Bilateral tension pneumothorax? Oh my!

[rmellish]

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.

Physics aside, this is a horrible idea.

 

[traumateam1]

BLSBoy.... hahahaha!!!
That was halarious, thanks for the laugh after a long day.

 

[BLSBoy]

Glad I could help. Did ya get my last PM?

 

[traumateam1]

Glad I could help. Did ya get my last PM?

Yes, thank you!

 

[Ridryder911]

Here's the deal. I have audited ATLS (only physicians are allowed to obtain a certificate). I don't recall of ever inserting a finger to relieve a tension pneumo. It is taught to insert a finger into the site where a chest tube is to be place to locate the pleura lining. Remember more than physics, anatomy of a tension pneumo. Air is in the pleural space not the lung so pressure is between the spaces is causing the tension.

As well, not to mention it is not taught nor an approved medical procedure for any EMS personnel to perform. This thread should be locked as it is giving false teaching and possibly distributing wrong and harmful information (even if it was in the ALS section). Remember, the posts was about bi-lateral tension as well.

I will gladly testify against any EMT as an expert witness for those that performed such a procedure for free. It is NOT an approved approach nor should ever be performed in the field setting.

R/r 911

 

[traumateam1]

Here's the deal. I have audited ATLS (only physicians are allowed to obtain a certificate). I don't recall of ever inserting a finger to relieve a tension pneumo. It is taught to insert a finger into the site where a chest tube is to be place to locate the pleura lining. Remember more than physics, anatomy of a tension pneumo. Air is in the pleural space not the lung so pressure is between the spaces is causing the tension.

As well, not to mention it is not taught nor an approved medical procedure for any EMS personnel to perform. This thread should be locked as it is giving false teaching and possibly distributing wrong and harmful information (even if it was in the ALS section). Remember, the posts was about bi-lateral tension as well.

I will gladly testify against any EMT as an expert witness for those that performed such a procedure for free. It is NOT an approved approach nor should ever be performed in the field setting.

R/r 911

Advanced Trauma Life Support right Rid? Only physicians are allowed to get a cert. in the US?

 

[Ridryder911]

Yeah, one can be accepted to "audit" a course but must be a physician to be certified.

R/r 911

 

[boingo]

Please then, lock the thread in case someone gets the idea that our discussing digital decompression will lead to someone breaching protocol. Do a little research before you discount the procedure.

BLS Boy: You haven't even worked ALS, you're two months out of a Florida medic mill, so you FAIL. I will debate Rid all day, for at least he speaks from his own, lengthy experience. I won't necessarily agree with him, but he's earned the right. When you have several more years of education and experience please feel free to add to the conversation, Padawan. :blush:

 

[apagea99]

Some part of me should have known this would devolve into some sort of argument that has nothing to do with the actual questions I asked LOL

So....I'll re-post them and see if they get answered.

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?

 

[Sasha]

Please then, lock the thread in case someone gets the idea that our discussing digital decompression will lead to someone breaching protocol. Do a little research before you discount the procedure.

BLS Boy: You haven't even worked ALS, you're two months out of a Florida medic mill, so you FAIL. I will debate Rid all day, for at least he speaks from his own, lengthy experience. I won't necessarily agree with him, but he's earned the right. When you have several more years of education and experience please feel free to add to the conversation, Padawan. :blush:

Considering this is posted in the BLS section, he didn't FAIL. He may or may not be from a medic mill, but at least he's not recommending some stupid, dangerous, and incorrect procedure. Don't discount someone becasue they have less experience than you, because lack of experience doesn't make you completely dumb, and experience, as you have shown here, doesn't make you automatically smart, and doesn't mean you know what you're talking about.

 

[boingo]

Yes, posting FAIL with stupid pictures adds to an academic discussion, sorry, I missed that part of school. I merely offered another option for decompressing a tension ptx caused by a penetrating injury, although I never condoned ANYONE perfoming outside their scope. I thought the professionals on this site enjoyed discussing these topics, even when the opinions differ, I guess I was wrong. As for stupid, dangerous, and incorrect procedures you clearly know nothing about it. If BLSBoy has an actual opinion other than FAIL, with some science of education behind it, I'm all ears. I don't have a problem listening to those with less experience, but his post offers no arguement, just juvenile humor. I'm done with this topic.

 

[traumateam1]

Yeah, one can be accepted to "audit" a course but must be a physician to be certified.

R/r 911

Oh, you just need to me advanced life support here in BC to take ATLS, and be a first responder/paramedic to take BTLS. Interesting.

 

[rescuepoppy]

Discussing Topics

Yes, posting FAIL with stupid pictures adds to an academic discussion, sorry, I missed that part of school. I merely offered another option for decompressing a tension ptx caused by a penetrating injury, although I never condoned ANYONE perfoming outside their scope. I thought the professionals on this site enjoyed discussing these topics, even when the opinions differ, I guess I was wrong. As for stupid, dangerous, and incorrect procedures you clearly know nothing about it. If BLSBoy has an actual opinion other than FAIL, with some science of education behind it, I'm all ears. I don't have a problem listening to those with less experience, but his post offers no arguement, just juvenile humor. I'm done with this topic.

Boingo you will find many people on this forum who will discuss topics with you. But if you are wanting a discussion you have to post something that is reasonable. Also be able to take advice and even cricism. When you make post like the one you did all you have done is open the door for someone to take shots at you.

 

[BossyCow]

Right, we're a lot less likely to jump all over someone who posts.. "Can this be done" instead of "Do this" One invites discussion, the other invites a whole other assortment of responses.

 

[ffemt8978]

I'm not going to lock this thread yet, because there is potential for a great discussion. However, I will be paying particular attention to this thread in the future.

Consider this your only warning...please keep this discussion civil and on topic (which it has done for the most part so far). If I have to lock this thread for any reason, rest assured that the person(s) responsible will get a short vacation from this forum.

 

[jrm818]

[...]some stupid, dangerous, and incorrect procedure [...]

I'm not going to comment on the advisability of performing surgical procedures as an EMT in extreme situations...that's for an individual to decide.

However, you sound a bit like you're attacking without doing much research. Try typing "digital decompression pneumothorax" into google scholar. Read the first paper (as an example..plenty of others. This one is a contemporary review with clinical advice, so it's particularly relevant): "Pleural decompression and drainage during trauma reception and resuscitation," Fitzgerald et. al 2008. Boingo didn't just make up some harebrained mcguyver procedure, it's a recognized technique (albeit in hospital in this context).

Stupid - maybe for an EMT, dangerous - possibly, but likely less so than needle decompression, incorrect - not really.

To wit, some relevant excerpts:

"Needle decompression of the chest is taught as a ‘life-saving’ procedure for patients in extremis with circulatory collapse secondary to tension pneumothorax.2 However, there is no evidence that needle thoracocentesis is a reliable or useful procedure for hospital trauma reception. Recent studies demonstrate significant failure rates associated with needle thoracostomy and the related technique of small gauge catheter-over-needle insertion"

"However, there is no evidence that NT is a reliable means of pleural decompression. The technique should be avoided during hospital trauma reception and resuscitation and used only as a technique of last resort. Blunt dissection and digital decompression should be the technique of first choice."

"However, blunt dissection and finger decompression appears to be a reliable and safe procedure and is the recommended procedure prior to chest tube insertion. Once successfully performed it reduces the urgency of the situation and allows time for the subsequent placement of a chest tube."

 

[jrm818]

As well, not to mention it is not taught nor an approved medical procedure for any EMS personnel to perform. This thread should be locked as it is giving false teaching and possibly distributing wrong and harmful information (even if it was in the ALS section).

R/r 911

What about EMS services that can insert chest tubes (I think they exist, especially HEMS...I may be wrong)? From what I can tell digital probing (which will likely cause decompression) is used to insert the tube. It would be approved for such a service, would it not?

 

[Ridryder911]

:

"Needle decompression of the chest is taught as a ‘life-saving’ procedure for patients in extremis with circulatory collapse secondary to tension pneumothorax.2 However, there is no evidence that needle thoracocentesis is a reliable or useful procedure for hospital trauma reception. Recent studies demonstrate significant failure rates associated with needle thoracostomy and the related technique of small gauge catheter-over-needle insertion"

"However, there is no evidence that NT is a reliable means of pleural decompression. The technique should be avoided during hospital trauma reception and resuscitation and used only as a technique of last resort. Blunt dissection and digital decompression should be the technique of first choice."
"However, blunt dissection and finger decompression appears to be a reliable and safe procedure and is the recommended procedure prior to chest tube insertion. Once successfully performed it reduces the urgency of the situation and allows time for the subsequent placement of a chest tube."

Okay a little clarity! It does NOT state to place finger into the wound! It describes to perform a blunt or finger decompression.... hence puncturing or incising another opening for a chest tube. For those that really know treatment that is done by trocar or styllete and then a sterile gloved finger is inserted to relieve the pressure followed then by a chest tube. The lining of the pleura and the lining of the lung is felt.

Again, not a simplistic and basic procedure.

The main problem I foresee is that this is a potential and negligent procedure. I am saddened that the moderators is still allowing this to even be discussed as a possible procedure to be performed by BLS and even ALS crews. I personally would hate to read where an EMT performed it as a last ditch procedure by reading this site.

 

[stephenrb81]

Up until reading this thread, I never had the SLIGHTEST idea there was a such thing as "digital decompression" for a tension pneumo.

Now, I am intelligent enough to know this is beyond my scope of practice and even if it was allowed, I am not trained and WOULD NOT attempt any maneuver based on an internet post/page/article without formal training.

Performing a medical procedure of any kind without formal training and beyond scope of practice is negligent in the U.S. Court of Law regardless if it "Saved a life". (I am pretty sure inserting a finger into someone's chest cavity is considered 'invasive' and therefore is above an EMT-B scope of practice lol)

I have to agree with r/r 100%, this is interjecting an idea into someone's mind that may be very impressionable and they may try it one day, therefore this could be contributing to their negligence.

EDIT: I realize there has to be injury for a lawsuit, but "saving a life" still wouldn't apply in a civil suit because an EMT-B caused further injury attempting this (Further lung damage, infection, etc...)

 

[jrm818]

I never said the article said "put a finger in the wound." That said, it seem to me that if there is already a sucking chest wound, digital decompression is possible without surgical dissection as there is already access to the pleural space - no need to make another incision. Dirty and cowboyish? No doubt? I suspect it would be effective in decompressing the chest nevertheless.

I'm was not trying to defend the use of this technique in the field, only pointing out to those that have (in some cases I think unjustified) flamed boingo's proposed technique that it has a basis in clinical literature and would probably work. At some gross level a hole is a hole, and if it's big enough for a finger and accesses the pleural space, it should work.

As for the allowance of the discussion: why not? Maybe it will spark discussion of the possibility of allowing it as an approved procedure (with proper training etc)? If that's a stupid idea it will soon become clear through educated posters such as yourself. That said the (small bit of) literature I've read about needle decompression suggests that that's not such a great technique. Its certainly a debate to be had.

EDIT:

The notion that it is a bad thing to raise awareness among prehospital providers about techniques performed in a hospital strikes me as ludicrous. Are you going to attempt open cardiac massage after hearing that some doctors do that? If anyone is impressionable enough to attempt a procedure after simply reading about it on EMTlife.com they have wayyy bigger problems and don't belong anywhere near a patient.

Sorry, I'm of the opinion that education is a GOOD thing. Learning about techniques in hospital can only increase a providers awareness of pathophysiology and treatment. Some here didn't understand how opening of a chest wound could help a pneumothorax....I suspect they now not only know something about digital decompression, but also understand better the pathophysiology of pneumothorax as a whole (need to understand that to understand theconcept of decompression)

Third: Progress occurs by discussing ideas that are outside the box or are not in use now. I don't see any reason that blunt dissection and digital decompression could not be taught as a prehospital treatment for pneumothorax...but in order for that to even be raised as a possibility the discussion needs to occur.