Bilateral tension pneumothorax? Oh my!

[apagea99]

On Monday night, my class went over chest injuries with an emphasis on pneumothoraces (open, closed, spontaneous, tension, hemopneumothorax), s/s, and what interventions can be offered by an EMT-B (or IV here in TN).

On Tuesday, my study partner and I did some online reading and came across an article on bilateral tension pneumothorax. Our reaction was mostly along the lines of $@%$*%&$^!!!!!!!! This is something that wasn't mentioned in class and I'm guessing it may be very rare (?). So my questions are these: Has anyone seen cases of this while working as a Basic? Were the s/s evident from the start or still developing? Did you recognize them right away? Did you have ALS with you or did you have to activate them en route? How did the pt fare?

After doing some further reading, it seems that all an EMT-B can really do is recognize the s/s, activate ALS asap, and provide rapid transport. Please feel free to kick me if I'm off base.......

BTW - I realize that the life saving interventions needed here are ALS skills. I just wanted to know if any Basics had come across them and how they dealt with them on a Basic level. That being said, I'd like to know what the medics have to say too

 

[FF894]

Like you said at the B level you just have to transport quick and hope to meet ALS on the way. The assessment to that point will be key to allow ALS to make a decision so the having good assessment skills at any level is key. At the ALS level, where I am, if the case is a trauma and the patient is rapidly headed towards arrest then it doesn't hurt to needle both sides.

 

[KEVD18]

if you have a pt with bilateral pneumothoraces at the bls level, you'd better hope there are medics available toot sweet.

 

[traumateam1]

Like I've said many many times, we don't have any ALS here, so IV, O2 and rapid transport. Activate a trauma alert at the hosp and go go go. Oh yeah and hope you have enough time to get to the hospital before he stops breathing, and then his heart stops.

Never seen a bilat. tension pneumothorax tho.

 

[Ridryder911]

There is a lot of things that Basics are not taught. Things such as there are not such things as a unilateral pelvic fracture or mandibular fracture.

I have treated a few bi-lateral tension pneumo's and prefer if possible care not to see anymore.

R/r 911

 

[tydek07]

Hi,

You are 100% correct that you need ALS asap. One of my main concerns (as Ryder pointed out) is that some stuff like this is not gone over like it should be in EMT courses. They may talk about it, as its in the book, but usually do not go very far into it. Its awsome that you are doing your own research and going further into stuff like this!

The biggest thing an EMT can do is recognize the problem and/or try to prevent it (ie. using an occlusive dressing(s)). Also get ALS en route right away for an intercept. This is a life or death situation, so being able to recognize the problem is key.

Have I seen a bi-lateral tension pneumo before? Nope, and hope that my luck continues for a long time

Again, its nice seeing that you are going further into stuff on your own time. It shows that you really want to learn and be the best EMT you can be.

Take Care,

 

[boingo]

If the tension is caused by a penetrating chest injury you could insert your finger and decompress it. It is not in your protocol, its not taught in EMT or medic school, but by opening the wound in the chest you can effectively release the pressure. I would certainly consult your medical control prior, however at the BLS level, without ALS available and a distance to the hospital, you don't have many choices. Your patient will die quickly, or you will think outside the box.

 

[Ridryder911]

If the tension is caused by a penetrating chest injury you could insert your finger and decompress it. It is not in your protocol, its not taught in EMT or medic school, but by opening the wound in the chest you can effectively release the pressure. I would certainly consult your medical control prior, however at the BLS level, without ALS available and a distance to the hospital, you don't have many choices. Your patient will die quickly, or you will think outside the box.

Gasp!... Want to keep out of jail and the least have some money for groceries? Then NEVER EVER PERFORM THAT PROCEDURE!

Part of the problem of Internet. The reason this is not in any text or taught, is simply its WRONG and could perceived as GROSS NEGLIGENCE and POSSIBLY MANSLAUGHTER!

Chest decompression is an advanced skill. Period! Now, the proper procedure for Advanced Personnel is chest decompression with a large bore needle with an attached flutter valve (or similarities). The only mention of incising and placing a sterile finger inside the pleura is when placing a chest tube.. in which there are very few EMS services allowed to perform the procedure.

R/r 911

 

[boingo]

LOL Wrong because its not in a book, or wrong because it doesn't work? I certainly don't suggest going off the reservation, thats why I said Medical control, but as a BLS provider, you have no options. Opening the pre existing hole CAN relieve the pressure, to suggest otherwise is false. I'm not telling anyone to go out there and do it, however it IS an option and it DOES work.

 

[Ridryder911]

LOL Wrong because its not in a book, or wrong because it doesn't work? I certainly don't suggest going off the reservation, thats why I said Medical control, but as a BLS provider, you have no options. Opening the pre existing hole CAN relieve the pressure, to suggest otherwise is false. I'm not telling anyone to go out there and do it, however it IS an option and it DOES work.

Why perform such a procedure if there is more appropriate and better way to treat a patient. Have you ever wondered why it is NOT taught or placed in curriculum's?
As a BLS provider you do have options. The way you are taught and allowed to perform. Anything else is performing (unapproved medical procedures) and practicing medicine without a license = litigation and jail time.

Remember the parts that has be to proven for gross negligence? ...hint: actions as other with the same license/certification would had have acted or performed the same as the actions you performed. As well; followed approved procedure(s) (based upon national and local curriculum/standards).

As well, I doubt there is a physician (if they like to keep their license and low malpractice) they will give an order of such. I would hope they would not to tell you to take actions above your level or at least an approved medical procedure.

Place a 3 sided occlusive dressing as taught and rendezvous with ALS, or rapid transport.

It's great to make recommendation(s) on EMS forums, but let's give sound medical advice that is approved and at least is legitimate by an authority body.

I would not even suggest discussing with your Medical Director, as they might percieve you as a "cowboy" and dangerous type.

R/r 911

 

[boingo]

But as an EMT B there is no way to treat this patient. The patient is in extremis and is going to die in short order. Tension pneumothorax is a life threatening emergency, and since an EMT B doesn't have the equipment or education to decompress a chest, the simple insertion of a finger, or opening the wound with traction can allow built up air to escape. I don't advocate anyone going out there and doing it, don't advocate breaking protocal, just pointing out that there are techniques other than a large bore needle that can help alleviate tension pneumothorax. I appologize to anyone who may have been given the impression that it was ok for them to try it tonight.

 

[Ridryder911]

Hence the need for Paramedic Life support on all EMS units.

R/r 911

 

[traumateam1]

Haha shoulda read rest of the posts before typing that long reply. -sigh- oh well.

 

[Sasha]

But as an EMT B there is no way to treat this patient. The patient is in extremis and is going to die in short order. Tension pneumothorax is a life threatening emergency, and since an EMT B doesn't have the equipment or education to decompress a chest, the simple insertion of a finger, or opening the wound with traction can allow built up air to escape. I don't advocate anyone going out there and doing it, don't advocate breaking protocal, just pointing out that there are techniques other than a large bore needle that can help alleviate tension pneumothorax. I appologize to anyone who may have been given the impression that it was ok for them to try it tonight.

How would opening a sucking chest wound even more provide pressure relief?

 

[boingo]

Because if the air is able to enter but not exit the chest the pressure (tension) will continue to rise leading to rapid cardiovascular collapse. Opening the defect to digitally decompress the chest would allow the air under pressure to escape. After the pressure has been relieve, an occlusive dressing would be applied to prevent any air from entering the chest via the defect.

 

[BossyCow]

Because if the air is able to enter but not exit the chest the pressure (tension) will continue to rise leading to rapid cardiovascular collapse. Opening the defect to digitally decompress the chest would allow the air under pressure to escape. After the pressure has been relieve, an occlusive dressing would be applied to prevent any air from entering the chest via the defect.

And while you are mucking around in there with your finger... the air is prevented from going in how?

 

[boingo]

And while you are mucking around in there with your finger... the air is prevented from going in how?

Because of the law of physics. The air inside the chest is under much higher pressure than outside, therefore when the chest is opened to atmospheric pressure, the net movement of air is OUT of the chest, not in. After the pressure is released an occlusive dressing would prevent the movement of air back into the chest.

 

[Sasha]

Because of the law of physics. The air inside the chest is under much higher pressure than outside, therefore when the chest is opened to atmospheric pressure, the net movement of air is OUT of the chest, not in. After the pressure is released an occlusive dressing would prevent the movement of air back into the chest.

In THEORY. But if that were the case, wouldn't the air move out of the smaller hole to begin with? Why would you need to make it bigger? Because when someone tries to inspire, they pull air INTO the chest, and you have created a bigger hole for the air to go INTO.

I would not recommend that, or suggesting that to ANYONE because you'll wind up in court with a wrongful death lawsuit.

 

[boingo]

Some wounds act as a one way valve, where air is pulled in, but cannot escape. This isn't theory, its fact. I am not suggesting anyone deviate from protocol or attempt this because I posted it. The fact is, digital decompression works, I've done it, it is taught by the trauma surgeons here during ATLS and it other con-ed. Anyone who has ever put in a chest tube can attest to the fact that air under pressure will rapidly escape once the pleura has been penetrated.

 

[BLSBoy]

If the tension is caused by a penetrating chest injury you could insert your finger and decompress it. It is not in your protocol, its not taught in EMT or medic school, but by opening the wound in the chest you can effectively release the pressure. I would certainly consult your medical control prior, however at the BLS level, without ALS available and a distance to the hospital, you don't have many choices. Your patient will die quickly, or you will think outside the box.