# Pneumothorax "what if"



## EMT B (Mar 6, 2013)

If you have a patient that has a pneumothorax due to external trauma, after you put on an occlusive dressing and create a flutter valve (by taping down only 3 sides of the dressing), could you use positive pressure ventilations via a BVM to try and reinflate the lung and push the air back out the hole?


----------



## Brandon O (Mar 6, 2013)

Yes. And if they need ventilatory support, you shall do so. Just make sure your flutter valve is actually venting.


----------



## Household6 (Mar 6, 2013)

Is the patient breathing adequately on their own? 

Do you mean a scenario where you tell the responsive and breathing patient "Grip tight dude, I'm gonna inflate your collapsed lung with this BVM real quick." Helllllll no..

If the patient IS breathing adequately with their remaining lung, do you intend to force air into a collapsed lung for them? Most humans have two lungs, they don't need both to stay alive..

If the patient isn't breathing adequately, why do you think you wouldn't?


----------



## chaz90 (Mar 6, 2013)

Remember the reason you're putting that occlusive dressing on at all. If this is a sucking chest wound that has caused a pneumothorax, your occlusive bandage taped down on three sides allows the patient to inhale and draw air in effectively by sealing up the external hole. Excess pressure "should" be what's vented out of the bandage. If you think too much pressure is building up and the lungs are not inflating (tension pneumothorax), it's probably because your occlusive bandage is sealed too well. If you see increasing shortness of breath, worsening hypotension, tachycardia, JVD, diminished lung sounds, and god forbid tracheal deviation, take your occlusive dressing off! This provides treatment based on the same theory as a needle decompression or chest tube placement. 

Positive pressure ventilation may be enough to break the seal on the occlusive dressing and allow venting, or it might make the problem worse if the seal stays shut. The moral of the story is to think through the science and physics of where the pressure is building up and how you can alter it.


----------



## mycrofft (Mar 6, 2013)

Stray shots:

1. _*If the lung has been breached*_ BVM will *not* help the bad lung, but push more air into the space and collapse it more. Can you positively tell if that happened or if it is simply a breach to the outside? Check opposite side breath sounds, BVM them if needed, but don't expect it to help the bad side.

2. This can become a case of the dog catching the car. At a basic care level what care options do you have? How long will they take versus getting to a local receiving facility? Will this save a life or reduce pain? Once it is set up, then what?

3.  The typical occlusive dressing (vaseline gauze) takes a lot of pressure to vent through and does not want to fall back into place. Improvised Heimlich valves made from glove fingers have been cited but not for something you plan on. Using the sterile side of the foil or plastic wrappers for vaseline gauze, Adaptic etc. are easier to use than greasy bandages but still do not vent and reseal very well. Medics in Nam were known to use any cloth (including bloody socks) to seal a sucker but not try to vent it.

If the whole three-sealed bandage thing worked well, hospitals would use those instead of expensive water seal setups. Seal it, turn them onto the affected side (presuming there aren't two affected sides), treat CAB's, get to hospital while monitoring. Right?

Advanced people: 1. Can bagging a closed pneumo cause secondary issues through mediastinal shift?
                          2. IS oxygen really useful here?
                          3. What are our time elements here? Is it better to get going than try to establish a three-sealed cover?
                          4. Anyone actually see one of those work?


----------



## Veneficus (Mar 6, 2013)

mycrofft said:


> Advanced people:
> 1. Can bagging a closed pneumo cause secondary issues through mediastinal shift? *yes*
> 2. IS oxygen really useful here? *no*
> 3. What are our time elements here? Is it better to get going than try to establish a three-sealed cover? *tensions develop over time, it will depend on the extent of the injury. Most tensions I have seen developed in the hospital ED not prior to or during EMS transport.*
> 4. Anyone actually see one of those work?* I have used an asherman chest seal a handful of times, I was happy with it. But I am happier opening up the aluminum packaging that the petroleum  gause is kept in, and just pressing the whole thing (gause and package) over the wound. I discovered the hard way trying to peel petroleum gause out of its packaging creates more headache than it is worth*



3 characters.


----------



## mycrofft (Mar 6, 2013)

Veneficus said:


> 3 characters.



I used the scissors to flip it out of the package. Tape and Vaseline don't mix.

OP, get this?


----------



## Handsome Robb (Mar 6, 2013)

Veneficus said:


> I have used an asherman chest seal a handful of times, I was happy with it. But I am happier opening up the aluminum packaging that the petroleum gause is kept in, and just pressing the whole thing (gause and package) over the wound. I discovered the hard way trying to peel petroleum gause out of its packaging creates more headache than it is worth



Agreed. That stuff works like a champ to seal chest wounds. Generally sticks better to a real diaphoretic patient than regular tape will as well. It's my go to for chest wounds, we don't carry any fancy chest seals. 

Like someone else said, unless the patient is presenting with ventilatory insufficiency I'd just seal it, titrate O2 to an acceptable SpO2% and transport them while watching them carefully, I'd ask for ALS as well and meet them en route if it makes sense, if not then just let the ER do their thing. While ALS can decompress a tension pneumo with a needle thoracentesis this patient ultimately needs a CXR and an MD to decide if they need a chest tube or not and potentially intubation.


----------



## mycrofft (Mar 6, 2013)

In a pinch...diaphoretic EKG electrode or AED pad?

I think the "three sided seal" bandage deal is wishful thinking.


----------



## Veneficus (Mar 6, 2013)

mycrofft said:


> In a pinch...diaphoretic EKG electrode or AED pad?
> 
> I think the "three sided seal" bandage deal is wishful thinking.



forget the pad, just use the packaging. 

Back in the day we just kept sterile aluminum foil of the truck. It worked great.


----------



## mycrofft (Mar 6, 2013)

Veneficus said:


> forget the pad, just use the packaging.
> 
> Back in the day we just kept sterile aluminum foil of the truck. It worked great.



As a seal, right?  I'm talking about trying to make a bandage act as a flapper valve.


----------



## Brandon O (Mar 6, 2013)

Anybody used a Tegaderm?


----------



## Veneficus (Mar 6, 2013)

Brandon Oto said:


> Anybody used a Tegaderm?



I never had one big enough, but I don't see why you couldn't.


----------



## mycrofft (Mar 6, 2013)

*The ASherman*







The Bolin:






Or at this website (Internatinal Red Cross Surgery for Victims of War, 1998): http://helid.digicollection.org/es/d/Jh0218e/14.3.1.html






But these are NOT basic level interventions! Take a class or three.

========

Tegaderm/OPSITE etc: a doctor told me once it was "pesky" to work around those filmy materials, ditto Saran wrap.


----------



## Veneficus (Mar 6, 2013)

mycrofft said:


> But these are NOT basic level interventions! Take a class or three.
> 
> ========
> 
> Tegaderm/OPSITE etc: a doctor told me once it was "pesky" to work around those filmy materials, ditto Saran wrap.



I have found that you really don't need the flapper over the needle.


----------



## EMT B (Mar 6, 2013)

mycrofft said:


> OP, get this?



yup..call ALS. There is really nothing I am going to do at the BLS level to fix a pneumo. I suppose I should stop trying to think outside the box :wacko:


----------



## Brandon O (Mar 6, 2013)

EMT B said:


> yup..call ALS. There is really nothing I am going to do at the BLS level to fix a pneumo. I suppose I should stop trying to think outside the box :wacko:



Never stop thinking. Just ask questions before trying something too clever on a patient


----------



## Veneficus (Mar 6, 2013)

I was under the impression that sealing an open pneumo was a basic skill?


----------



## EMT B (Mar 6, 2013)

it is...but that wont necessarily fix the problem


----------



## Veneficus (Mar 6, 2013)

EMT B said:


> it is...but that wont necessarily fix the problem



Don't be upset by that. It takes a few days for a pneumo to right itself. The medical care including a chest tube is really just to manage the pressure, not actually fix the problem.


----------



## Thricenotrice (Mar 6, 2013)

Veneficus said:


> I have found that you really don't need the flapper over the needle.



Having never done a needle T on a real patient, I have this as a plan as well, just throwing the needle in securing in place without a valve of any sort. Again, never had to do it yet but that's my plan


----------



## Veneficus (Mar 6, 2013)

Thricenotrice said:


> Having never done a needle T on a real patient, I have this as a plan as well, just throwing the needle in securing in place without a valve of any sort. Again, never had to do it yet but that's my plan



You don't even need to secure the needle. 

If you use the longer 14g and put it in all the way to the hub, it doesn't go anywhere.


----------



## Household6 (Mar 6, 2013)

mycrofft said:


> In a pinch...*diaphoretic EKG electrode or AED pad?*
> 
> I think the "three sided seal" bandage deal is wishful thinking.



That's what we were taught, it came up in discussion last night.

edit: I mean instead of an occlusive..


----------



## Brandon O (Mar 6, 2013)

Always seemed to me that the inside of a clean (if not sterile) plastic wrapper from... from whatever would make an effective occlusive, if taped properly.


----------



## Veneficus (Mar 6, 2013)

Brandon Oto said:


> Always seemed to me that the inside of a clean (if not sterile) plastic wrapper from... from whatever would make an effective occlusive, if taped properly.



They actually make that for surgery.


----------



## systemet (Mar 6, 2013)

Brandon Oto said:


> Anybody used a Tegaderm?



I've used these over stab wounds and GSWs, but none that have been true "sucking chest wounds".  Of course, these then occlude the wound completely, which is ultimately counterproductive, especially if it doesn't appear to be actively entraining air.

I would think that the wrapper IV bags come in, and some two inch fabric tape would probably work better.  This is my new go-to plan, but honestly I don't see a ton of penetrating trauma.


----------



## MSDeltaFlt (Mar 6, 2013)

EMT B said:


> If you have a patient that has a pneumothorax due to external trauma, after you put on an occlusive dressing and create a flutter valve (by taping down only 3 sides of the dressing), could you use positive pressure ventilations via a BVM to try and reinflate the lung and push the air back out the hole?



Back on topic, though a bit late, the answer is generally "no".  That is unless they are not ventilating well enough on their own.  Your flutter valve is treating he pneumo.  Your oxygen will treat the associated hypoxia.  Your BVM treat any hypercarbia and/or altered level of consciousnrss associated with the pneumo.

Does this make sense?


----------



## Mariemt (Mar 6, 2013)

A freezer bag is about perfect.

Cut the edges off, use the inside. However, we are within 2 miles of a hospital.


----------



## Tigger (Mar 6, 2013)

Veneficus said:


> forget the pad, just use the packaging.
> 
> Back in the day we just kept sterile aluminum foil of the truck. It worked great.



Still a state requirement in MA!

Per one of our team docs and the paramedic crew, we have a few large (5X9) tegaderms in the red bag in the event of some sort penetrating trauma.


----------



## Veneficus (Mar 7, 2013)

Tigger said:


> Still a state requirement in MA!



Don't knock it until you have tried it.

Not sure I think it should be required, but it does work very well.


----------

