# Flutter Valves



## RocketMedic (Nov 1, 2012)

I got chewed today for performing an NCD (on a mannequin @ EMSA Academy) without using a flutter valve. I've always been taught to simply decompress and secure the open catheter, since air won't go against a pressure gradient. However, the instructors here were saying that it was "a sucking chest wound" and guaranteed to cause another tension pneumothorax.

Any thoughts on flutter valve use? I've got to use them thanks to protocol, but I strongly suspect that the flutter valve is unnecessary.


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## Aidey (Nov 1, 2012)

I've been told (by more than one ED doc) that technically you are supposed to use them, but the hole created by a decompression needle is small enough there isn't much of a point.


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## usalsfyre (Nov 1, 2012)

Your instructors are undereducated. If I remember correctly, it takes a hole in the chest 2/3's the size of the trachea to entrain enough air to create a "sucking chest wound".

But we're talking about EMS instructors, so I guess I should suspend physics, physiology and chemistry...


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## shfd739 (Nov 1, 2012)

usalsfyre said:


> Your instructors are undereducated. If I remember correctly, it takes a hole in the chest 2/3's the size of the trachea to entrain enough air to create a "sucking chest wound".
> 
> But we're talking about EMS instructors, so I guess I should suspend physics, physiology and chemistry...



Yep..

And a finger of a glove flutter valve is supposed to be effective :blink: :rofl:


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## STXmedic (Nov 1, 2012)

usalsfyre said:


> Your instructors are undereducated. If I remember correctly, it takes a hole in the chest 2/3's the size of the trachea to entrain enough air to create a "sucking chest wound".


Exactly what I was taught. I agree, instructors could use some refreshing.


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## abckidsmom (Nov 1, 2012)

I've always used a 3-way stopcock or an extension set with a slide clamp.  Most of the times when the pneumo re-develops, opening the clamp allows the entrained air to escape.

I wouldn't leave it open, but I don't think it would be the end of the world if you did.  Air in through the catheter means air can go out through the catheter.


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## RocketMedic (Nov 1, 2012)

usalsfyre said:


> Your instructors are undereducated. If I remember correctly, it takes a hole in the chest 2/3's the size of the trachea to entrain enough air to create a "sucking chest wound".
> 
> But we're talking about EMS instructors, so I guess I should suspend physics, physiology and chemistry...



I tried that argument (pressure gradients, lung injuries, simple vs tension pneumos) and I got The Look. You know, the one that's code for 'just roll with it'. Since I need this job to keep being paid, I decided to toe the party line.

That being said, I can say that EMSA-Oklahoma's operations are a textbook example of defensive medicine. There is very little going on here that is progressive. Heck, the NCD protocol forces you to wait for the systolic BP to drop, "air hunger", JVD and tracheal deviation to decompress, if instructors are to be believed. 

I'm starting to see why this place has such problems with turnover. I never thought I'd say this coming out of the Army, but I think many agencies are behind the military in trauma management. It's like stepping back to 1996 or something.


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## usalsfyre (Nov 1, 2012)

That's pretty disappointing if I can learn something new while instructing I welcome it. An attitude like that stifles good medicine.


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## NYMedic828 (Nov 1, 2012)

Any competent EMS instructor and/or physician I have spoken to about it has told me a flutter valve is completely worthless.

Mind you, the gloves FDNY expects us to use are like 1mil thick rubber kitchen gloves. It would take quite a bit of vacuum pressure to close such a glove over the catheter. I use gloves out of the IV kits for EVERYTHING. 

I have never performed a decompression on a real patient but I always figured if the time came I would just put an occlusive dressing over it and "burp" it as necessary. If nothing else it keeps the site a little more sterile not that it matters much at that point.


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## medicsb (Nov 1, 2012)

Rocketmedic40 said:


> That being said, I can say that EMSA-Oklahoma's operations are a textbook example of defensive medicine. There is very little going on here that is progressive. Heck, the NCD protocol forces you to wait for the systolic BP to drop, "air hunger", JVD and tracheal deviation to decompress, if instructors are to be believed.



Chest decompression by EMS is relatively controversial.  A number of studies have found that in many instances when they are placed, there is no pneumothorax actually present.  It is suspected by many traumatologists that chest decompressions are over-performed by EMS and that there may be more harm than benefit, so strict criteria for pneumos seems prudent.    

Now, with regard to flutter valves.  I would recommend one be used for the spontaneously breathing patient because to breath in requires a negative intrathoracic pressure.  If you have an open catheter in the pleural space, it will suck some amount of air in during inspiration (but it should also blow some out on expiration when the intrathoracic pressure increases).  Since one wants to maximize lung inflation, I think it would be in the patient's best interest for a flutter valve to be used.  Now, if they're intubated and PPV is being used, the intrathoracic pressure should always be positive to some degree and a flutter valve won't matter as much.


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## NomadicMedic (Nov 1, 2012)

We use an asherman chest seal over our 14g chest poppers... More to simply keep it in place than anything else.


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## RocketMedic (Nov 1, 2012)

medicsb said:


> Chest decompression by EMS is relatively controversial.  A number of studies have found that in many instances when they are placed, there is no pneumothorax actually present.  It is suspected by many traumatologists that chest decompressions are over-performed by EMS and that there may be more harm than benefit, so strict criteria for pneumos seems prudent.
> 
> Now, with regard to flutter valves.  I would recommend one be used for the spontaneously breathing patient because to breath in requires a negative intrathoracic pressure.  If you have an open catheter in the pleural space, it will suck some amount of air in during inspiration (but it should also blow some out on expiration when the intrathoracic pressure increases).  Since one wants to maximize lung inflation, I think it would be in the patient's best interest for a flutter valve to be used.  Now, if they're intubated and PPV is being used, the intrathoracic pressure should always be positive to some degree and a flutter valve won't matter as much.



That makes sense, but even so, what difference would the catheter being open make as opposed to a flutter valve? It's already only a 14G hole, which is (even in a breathing patient) being acted on by the vacuum divided between the trachea, other holes, and your catheter. I strongly suspect that the only air movement on inspiration, if any, would be dead space.

I don't see the harm in a flutter valve, and I'll use them in the future, since I like being employed. It's just a little odd doing things that you've always been trained differently on by multitudes of different agencies and standards.


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## medicsb (Nov 1, 2012)

Rocketmedic40 said:


> That makes sense, but even so, what difference would the catheter being open make as opposed to a flutter valve? It's already only a 14G hole, which is (even in a breathing patient) being acted on by the vacuum divided between the trachea, other holes, and your catheter. I strongly suspect that the only air movement on inspiration, if any, would be dead space.



Yeah, its tough to say how much of a difference a flutter valve may make during the prehospital phase of treatment.  The net movement of air between the atmosphere and the pleural space may be 0 (i.e. air in = air out) with no valve.  The idea with a valve is to have some air pushed out on expiration to maximize lung inflation on inspiration (air out > air in).  The other benefit would be if you were incorrect with the diagnosis - hopefully the valve could minimize any iatrogenic pneumothorax.

Anyhow, I get the frustration involved with being taught something different and then getting chastised by someone else.  I just finished an Ob/Gyn rotation and I delivered babies with a midwife and 4 different docs.  There were a lot of consistencies, but still there was a lot of variation in practice, so I'd just do what I was taught and roll with it when the doc told me to do something different. (One doc would suction as soon as the head was out, others would wait until baby was all the way out; one would immediately place baby on mom before clamping the cord, others would clamp the cord then place baby on mom; one would use a needle and syringe to collect cord blood while others would drain the blood into a cup or directly into tubes; one would drain the placenta before delivering it, others would not).


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## RocketMedic (Nov 1, 2012)

It was hard not to giggle at the guy trying to tell me that the Combat Application Tourniquet was appropriately secured with the band through one loop "because it's protocol" and "because it would be too tight if you looped it through both loops." He literally could not comprehend that the only reason a CAT has two loops is to enable self-placement with only one hand and limited neck mobility and intelligence. Attempting to explain that a tourniquet is supposed to be tight would be wasted time. 

Arguing tourniquets with a 68W is like arguing ballistics with a sniper.


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## Smash (Nov 2, 2012)

n7lxi said:


> We use an asherman chest seal over our 14g chest poppers... More to simply keep it in place than anything else.



Standard 14g long cannula or something different?  Lots of evidence that a 14g will not even reach the pleural cavity in at least a third of patients. 

Flutter valves?  Cumbersome, annoying and not very useful and they take up time that can be better used elsewhere. Make a hole, move on.  I will set them up only once everything else is done and I have some spare time. Mostly to make it look as though I have been busy...


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## Handsome Robb (Nov 2, 2012)

Aidey said:


> I've been told (by more than one ED doc) that technically you are supposed to use them, but the hole created by a decompression needle is small enough there isn't much of a point.



Same thing here, all cited pressure gradients as the main reason as to why it doesn't matter. I've also heard that same thing about how big the wound has to actually be to create a "sucking" chest wound but with that said I had a lady stabbed 3 intercostal, mid clavicular with a kitchen knife and she had a sucking chest wound, it even bubbled just like the book said it would! 

By protocol we have to use them and a one-way valve is included in our needle decompression kits so it's not a huge deal to place the cath and pop the valve on. Where are they having you place them? We have the option of mid clavicular, 2nd intercostal or anterior axillary 4th or 5th intercostal and per our annual skills last week we are to use the anterior axillary placement unless it's inaccessible, then we can go to 2nd intercostal, mid clavicular.

Never actually decompressed anything other than Hector our high-fidelity mannequin so I can't speak to how they actually work in real life.


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## Veneficus (Nov 2, 2012)

Aidey said:


> I've been told (by more than one ED doc) that technically you are supposed to use them, but the hole created by a decompression needle is small enough there isn't much of a point.



I would tell you the same thing 

Some people around here are hell bent on affixing an open syringe full of water to verify for documentation purposes. 

Since it makes so little difference either way, if they are hell bent on it, just tear off a finger from a glove and attach it to the needle before you insert it. (that is how we did it prior to commercially made devices)


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## NomadicMedic (Nov 2, 2012)

Smash said:


> Standard 14g long cannula or something different?  Lots of evidence that a 14g will not even reach the pleural cavity in at least a third of patients.



It's long... 3.5", I believe. It worked like a champ in the last guy I popped.


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## Veneficus (Nov 2, 2012)

n7lxi said:


> It's long... 3.5", I believe. It worked like a champ in the last guy I popped.



Knowing your equipment is everything...

the 3.5" is designed to be used in the midclavicular line. The standard 1 1/4" (i believe is the size) is not. 

If you have the shorter needle, if you put it in the midaxilary line, you will have more success. the reason chest tubes are put there is because of the lack of tissue levels in that specific location.

(it is amazing how much more can be done with so little when people know why)


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## Jon (Nov 2, 2012)

n7lxi said:


> It's long... 3.5", I believe. It worked like a champ in the last guy I popped.



First - so many things I could say overall. Not touching it.

I've never popped a chest, but my service carries 3.5" 12 gauges.


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## fast65 (Nov 2, 2012)

n7lxi said:


> It's long... 3.5", I believe. It worked like a champ in the last guy I popped.


That's what we use as well...I can't remember the exact length, but I believe our 10 ga angiocaths in the decompression kit are 3.5". I checked last week after I read a study on needle decompression on RESUSME, but I've already forgotten. 

That being said, my friend did bring up the flutter valve issue to our MD the other day, and he still wants us to use them. I can't really speak to the efficacy of them, since I've only decompressed one chest, and it was on an intubated patient where I used a 3 way stopcock.


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## mikie (Nov 2, 2012)

Smash said:


> Lots of evidence that a 14g will not even reach the pleural cavity in at least a third of patients.



Here's some of that evidence: 

http://www.ncbi.nlm.nih.gov/pubmed/22987168


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## NomadicMedic (Nov 2, 2012)

Sorry I don't know the exact size off hand, but I'll pull the chest decompression kit tonight and take a look. . I know it's a 14 and at least a 3.25, and we're only allowed to use the midaxillary line.


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## Luno (Nov 2, 2012)

*@Rocket*



Rocketmedic40 said:


> Arguing tourniquets with a 68W is like arguing ballistics with a sniper.



I think I've found my new e-mail quote...


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## fast65 (Nov 2, 2012)

n7lxi said:


> Sorry I don't know the exact size off hand, but I'll pull the chest decompression kit tonight and take a look. . I know it's a 14 and at least a 3.25, and we're only allowed to use the midaxillary line.



I just checked our kit, and the 10ga angiocath is 3" long.


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## NYMedic828 (Nov 2, 2012)

fast65 said:


> I just checked our kit, and the 10ga angiocath is 3" long.



Ouch that's a big boy needle.


We use 14g for adults here. No fancy premade kit either. We just take out a 14g angiocath and remove the flash cap. (We don't carry the auto retracting IV needles)


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## usalsfyre (Nov 2, 2012)

NYMedic828 said:


> Ouch that's a big boy needle.
> 
> 
> We use 14g for adults here. No fancy premade kit either. We just take out a 14g angiocath and remove the flash cap. (We don't carry the auto retracting IV needles)



Still infinitely smaller than a 36fr chest tube.


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## TransportJockey (Nov 2, 2012)

usalsfyre said:


> That's pretty disappointing if I can learn something new while instructing I welcome it. An attitude like that stifles good medicine.



Since when is the status-quo EMS about medicine?

And I haven't made a flutter valve w/ the two I've done in the field. We don't carry extension tubing(ugh!) or stopcocks either.


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## RocketMedic (Nov 3, 2012)

Per our OMD Education /Tac-Med guy, "we haven't used those in ten years because they're worthless."

Nothing like multiple standards to make life confusing.


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## Handsome Robb (Nov 3, 2012)

fast65 said:


> I just checked our kit, and the 10ga angiocath is 3" long.



3.25" 14g here. All packaged up with a commercial valve and betadine swabs.


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## fast65 (Nov 3, 2012)

NVRob said:


> 3.25" 14g here. All packaged up with a commercial valve and betadine swabs.



You always have to one up me Rob!


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## lightsandsirens5 (Nov 3, 2012)

fast65 said:


> You always have to one up me Rob!



Length wise.....but sure not width wise. 10 ga is huge compared to 14.


Wow, that sounds weird.


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## usalsfyre (Nov 3, 2012)

lightsandsirens5 said:


> Length wise.....but sure not width wise. 10 ga is huge compared to 14.
> 
> 
> Wow, that sounds weird.



It's not the...never mind......


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## Akulahawk (Nov 3, 2012)

Way back when, Sac City FD ambulances carried 3.5 - 4.0 inch 12 ga angiocaths specifically for this purpose. I do not know if they have them any longer. Most of the private companies I have worked for used the longest 14ga angios they could find, if we didn't have them on the truck, we could simply use one of our regular 14ga angiocaths, but with the understanding that they might be a bit short on some patients... I've yet to do a needle decompression.


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## NomadicMedic (Nov 3, 2012)

Just looked... Ours are 3.5".


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## Handsome Robb (Nov 3, 2012)

usalsfyre said:


> It's not the...never mind......



Dammit you beat me to it!


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