# Needle Decompression



## Sizz (Apr 30, 2011)

Hey all

I just watched a YouTube video with decompression using a large bore w/a saline flush attached after removing the plunger. It appeared easy to confirm placement as well as not allowing air to return into the chest. Has anyone used this method or is it not so good due to possible saline leaking through the cath back into the chest or am I missing something? 

Check out this video on YouTube:

http://www.youtube.com/watch?v=TZpq8EPJ13Q&feature=youtube_gdata_player

Thanks for the input


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## Veneficus (Apr 30, 2011)

Sizz said:


> Hey all
> 
> I just watched a YouTube video with decompression using a large bore w/a saline flush attached after removing the plunger. It appeared easy to confirm placement as well as not allowing air to return into the chest. Has anyone used this method or is it not so good due to possible saline leaking through the cath back into the chest or am I missing something?
> 
> ...



Haven't used it, it looks like they just use the saline to create a water seal .

From what I saw and what they were saying, I am guessing they were using the needle decompression as a diagnostic tool rather than just inserting a chestube.

I wouldn't worry about such a small amount of saline in the thorax.


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## Sizz (Apr 30, 2011)

Thanks Veneficus,

I'm guessing (as I've never preformed this procedure on an actual patient) that once you hit the pleural cavity with the large bore you will hear a pretty good rush of air? I suppose it would be simpler to just create a flutter valve or use a kit with one already to go, instead of trying to secure the catheter with the saline flush attached. 

Just my brain buzzing me this morning is all. 

Thanks


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## Shishkabob (Apr 30, 2011)

Not so much as a water seal as to tell when you're in the plural space as the air escaping will cause bubbles to form, incase you can't hear the hiss (if it hisses) due to loud ambient noise.


That's how we were taught in my current agencies academy.


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## Sizz (Apr 30, 2011)

Linuss said:


> Not so much as a water seal as to tell when you're in the plural space as the air escaping will cause bubbles to form, incase you can't hear the hiss (if it hisses) due to loud ambient noise.
> 
> 
> That's how we were taught in my current agencies academy.



I was thinking along the same lines Linuss, a good confirmation tool in-case you cannot hear it or miss the initial rush of air. Have you been able to experience  this on a patient yet? Would you leave the syringe attached and secure throughout transport or after confirming you have good placement in the plural space remove the saline and setup w/ a flutter valve?

Thanks for the input


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## Veneficus (Apr 30, 2011)

Sizz said:


> Thanks Veneficus,
> 
> I'm guessing (as I've never preformed this procedure on an actual patient) that once you hit the pleural cavity with the large bore you will hear a pretty good rush of air? I suppose it would be simpler to just create a flutter valve or use a kit with one already to go, instead of trying to secure the catheter with the saline flush attached.
> 
> ...



In the field it would be easier to just needle the chest and leave it at that.
There is too much movement and too many more important things to worry about than a water seal on a 14g needle. After a life or two there wouldn't be any water in it anyway and you would basically have just an open needle anyway.


I am fond of the Asherman chest seal even though for a decompression it is superfluous. (of course it is easier to deploy if you don't use the tab and fold it in 1/2 half and peel the back off from the middle it works better.

PS. It is the water seal that creates the bubbling.


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## medicsb (Apr 30, 2011)

This seems like a far better technique (vs. listening for a rush of air) for a chest decompression considering that a significant portion of presumed-pneumothorax patients are misdiagnosed in the field and thus inappropriately treated.  No bubbles = remove immediately.


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## Veneficus (Apr 30, 2011)

medicsb said:


> This seems like a far better technique (vs. listening for a rush of air) for a chest decompression considering that a significant portion of presumed-pneumothorax patients are misdiagnosed in the field and thus inappropriately treated.  No bubbles = remove immediately.



If I could point out, it is a different technique.

About the only place I could forsee it helping is in a non trauma facility when x-ray is not immediately available.

In the field, if you suspect a pneumo, you are going to put the needle in. Once the needle goes in, it is best to leave it in.

Even if you were to see no bubbles. Once they get to the hopital, there is going to be an x-ray. 

A pneumo usually develops over time. In my experience, unless there is a prolonged transport or response, the pneumo is clinically detectable long after they drop the patient off. (20 minutes to an hour) 

If you were to put in a needle and not observe bubbling, what happens when you pull it out and there was a subclinical developing pneumo?

The patient will get another decompression in the hospital.

If anyone hasn't seen major trauma center operations, a bedside CXR usually happens within about 10 minutes of arrival. Usually less, depending on the skill of the team.

Once it is evident there is no pneumo, somebody on the trauma service will yank the catheter. 

Usually throwing it on the floor and cursing EMS for being overzealous

The nicer teams put it in the medical waste container and mention something about it is better to treat a non-existant pneumo than to not treat one that does exist.

While I think medical treatment should always be as accurate as possible, somethings are less accurate in the field setting and will always be.

There is no responsible way to prevent over treatment in any emergency situation. The goal can only be to limit it as much as is practical.


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## usalsfyre (Apr 30, 2011)

medicsb said:


> This seems like a far better technique (vs. listening for a rush of air) for a chest decompression considering that a significant portion of presumed-pneumothorax patients are misdiagnosed in the field and thus inappropriately treated.  No bubbles = remove immediately.



Confirmation of a tension pneumo being released comes from immediate improvement in hemodynamic status, not "a rush of air" or bubbles in a syringe.


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## medicsb (Apr 30, 2011)

Veneficus said:


> About the only place I could forsee it helping is in a non trauma facility when x-ray is not immediately available.



Such as the prehospital setting.



> In the field, if you suspect a pneumo, you are going to put the needle in. Once the needle goes in, it is best to leave it in.



The general teaching is that only a tension pneumo is to be decompressed, not a "simple" pneumo.   Certainly if S/Sx suggest a tension pneumo, then by all means decompress it.  But if all you have is unilateral diminished or absent breath sounds without hemodynamic compromise, then it would be best to avoid a potential iatrogenic injury and leave the needle in the kit and instead frequently reassess. (It should be considered that a trauma patient is often not exclusively a trauma patient but may have pre-existing disease that produces dyspnea and diminished unilateral breath sounds.)  If you place a needle and you do not get a rush of air or bubbling, what is the point of leaving it in?  One of three possibilities: 1. the needle wasn't long enough and it didn't completely pierce the chest wall; 2., there was is no air to be let out at the site you just pierced; or, 3., there is some sort of obstruction.  Doesn't mean you should try again, though.




> If you were to put in a needle and not observe bubbling, what happens when you pull it out and there was a subclinical developing pneumo?


Either diligent reassessment catches the tension pneumo or the hospital catches the pneumo.  In the former, you decompress.  In the latter, a chest tube is placed (or maybe not, if it is small enough).  I don't see the issue here.  




> Once it is evident there is no pneumo, somebody on the trauma service will yank the catheter.
> 
> Usually throwing it on the floor and cursing EMS for being overzealous



Probably an appropriate response considering the potential for worsening the patient's condition and/or inducing pain and suffering.



> The nicer teams put it in the medical waste container and mention something about it is better to treat a non-existant pneumo than to not treat one that does exist.


Which would be appropriate if the S/Sx were equivalent to that of tension pneumo.  



> While I think medical treatment should always be as accurate as possible, somethings are less accurate in the field setting and will always be.
> 
> There is no responsible way to prevent over treatment in any emergency situation. The goal can only be to limit it as much as is practical.



To limit it one should.  But, yes, I agree in many emergency situations over-treatment or misdiagnosis to some degree is probably a fact of life.


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## Veneficus (Apr 30, 2011)

medicsb said:


> Such as the prehospital setting.



Once you put the needle in, whether the injury is confirmed or not doesn't matter. If there was a pneumo it is treated, if not, if it wasn't, what does nonconfirmation really mean at that point?




medicsb said:


> The general teaching is that only a tension pneumo is to be decompressed, not a "simple" pneumo.



In my experience, providers do not distinguish the difference, not that they shouldn't, but it is what it is.

Considering that many can't tell the difference between tracheal deviation and gross tracheal deviation and when it appears and how it is determined, there will always be overtreatment.




medicsb said:


> Certainly if S/Sx suggest a tension pneumo, then by all means decompress it.  But if all you have is unilateral diminished or absent breath sounds without hemodynamic compromise, then it would be best to avoid a potential iatrogenic injury and leave the needle in the kit and instead frequently reassess.



Yes it would. But again from the practical side, many people in smaller hospitals and EMS agencies of all sizes, do not see tensions regularly. I would bet money in the absense of a CXR when they have a patient who has any injury, hemodynamic compromise from any etiology, and any sign of a pneumo, there will be a decompression. Especially if they are not comfortable arond trauma. 



medicsb said:


> If you place a needle and you do not get a rush of air or bubbling, what is the point of leaving it in?



So other providers who subsequently see the patient (read ED staff) know that a decompression was made and can take steps to do things like clean the wound site even if the decompression wasn't needed?

In the field you don't always hear the rush of air, not everyone sets up a water seal, so if you end up treating a simple pneumo that hasn't progressed to tension, should you reverse course?

Is it really going to make much of a difference to leave the catheter in for a few more minutes during transport?

I have not seen much difference in the past and I have seen pneumos significant enough to require multiple needles to bring relief of tension.



medicsb said:


> Either diligent reassessment catches the tension pneumo or the hospital catches the pneumo.  In the former, you decompress.  In the latter, a chest tube is placed (or maybe not, if it is small enough).  I don't see the issue here.



It was rhetorical.  



medicsb said:


> Probably an appropriate response considering the potential for worsening the patient's condition and/or inducing pain and suffering.
> 
> Which would be appropriate if the S/Sx were equivalent to that of tension pneumo.


 
The purpose of my 2 statements were to illustrate that once the needle is placed, it really doesn't matter. The only option is to move forward with the appropriate treatment at that point.


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## Melclin (May 7, 2011)

As well as all the usual stuff, jugular venous distension, hypotension, tachycardia, increased resp distress/rate, subcut emphysema, absent breath sounds, worsening GCS, we talk about two things as being definite reasons to mark a pt up and pull the trigger on tensions:
In the setting of chest trauma, 
-hypotension unresponsive to fluid 
-O2 saturation <92 on O2. 

The needle test with a saline filled syringe is certainly by the book here. Not without the plunger though, the idea is that you aspirate air to confirm a tension. If its suggestive of a tension pneumo, you withdraw and secure and ta-da, you've now got an open pneumo instead of a tension. If its not or you've got a haemothorax, withdraw the cannula, seal the hole that you poked in their chest and clearly mark the sight.

I wouldn't be too worried about saline escaping into the pleural cavity, in fact, if you suspect the cannula has become blocked you can flush it with saline to regain patency. 

That said, I'm glad it won't be in my scope for a little while to come. I reckon it would be a hard button to push being so young in the job :blush:



usalsfyre said:


> Confirmation of a tension pneumo being released comes from immediate improvement in hemodynamic status, not "a rush of air" or bubbles in a syringe.



This. 

Rush of air gets talked about a lot. Admittedly in the one decompression I've seen, it was quite audible, but most people who've taught me have rarely heard it.


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## MrBrown (May 7, 2011)

Melclin said:


> That said, I'm glad it won't be in my scope for a little while to come. I reckon it would be a hard button to push being so young in the job :blush:



That is what you have Brown for, Brown drives around with a Turkel decompression kit and ketamine in Brown's back pocket to go and back up crew's when required .... even off duty, ah bloody brilliant that Ambulance scanner is 

/taking the piss


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## Melclin (May 7, 2011)

MrBrown said:


> That is what you have Brown for, Brown drives around with a Turkel decompression kit and ketamine in Brown's back pocket to go and back up crew's when required .... even off duty, ah bloody brilliant that Ambulance scanner is
> 
> /taking the piss



Like the paramedic student here a while back who collared and cannulated an unconscious pt he came across on his way to a placement, with gear he stole from uni....what a winner. :lol:

I got a scanner for my birthday when I was a little kid to listen to the police. I'm shattered ambulance moved to digital years back. I could have responded POV and "rendered first aid" with my extensive medical distance education undertaken via Scrubs and Grey's Anatomy. B)


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## MrBrown (May 7, 2011)

Melclin said:


> Like the paramedic student here a while back who collared and cannulated an unconscious pt he came across on his way to a placement, with gear he stole from uni....what a winner. :lol:



Sounds like a future Intensive Care Paramedic if ever Brown saw one 

Ambulance is not digital here yet but with the introduction of MDTs very little radio traffic is passed verbal any more.  It will probably go digital in a few years, the Police have gone digital and apparently there are teething problems with the new Motorola radios because they have to log onto the encrypted network when you hit talk before being able to transmit


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## Chief Complaint (May 31, 2011)

Rather than start a new thread...

We didnt really spend a whole lot of time going over needle decompressions in medic school.  Well, not enough for my liking at least.

What do you do if you cant find your land mark?  I imagine it can be a bit difficult in obese patients, and even more so in somebody with a substantial muscle build.

Im a pretty muscular guy and even my instructors were having a hard time finding the correct spot to decompress.  I dont imagine that its a good idea to blindly guess in the field, so what if you just cant find your site?  Avoid the procedure all together?


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## usalsfyre (May 31, 2011)

You'll probably be able to find the rib somewhere. Follow it around and do the best you can, if you stay at the midaxilary line you should stay away from the vital structures.

As far as inserting blind, yes you should avoid it, BUT.....not performing needle decompression in a true tension pneumo will lead to death. So the alternative isn't exactly palatable.


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## 8jimi8 (May 31, 2011)

Sizz said:


> Thanks Veneficus,
> 
> I'm guessing (as I've never preformed this procedure on an actual patient) that once you hit the pleural cavity with the large bore you will hear a pretty good rush of air? I suppose it would be simpler to just create a flutter valve or use a kit with one already to go, instead of trying to secure the catheter with the saline flush attached.
> 
> ...



Without having read any of the responses.  I was taught to aspirate while inserting to confirm placement.  Same techniques for needle crichothyrotomy.


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## rwik123 (May 31, 2011)

In regards to someone above mentioning the worsening of a condition due to a misdiagnosed pneumothorax, I saw a study based on battlefield medicine encouraging the placement of catheters at any sign of a pneumo. It stated that the detrimental effects of placing a gatherer in the intercostal place for a non existing condition are very little to none. I'll have to dig up that source.


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## squrt29batt12 (May 31, 2011)

Chief Complaint said:


> Rather than start a new thread...
> 
> We didnt really spend a whole lot of time going over needle decompressions in medic school.  Well, not enough for my liking at least.
> 
> ...



I agree that would definately be a problem but if you need to do it in order to keep the pt alive, then go where you most likely think the landmark is. Do No Harm is good, but sometimes not doing crap can kill them.


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## Chief Complaint (May 31, 2011)

usalsfyre said:


> You'll probably be able to find the rib somewhere. Follow it around and do the best you can, if you stay at the midaxilary line you should stay away from the vital structures.
> 
> As far as inserting blind, yes you should avoid it, BUT.....not performing needle decompression in a true tension pneumo will lead to death. So the alternative isn't exactly palatable.





squrt29batt12 said:


> I agree that would definately be a problem but if you need to do it in order to keep the pt alive, then go where you most likely think the landmark is. Do No Harm is good, but sometimes not doing crap can kill them.



Thanks, thats what i expected to hear.


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## ChorusD (Jun 1, 2011)

For what it's worth, I was taught while a member of a certain warfighting organization that you can also find the site for decompression at two finger widths below the clavicle at the mid clavicular line.  It should get you close.


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## MasterIntubator (Jun 5, 2011)

Interesting technique.  Its like a redneck pleurovac. 

Kinda neat.

It does create a splash issue, and would be top heavy.  All of the decompresses I have done, I have removed the stylus/trocar, which would take away the stiffness and it will kink.  Once the sheath kinks, they become very restrictive ( even after straightening it out. You would think that leaving an angiocath stylet in would be more traumatic to internal structure as that top heavy weight wiggles around... just lacerating everything it swings by.  

A pediatric heimlich valve on an extention works great ( for the old schoolers.... the intracaths... with its built in flapper valve ).


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