. Tension ptx is correctable.

But if they are in extremis from a htx or the haemo component of a hptx, they are probably in hemorrhagic shock, yes? And that shock is likely to progress. In a wilderness setting with a significant extrication time, they likely have an extraordinarily poor prognosis even if you release tension, wouldn't you agree?



> In my experience the needle devices only exacerbate the same problem.


Can you expound on needles exacerbating the hemothorax in a significant way?



VFlutter said:


> If you are in a truly austere environment you can reuse the needle (not catheter) multiple times.



Yes indeed


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## VFlutter (Jun 30, 2018)

I always wondered if you could rig up a JP drain or something to a needle thoracostomy to provide a little suction to prevent the catheter from clotting off.


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## Summit (Jun 30, 2018)

VFlutter said:


> I always wondered if you could rig up a JP drain or something to a needle thoracostomy to provide a little suction to prevent the catheter from clotting off.


I am sure that we could find a luer adapter, but who would carry a JP? You can supply intermittent sxn with a syringe... Of course if the catheter collapses or aspirates a clot...


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## Carlos Danger (Jun 30, 2018)

Interesting question. Timely for me as my brother and I (and potentially a couple friends) are in the early stages of planning a cross-country, mostly off-road motorcycle trip.   

My philosophy about backcountry care, or care anywhere that trained help and equipment is potentially several hours away, has always been that any invasive intervention is impractical and likely to be ultimately unsuccessful in a severely traumatized patient. Bleeding control and stabilization of fractures is pretty much all you can do, realistically. Accordingly, I've always felt like no matter how highly trained you are, carrying anything above basic bandaging and splinting supplies (and maybe an epi-pen and a few other basic meds) is probably unnecessary. And since those things can mostly be improvised, carrying a formal first aid kit is something that I've mostly felt was unnecessary. Unless, of course, you are carrying a full medical kit that has almost everything you'd find on an ALS ambulance minus the monitor / defibrillator. But even then you probably aren't well equipped to provide care to a severely injured person for more than a fairly short time. As we all know, trauma is primarily a surgical problem.

The tension pneumo thing makes sense, though. It's a common complication of thoracic trauma and as you guys say, potentially completely reversible without heavy, bulky, or sophisticated equipment. 

I guess not a very contributory post; just saying that I'm interested in hearing what you guys come up with. I'm not all that up on the newer devices that are being deployed for prehospital use.


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## Summit (Jun 30, 2018)

Remi said:


> My philosophy about backcountry care... carrying anything above basic bandaging and splinting supplies (and maybe an epi-pen and a few other basic meds) is probably unnecessary. And since those things can mostly be improvised, carrying a formal first aid kit is something that I've mostly felt was unnecessary.



I think this would be a fun thread on its own!


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## E tank (Jun 30, 2018)

Remi said:


> My philosophy about backcountry care, or care anywhere that trained help and equipment is potentially several hours away, has always been that any invasive intervention is impractical and likely to be ultimately unsuccessful in a severely traumatized patient. Bleeding control and stabilization of fractures is pretty much all you can do, realistically. Accordingly, I've always felt like no matter how highly trained you are, carrying anything above basic bandaging and splinting supplies (and maybe an epi-pen and a few other basic meds) is probably unnecessary. And since those things can mostly be improvised, carrying a formal first aid kit is something that I've mostly felt was unnecessary. Unless, of course, you are carrying a full medical kit that has almost everything you'd find on an ALS ambulance minus the monitor / defibrillator. But even then you probably aren't well equipped to provide care to a severely injured person for more than a fairly short time. As we all know, trauma is primarily a surgical problem.
> 
> The tension pneumo thing makes sense, though. It's a common complication of thoracic trauma and as you guys say, potentially completely reversible without heavy, bulky, or sophisticated equipment.



Agree...even with the tension pneumo thing, the odds of it not involving hemothorax is pretty low. Like someone else said above, blood just clots off any conduit you'd have and, after all, a surgeon stops bleeding unless you run out of blood. The most effective factor someone can bring to remote trauma is youth.


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## Summit (Jun 30, 2018)

E tank said:


> The most effective factor someone can bring to remote trauma is youth.


That doesn't fit in a backpack. Temporizing measures do.


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## VFlutter (Jun 30, 2018)

Summit said:


> That doesn't fit in a backpack. Temporizing measures do.



Decent GPS for LZ coordinates...


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## Summit (Jun 30, 2018)

VFlutter said:


> Decent GPS for LZ coordinates...


InReach or a PLB


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## E tank (Jun 30, 2018)

Summit said:


> That doesn't fit in a backpack. Temporizing measures do.



 uhhh....thanks...I was just pointing out that a thoracostomy in a 65 year old is something entirely different than a thoracostomy in a 25 year old when you're 2 hours from a trauma center. I'll keep in mind the backpack thing though...


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## E tank (Jun 30, 2018)

VFlutter said:


> Decent GPS for LZ coordinates...



Just went fishing/camping/mountain-ing with a couple of pre-teens where an emergency, civilian use  SO radio was about a half hour away. My Garmin device was only of use in marking excellent elk camp sites. Crappy part was that the radio was at least 60-45 minutes from a reasonable LZ in the other direction.

Bottom line is don't have multisystem trauma when you're off the grid, and if you do, make sure you're under 40 years old.


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## Peak (Jul 1, 2018)

Summit said:


> Indeed, even with a syringe and a 10ga 3.25", you can't really expect to effectively drain a hemothorax much, or at all, depending on location of the needle and the bleed, plus the age of the injury (a little clotting may mean you get nothing). These people need a properly placed tube thoracostomy and a pleurevac, something they can't get in the wilderness.
> 
> But who do we consider an invasive chest procedure on in the wilderness? Tension. That's it. They have to be in extremis to warrant it. Tension ptx is correctable.
> 
> But if they are in extremis from a htx or the haemo component of a hptx, they are probably in hemorrhagic shock, yes? And that shock is likely to progress. In a wilderness setting with a significant extrication time, they likely have an extraordinarily poor prognosis even if you release tension, wouldn't you agree?



I've had them clot off from even a small amount of blood that wasn't a significant source of bleeding but did prevent the evacuation of air in a pneumothorax.  I agree that draining large hemothorax without replacement products isn't a recipe for success, these patients often don't face a great outcome with any significant response/transport time from a good trauma receiving team.



Summit said:


> Can you expound on needles exacerbating the hemothorax in a significant way?



Sorry, my statement wasn't well worded. What I meant was that in my experience the angiocaths clot off more quickly and more often than the pigtail catheters and similar products that are used in in the hospital.


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## Summit (Jul 1, 2018)

Has anyone tried to syringe insufflate 1-3ml of air to clear a clotted cath? Never heard such an idea discussed but it seems perfectly logical. It probably won't help if the angiocath has collapsed, but it seems reasonable and lower risk than jumping to another poke.


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## Carlos Danger (Jul 1, 2018)

Summit said:


> Has anyone tried to syringe insufflate 1-3ml of air to clear a clotted cath? Never heard such an idea discussed but it seems perfectly logical. It probably won't help if the angiocath has collapsed, but it seems reasonable and lower risk than jumping to another poke.


I would guess that saline would work better than air.


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## Summit (Jul 1, 2018)

Remi said:


> I would guess that saline would work better than air.


That makes sense... many flushes in the truck, not so much in the pack.


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## inthefield (Jul 6, 2018)

Needle in the mid-clavicular line. There has been increasing discussion of putting them into the lateral chest but no policy changes as of yet


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