# tension pneumo + hypotension



## zzyzx (May 4, 2012)

Several EMS systems here in California have adjusted their protocols for needle decompression by saying that the medic can only decompress (w/o an order) when hypotension if present. 

It's been my understanding that hypotension in a tension pneumo is a very late sign. Isn't this correct?

Apparently these protocol changes have been made because there's been a large percentage of needle T's done on patients who didn't in fact have a pneumo.


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## DallasFireRescueMedic (May 4, 2012)

Since your question is related to hypotension, I think you mean a Hemothorax as opposed to a Pneumothorax. Anyway, I'm with you. Although the thoracic cavity can hold a substantial amount of blood, I would think a person with a hemo or hemo/pneumo is likely circling the drain even prior to presenting with hypotension.

Let's visualize what they are asking... You've got an 18yr old PT drowning in his own blood and by all indications, he has pneumo. They want you to stand over him with a needle waiting for his BP to drop low enough for you to stick him? Heck, why not just wait until he goes into cardiac arrest so you can be 100% certain he even needs medical attention.

My insignificant opinion would be to train on how to better diagnose the problem rather than wait until you have multiple problems on your hands, i.e. - hypotention.


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## Akulahawk (May 4, 2012)

I would say it more like this: in those systems, a Paramedic may only decompress a tension pneumo on standing order in the presence of hypotension.


Yes, it's a late sign, but probably not so late as tracheal deviation...

For example, Sacramento's protocol is (under Trauma) 



> If all the following are present in a patient:
> 1. Severe respiratory distress.
> 2. SBP less than 90 mmHg or loss of radial pulse due to shock.
> 3. Unilateral decreased breath sounds with a history of chest trauma.


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## mycrofft (May 4, 2012)

Welcome back!
Read this (Merck Manual):

http://www.merckmanuals.com/profess...tinal_and_pleural_disorders/pneumothorax.html

"Tension pneumothorax is suspected in patients with sudden, unexplained hypotension and dyspnea or some risk factor, particularly positive pressure ventilation. If such a patient also has signs of pneumothorax, such as decreased breath sounds and hyperresonance to percussion, tension pneumothorax should be assumed". 

Tx: immediate needle decompression, oxygen admin, and stuff better done in hospital (chest tubes, observation and CXR).


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## Handsome Robb (May 5, 2012)

DallasFireRescueMedic said:


> Since your question is related to hypotension, I think you mean a Hemothorax as opposed to a Pneumothorax. Anyway, I'm with you. Although the thoracic cavity can hold a substantial amount of blood, I would think a person with a hemo or hemo/pneumo is likely circling the drain even prior to presenting with hypotension.
> 
> Let's visualize what they are asking... You've got an 18yr old PT drowning in his own blood and by all indications, he has pneumo. They want you to stand over him with a needle waiting for his BP to drop low enough for you to stick him? Heck, why not just wait until he goes into cardiac arrest so you can be 100% certain he even needs medical attention.
> 
> My insignificant opinion would be to train on how to better diagnose the problem rather than wait until you have multiple problems on your hands, i.e. - hypotention.



A tension pneumo most definitely can cause hypotension, doesn't have to be a hemopneumo or hemothorax.

If they do have the hemo or hemopneumo do you think a 14g angiocath is going to actually do anything for that person's condition?

I'm sure you know that since I'm assuming you've been around longer than me.


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## usalsfyre (May 5, 2012)

The defining characteristic between a large, but still simple pneumo and one that has tensioned tends to be hypotension, as a tension pneumo will kink the IVC.  



DallasFireRescueMedic said:


> Since your question is related to hypotension, I think you mean a Hemothorax as opposed to a Pneumothorax. Anyway, I'm with you. Although the thoracic cavity can hold a substantial amount of blood, I would think a person with a hemo or hemo/pneumo is likely circling the drain even prior to presenting with hypotension.


First, there's no such thing as a "tension hemo". It would take more blood than is currently circulating in the body. 



DallasFireRescueMedic said:


> Let's visualize what they are asking... You've got an 18yr old PT drowning in his own blood and by all indications, he has pneumo.


If it's a hemothorax, they won't be "drowning in their own blood". A hemothorax is in the pleural space which is outside of the lung parenchyma and therefore not subject to blood entering the alveolar space. A pulmonary contusion, where there is blood in the alveolar space, is not helped by a needle because the needle stays in the pleural space. They need suction and PEEP. 



DallasFireRescueMedic said:


> They want you to stand over him with a needle waiting for his BP to drop low enough for you to stick him? Heck, why not just wait until he goes into cardiac arrest so you can be 100% certain he even needs medical attention.


Needle decompression is not indicated for hemothorax, it won't help. A tube thoracostomy is, but that's clamped after so much blood return is noted because as you note, the thoracic cavity holds a decent amount of blood. It's very possible for (and I've seen) a patient exanguante on to a trauma room floor post thoracostomy. 



DallasFireRescueMedic said:


> My insignificant opinion would be to train on how to better diagnose the problem rather than wait until you have multiple problems on your hands, i.e. - hypotention.


As I said before, hypotension is the hallmark sign between simple vs tension pneumo. When decompressed, they get instantly better in most cases.


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## mycrofft (May 5, 2012)

How about auscultative signs? Blood doesn't sound like air, and mechanism suggests diagnosis. (Ditto other clinical signs, since haemo by itself won't progress to a deviated cryc, it tends to kill first, right?).

Maybe a good assessment could one day be considered basis for a needle decompression, except it is really more of a "recon in force"; if it's a pneumo, good start. If it's a haemo, then withdraw the needle and go for Alternative 2. 
In those cases a portable ultrasound does start to sound good, even to me.


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## Shishkabob (May 5, 2012)

zzyzx said:


> Several EMS systems here in California have adjusted their protocols for needle decompression by saying that the medic can only decompress (w/o an order) when hypotension if present.
> 
> It's been my understanding that hypotension in a tension pneumo is a very late sign. Isn't this correct?



Late sign?  Sure... but that's really the only time it needs to be done anyhow (usually seen along with severely increased ventilatory effort and crappy sats).  Not all pneumos become tension pneumos, and having a pneumothorax without the tension aspect isn't that big of a deal.  All they'll get at the hospital is a chest x-ray and a lookey-loo.


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## mycrofft (May 5, 2012)

Yeah. In fact, a not-uncommon sequelum to a pneumothorax is other, usually smaller, pneumothoraces. ("-thoraxes"?).


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## MSDeltaFlt (May 5, 2012)

zzyzx said:


> Several EMS systems here in California have adjusted their protocols for needle decompression by saying that the medic can only decompress (w/o an order) when hypotension if present.
> 
> It's been my understanding that hypotension in a tension pneumo is a very late sign. Isn't this correct?
> 
> Apparently these protocol changes have been made because there's been a large percentage of needle T's done on patients who didn't in fact have a pneumo.



Yes, zzyzx my friend, it is a late sign.  And, unfortunately, you are in the same boat as myself. You are apparently a victim of the weakest link(s).  Because some of your colleagues have been promoted beyond their abilities, everyone must suffer the consequences.


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## FLdoc2011 (May 5, 2012)

Honestly that's how I think it should be pre-hospital.  Certainly risks to it and if hemodynamically stable then supportive care until you can get them to an ER to verify a PTX where a tube thoracostomy can be performed.   

I've had to do a few needle decompressions here in the hospital even before X-ray has a chance to get there only because they were hemodynamically unstable with other risk factors so it was pretty obvious, but even then it was a little nerve wrecking.    

Like others have side, it's not the tx choice for hemothorax.  And if they're not actively crashing/unstable then they can prob wait a little for the hospital.  If unstable/hypotension then it can be life saving, go for it,  if not then it would extremely poor form to do it and hit an artery and add to the problem.


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## Smash (May 5, 2012)

I have no real issue with waiting for hemodynamic compromise or respiratory distress.  I wouldn't necessarily wait for frank hypotension per se, but deteriorating hemodynamics in the setting of presumed pneumothorax is not unreasonable (assuming other factors are taken care of, or are being taken care of)

The trouble with the traditional signs of pneumothorax is that they are all either late or very subtle.  Auscultation is unreliable and tracheal deviation is usually very subtle. 
If respiratory/hemodynamic compromise is present we are pretty aggressive with decompressing, but there does have to be suspicion first, and some compromise second.

If the patient has a simple pneumothorax that has not converted to a tension pneumothorax, I don't see the benefit in poking more holes in them.  Wait until a proper chest tube can be placed (unless extenuating circumstances such as aeromedical evacuation are present)  Like FLdoc says, it's pretty bad when someone without a tension gets a needle through their internal mammary for no reason.


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## Doczilla (May 5, 2012)

Anyone remember the saying "people don't suddenly crash, people suddenly notice"? 

Hypotension takes the back burner to airway in this case. You'll see low sats, poor compliance, and shallow end-inspiration before you see hypotension in my experience. If hypotension if your "clue", then you've been missing a whole lot before that. Also,with cocominant injuries, the hypotension may be completely unrelated.


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## Veneficus (May 5, 2012)

*Tracheal deviation as a late sign drives me nuts*



Smash said:


> The trouble with the traditional signs of pneumothorax is that they are all either late or very subtle.  Auscultation is unreliable and tracheal deviation is usually very subtle. .



Thank you...

Everytime I see somebody claim tracheal deviation as a late sign makes me want to manually deviate their trachea. 

I have tried to hunt down the source of this misinformation and nearly a decade ago actually figured I narrowed down to where it comes from.

In many US paramedic texts, there are quotes out of context from actual medical textbooks. (with the language usually dumbed down) In this particular case, "tracheal deviation" as a sign was kept, but the definition was not, from surgical textbooks of the 70s and 80s.

Tracheal deviation is defined as 3mm or more from an imaginary line between the mental symphysis and the center of the suprasternal notch. It is not a late sign.

Even under the best of circumstances is difficult to detect and assumes normal fusion of the mandible and no variation in sternal position. However, using a piece of suture (I was taught how to look for it by an old school surgeon in the US) or another type of plane can help greatly in measuring. 

The gross deviation which everyone imagines as "tracheal deviation" is a late sign, but by the time you actually see it, you really missed many earlier signs or you didn't get to the patient in time to really help. This seems to be what is passed down through EMS education but it is definately not the full story.

Perhaps the people who perpetuate it thought they figured out an obvious error that surgeons overlooked?


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## Akulahawk (May 5, 2012)

Doczilla said:


> Anyone remember the saying "people don't suddenly crash, people suddenly notice"?
> 
> Hypotension takes the back burner to airway in this case. You'll see low sats, poor compliance, and shallow end-inspiration before you see hypotension in my experience. If hypotension if your "clue", then you've been missing a whole lot before that. Also,with cocominant injuries, the hypotension may be completely unrelated.


Unfortunately, until recently (past 10 years or less), the protocols I saw for treating tension pneumo were all keyed to tracheal deviation... Never mind that we were also taught those other signs for pneumothorax. We just weren't allowed to do a needle thoracostomy unless/until those signs _and_ tracheal deviation occurred. The other thing that "they" drummed into our heads is that if we do a needle thoracostomy and the patient didn't have a pneumo or it wasn't bad enough yet, we just put the patient right down the path to a chest tube if the patient wasn't going to need one...


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## medicsb (May 5, 2012)

Veneficus said:


> Thank you...
> Tracheal deviation is defined as 3mm or more from an imaginary line between the mental symphysis and the center of the suprasternal notch. It is not a late sign.



I'd like to meet a physician who can reliably detect a 3mm deviation of the trachea without a radiograph.


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## Dwindlin (May 5, 2012)

medicsb said:


> I'd like to meet a physician who can reliably detect a 3mm deviation of the trachea without a radiograph.



Or one that cares about 3mm. . .


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## medicsb (May 5, 2012)

Dwindlin said:


> Or one that cares about 3mm. . .



Hah, or that.


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## OzAmbo (May 5, 2012)

Pneumothoracies will always have a degree of tensioning, whether they have enough to be clinically significant is a different story but its not possible to have free air in the pleural space without it being equal ot or greater than the atmosphere as the drawn in by negative pressure and then not allowed to escape.

Im surprised that you would have to wait for them to become so compromised before you intervene, toying with a respiratory arrest after they become hypoxic or intervening when the signs of poor perfusion are becoming evident i would have thought earlry intervention would be better than chasing the eight ball once they are ready to drop their bundle.


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## Veneficus (May 6, 2012)

medicsb said:


> I'd like to meet a physician who can reliably detect a 3mm deviation of the trachea without a radiograph.



Since I was taught to do it by a surgeon, I would say it is rather easy, without a radiograph. But does require something to measure with.

While radiographs are a great tool, it is important to be able to function and make decisions when they are not available.  (austere environments, disasters, etc.) 

Doctors who don't care?

They are found everywhere, that is a problem beyond my ability to solve.

Doctors who require large amounts of technology to function because of their lack of knowledge should probably not advertize that too loudly.

But it does not excuse the perpetuation of inaccurate teaching.


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## Melclin (May 6, 2012)

Veneficus said:


> Thank you...
> 
> Everytime I see somebody claim tracheal deviation as a late sign makes me want to manually deviate their trachea.
> 
> ...



Is it really practical to be identifying such subtle changes in many prehospital environments (actual question, not rhetorical)? I get that its our job to be turning chaos into order to a degree, but there is a limit. You take a major trauma pt. Blunt pelvic, abdominal and chest trauma. They're proper sick but you don't quite have all the hands or space your need. You're pouring morphine into them but you're still not quite on top of their pain yet. They're moving about a lot. Screaming/talking/moaning. You feel like you're on top of most of the picture. They weren't obviously tensioning when you started but they've had a bit of fluid because you've been chasing some some ?pelvic trauma related haemodynamic instability, and they're still a bit dicey in that way. Their O2 sats drop a bit but you have to trouble shoot some pleth waveform issues on top of everything else. At some stage you have to move or are already moving down a bumpy road, rocking and rolling around in the back. I'm completely open to the idea that I might be wrong and that I should be managing my time better or something, but I just can't see a lot subtly happening in that environment, with the exception of some special situations.




> Im surprised that you would have to wait for them to become so compromised before you intervene, toying with a respiratory arrest after they become hypoxic or intervening when the signs of poor perfusion are becoming evident i would have thought earlry intervention would be better than chasing the eight ball once they are ready to drop their bundle.



Yeah but the 'lowest common denominator' argument come in here. If you are captain of the good ship clinical practice guideline and you're sitting in the captain's chair one day thinking, "I've a ship's company of almost 3000. Some of them are barely capable of keeping their drool in the mouth. How do I go about proticolizing the sticking of large, sharp pieces of metal into an already profoundly sick person's chest?" Then the answer is probably, "when its painfully obvious that its needed".


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## Veneficus (May 6, 2012)

Melclin said:


> Is it really practical to be identifying such subtle changes in many prehospital environments (actual question, not rhetorical)? I get that its our job to be turning chaos into order to a degree, but there is a limit. You take a major trauma pt. Blunt pelvic, abdominal and chest trauma. They're proper sick but you don't quite have all the hands or space your need. You're pouring morphine into them but you're still not quite on top of their pain yet. They're moving about a lot. Screaming/talking/moaning. You feel like you're on top of most of the picture. They weren't obviously tensioning when you started but they've had a bit of fluid because you've been chasing some some ?pelvic trauma related haemodynamic instability, and they're still a bit dicey in that way. Their O2 sats drop a bit but you have to trouble shoot some pleth waveform issues on top of everything else. At some stage you have to move or are already moving down a bumpy road, rocking and rolling around in the back. I'm completely open to the idea that I might be wrong and that I should be managing my time better or something, but I just can't see a lot subtly happening in that environment, with the exception of some special situations.



Medical answer: it depends.

If you have a seriously crashing patient that is the focus of all of your efforts, taking time to measure for tracheal deviation is on my list at about the same priority level as what I plan to do for lunch after the call. (actually slightly lower)

I also wouldn't be too concerned with tracheal deviation when transport time is only a few minutes. But when you start to get in the 45+ minute range, I don't like surprises.

But, when your scenario changes to being soley responsible for airway and breathing, then using clinical skills to anticipate and prepare for ongoing complications is certainly indicated. Especially if all you are doing is squeezing the bag. If you are tasked with managing an airway, you should do it 100%.

Not all pneumos present in multitrauma and even when they do, they most often appear over time, not on initial patient contact. Perhaps the population I have seen the most pneumos in during street time is people who were assaulted with fists and feet. So when you are evaluating a person who looks hemodynamically stable and you are deciding if you are going to turf him to a lower level of care or leave him onscene to his own devices, a little bit of clinical accumen may go a long way.

In major incidents, it is a tool of retriage and reassesment in anticipating your future transport and resource needs.

In austere conditions, I think the ability to function without dependancy on technological resources is absolutely a must.

Personally, I am a reformed sinner, when I was being taught these "primitive" techniques, I was quick to complain and point out all the modern wonders of technology.

But having worked in disasters, with indigent populations who could not afford such technology, and in austere conditions, I am more than sold on the need to have these "archaic" skills.

I have adopted the philosophy of a few of my teachers that anyone can use technology, but knowing what to do when you don't have it and being able to apply that knowledge is really what seperates the men from the boys.

Technology should amplify ability, not replace it. 

(But I would still be grateful if anyone would buy me one of those pocket sized ultrasounds for whatever holiday or occasion strikes you) 




Melclin said:


> Yeah but the 'lowest common denominator' argument come in here. If you are captain of the good ship clinical practice guideline and you're sitting in the captain's chair one day thinking, "I've a ship's company of almost 3000. Some of them are barely capable of keeping their drool in the mouth. How do I go about proticolizing the sticking of large, sharp pieces of metal into an already profoundly sick person's chest?" Then the answer is probably, "when its painfully obvious that its needed".



When it comes to trauma, I think EMS providers are not responsible for a majority of blame from lack of knowledge or ability.

Trauma is an extremely broad and complicated medical topic. Rather than spend the time this topic deserves most providers (including non EMS trauma providers) are often given some very basic procedures to follow rather than have them start weighing decisions.

US EMS, not only because of educational time components, but because of the system philopsophy, really gets short changed to basically "just drive." They also face the complication of not having dedicated rotation time at a major trauma facility. 

So they are basically set up to fail. If you don't regularly see major trauma, even minor stuff looks very severe to you. It is set up for the error of overtreatment. 

As far as I recall, in the US, paramedics are expected to diagnose and treat tention pneumo. Implying there is already tension present. 

They are not expected to decompress simple pneumo because if it is not major, (usually accepted as greater than 16%)  watchful waiting to see if it self limits is a valid treatment. It doesn't automatically equate to a chest tube.

Of course when a chest tube is required, its utility is undisputed.


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## Dwindlin (May 6, 2012)

Veneficus said:


> Doctors who don't care?
> 
> They are found everywhere, that is a problem beyond my ability to solve.
> 
> ...



Yes, yes. We all know US docs are helpless/worthless without our beloved technology.  My point was 3mm of deviation is nothing, that could be purely physiologic and normal.  And I was unable to find any text that defined deviation as 3mm or greater (searched AccessMedicine, AccessSurgery, AccessEmergencyMedicine, and MDConsult).  So if you provide some links to this reference I would love to see it.

Edit:  I did not check pubmed, as I was simply curious what was in teaching text, before someone brings up that I didn't look everywhere, that was intentional.  For those that are unaware the resources I listed above are online collections of many of the major medical/surgical texts that are available that are searchable.


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## OzAmbo (May 6, 2012)

Melclin said:


> Yeah but the 'lowest common denominator' argument come in here. If you are captain of the good ship clinical practice guideline and you're sitting in the captain's chair one day thinking, "I've a ship's company of almost 3000. Some of them are barely capable of keeping their drool in the mouth. How do I go about proticolizing the sticking of large, sharp pieces of metal into an already profoundly sick person's chest?" Then the answer is probably, "when its painfully obvious that its needed".


In our case mate, the good ship CPG is a lot more aggressive than the lowest common denominator realise.


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## Veneficus (May 6, 2012)

Dwindlin said:


> Yes, yes. We all know US docs are helpless/worthless without our beloved technology..



It seems more so with every passing day and post about just x-ray or CT. 

But the deviation as I mentioned before I learned from a US surgeon. I'll PM you his info.



Dwindlin said:


> My point was 3mm of deviation is nothing, that could be purely physiologic and normal.  And I was unable to find any text that defined deviation as 3mm or greater (searched AccessMedicine, AccessSurgery, AccessEmergencyMedicine, and MDConsult).  So if you provide some links to this reference I would love to see it..



In just a quick google search I found articles in radiology, ENT, pediatrics, endocrinology, C/T surgery, anesthesia, and oncology as 3mm or greater being considered tracheal deviation in an adult and 5mm in children. (I didn't know about the child measurement before the search.) 

I am going to simply conclude this is a general rule of deviation and not specific to tensionpneumo.



Dwindlin said:


> Edit:  I did not check pubmed, as I was simply curious what was in teaching text, before someone brings up that I didn't look everywhere, that was intentional.  For those that are unaware the resources I listed above are online collections of many of the major medical/surgical texts that are available that are searchable.



Should the articles not suffice, I can look through the library next time I am there. I don't have access to searchable texts other than the current editions of the ones I own.


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## Doczilla (May 6, 2012)

I dunno, I just think that through training and experience, you gain the ability to use the clinical picture to figure it out. When someone tries to tie your hands about making a judgement call based one ONE sign that may or may not be related to a pneumo, thats a paranoid "mother may I " system. 

But then, its California


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## medicsb (May 6, 2012)

Veneficus said:


> Since I was taught to do it by a surgeon, I would say it is rather easy, without a radiograph. But does require something to measure with.



I am highly skeptical of your anecdote, especially considering the wide variation in body habitus.  Maybe with some "cream skimming" of low BMI patients, I could believe it.  But, even if it is possible that a physician can reliably identify a deviation of "3mm", would it even mean anything?  

Considering the variation in human anatomy, it would seem that 3mm deviation is probably a relatively normal variant and probably useless during the exam of a patient with a suspected pneumothorax.  Is this definition based on any empirical data or is it just the traditional teaching established by someone decades ago based on their opinion?


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## Veneficus (May 6, 2012)

medicsb said:


> I am highly skeptical of your anecdote, especially considering the wide variation in body habitus.  Maybe with some "cream skimming" of low BMI patients, I could believe it.  But, even if it is possible that a physician can reliably identify a deviation of "3mm", would it even mean anything?
> 
> Considering the variation in human anatomy, it would seem that 3mm deviation is probably a relatively normal variant and probably useless during the exam of a patient with a suspected pneumothorax.  Is this definition based on any empirical data or is it just the traditional teaching established by someone decades ago based on their opinion?




Asked and answered.

In just a quick google search I found articles in radiology, ENT, pediatrics, endocrinology, C/T surgery, anesthesia, and oncology as 3mm or greater being considered tracheal deviation in an adult and 5mm in children. (I didn't know about the child measurement before the search.) 

I am going to simply conclude this is a general rule of deviation and not specific to tension pneumo.


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## mycrofft (May 8, 2012)

Just ride the bus and look at throats. You'll see the variations..

People teach and write who have little or no first hand experience in prehospital medicine. They either have only seen widely deviant tracheae (death's door), or are passing on what they were told; in the case of teachers, with flagrantly displaced adam's apples denoting pneumo. (Another strike against training moulage; how do you teach a 3mm deviance with greasepaint?).

Pt with recurrent small spontaneous pneumos (CXR reveled a small crop of potential blebs just waiting for something to come along) blew a couple while with us, but never went to tension, despite NO decompression, and evidence was he had done so before.


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## Doczilla (May 8, 2012)

I agree WHOLEHEARTEDLY. People shouldn't quibble over one detail, it'll give them tunnel vision. it just dosent work like that. You have to look at the whole picture. You should be spending more time trending vital signs, getting lung sounds and percussing, and doing a thorough reassessment.

I'll post some pics of a case study I kept from over there, where we accidently found a pneumo secondary to getting his foot blasted off from a landmine. Sneaky stuff. Prime example of the need to put the whole picture together.


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## Veneficus (May 8, 2012)

Doczilla said:


> I agree WHOLEHEARTEDLY. People shouldn't quibble over one detail, it'll give them tunnel vision. it just dosent work like that. You have to look at the whole picture. You should be spending more time trending vital signs, getting lung sounds and percussing, and doing a thorough reassessment.
> 
> I'll post some pics of a case study I kept from over there, where we accidently found a pneumo secondary to getting his foot blasted off from a landmine. Sneaky stuff. Prime example of the need to put the whole picture together.



Why would a pneumo not be suspected secondary to a blast injury?

There is still a shockwave.


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## mycrofft (May 8, 2012)

And those sneaky little shrapnel bahstids.


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## Veneficus (May 8, 2012)

mycrofft said:


> And those sneaky little shrapnel bahstids.



I didn't know you were from Boston 

Actually I have a rather goodbook on  describing IEDs sending blast debris along fascia planes instead of disrupting them.

I don't see why a landmine wouldn't do the same. (physics and all)


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## Doczilla (May 8, 2012)

Because A: the guy came in from a local hospital after sitiing there for two hours  and had no signs at that point (one of the first things I checked) and B: it reared its ugly head through a routine reassessment an our into our treatment.


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## Veneficus (May 8, 2012)

Doczilla said:


> Because A: the guy came in from a local hospital after sitiing there for two hours  and had no signs at that point (one of the first things I checked) and B: it reared its ugly head through a routine reassessment an our into our treatment.



Sounds like the normal progression of it.


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## Doczilla (May 8, 2012)

Yeah, I'm not saying it was atypical or amazing, but the case study is a good teaching point, especially with the pictures. I'll post it later


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## mycrofft (May 8, 2012)

Excellent.
Yeah, missiles of all sorts will follow funny paths ion side and outside the victim, especially if they are the typical "low" velocity of frags* (not primary missiles from high explosives at short range, though). 

Hypotension sounds like the LAST sign.




*Also cheap or small handguns; had one that went through the antihelix of the ear, entered the skin behind the external ear, skimmed along the left lateral-nuccal skull and essentially popped out the posterior-left nuccal area. Knocked him down but all soft tissue damage. Shortbarrel .38 fired from a vehicle at about fifteen or twenty feet, victim quickly turned his head when the shooter called him.h34r:


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## AnthonyM83 (May 10, 2012)

I was taught to look for signs of hemodynamic instability / signs of shock...primarily skin signs and pulse rate/quality. In other words signs that the pneumo has progressed into tension. This way the Needle-T can be accomplished during the ABC's and no wasting time getting a BP on-scene.

In Los Angeles, it's 80 mmHg systolic to decompress without online medical control contact...seems a bit extreme. 

As far as tracheal deviation, I was taught to feel for it, as one would notice the tension/tug when one pushes on either side before one visually notices a trachea moving to the side...


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## ZootownMedic (May 13, 2012)

I will admit that I was always taught that it(tracheal deviation) was a late sign.....but I am always open to new ideas. In the end though I think the the earliest sign of a tension would be like many have said and present with the hemodynamic instability. It won't take very long for the CO to drop once the heart starts to get pressure on it. Obviously diminished unilateral lung sounds and respiratory distress wouldn't hurt either to get a even better differential.


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## JakeEMTP (May 14, 2012)

I don't know if you read Rogue Medic's stuff but sometimes he has good discussions.  

There was a podcast and discussion about tension pneumos and needle decompression.

http://roguemedic.com/2011/02/inade...+(Rogue+Medic)&utm_content=Google+Feedfetcher

Also here.
http://510medic.com/2011/02/01/ems-research-podcast-episode-4/

It is a good arguement for ultrasound also.


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