Needle Decompression Landmarks (Or Lack Thereof)

[Tigger]

While interning I ran a mid 20s female who was ejected during a rollover. She was very combative and required a BVM to prevent her from going apneic, had a variety of orthopedic injuries, and I guess what you could call a flail segment on her left chest, except really her left chest was the flail segment. Pretty much absent breath sounds on that side, and her pressure dropped thirty points between being found in a field by fire and being moved to the ambulance.

In short, she needed to be decompressed and she needed to be RSIed (we also had a significant wait on the helicopter and a much a 45 minute code three ride to a trauma center). I wanted to decompress her prior to intubating for better conditions, but I could not find any landmarks. She was already overweight and most of the ribs were detached from her sternum and shattered everywhere else that I could feel them, which was difficult enough with the adipose tissue and all.

No one was willing to decompress her as a result, not the two paramedics on scene with me nor the flight crew. I have since been told a hand's width down from the axilla is a good enough approximation to the 4th or 5th intercostal space though I have not backed that up yet.

What would you do when faced with this situation?

 

[VentMonkey]

What would you do when faced with this situation?

Dug deep to find the landmark. How morbidly obese/ overweight are we talking? I've had my fair share of healthy patients, and found if I dug deep enough that you can find their landmarks.

I think your train of thought was right, and find it interesting everyone else was so opposed to decompression (what was their reasoning?). I had a similar case with a flail segment, and tension pneumo. As soon as we go to the patient, I performed it, and the "classic" rush of air was heard immediately.

The order of your sequence (decompression--->RSI) is good to. Something also worth mentioning is CPAP has been found to actually splint the segment from the inside out without having to RSI, and/ or ETI these folks. Of course, this assumes they can physically, and hemodynamically tolerate it.

 

[DesertMedic66]

Pretty sure the same thing would happen with a majority of the medics here. If I am unable to locate then I am not going to dart.

 

[Carlos Danger]

As long as you stay lateral to the MC line there isn't much to worry about hitting, in terms of vasculature or other important structures. The traditional landmarks are only approximations anyway.

 

[SandpitMedic]

Risk vs. reward.
Find it, as best you can.
If you don't, and she dies then you truly weren't being the best provider you could for your patient. There is another option.
The trauma center is still going to put in a chest tube... In the same spot you could attempt to decompress mid-axillary.
If you try and fail, you don't risk worsening this multisystem trauma much. The risk vs reward matrix for me says the rewards outweigh the risk.

The flight team should have put a chest tube in her. I would have gone that route.

 

[Tigger]

I was digging alright. I'd guess the patient weighed 250, but her chest wall was just mush. An inch lateral of the sternum and there were no more ribs to follow, just little bits and pieces.

I figured the damage was done in terms of lacerating vessels by the initial injuries, but everyone said they didn't want to hit anything and make it worse. The RSI did not go well (as you can imagine), she immediately desatted even with a cannula in. I think the flight medic ended up darting her enroute, but I was hoping they would at least do a finger thoracostomy before loading.

It wasn't a good call to have any part of. But I figure it's not impossible to have happen again and I want to know how to perform a decompression in that setting since the next time it will be making the decision and not my preceptor.

 

[TransportJockey]

A trick i learned for chest tube placement that might help. Find the bottom of the shoulder blade, follow it around, and you should be in the area of the mal sote

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[Handsome Robb]

I'd have darted her. Like Sandpit said the risk vs reward leans far towards reward in this scenario.


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[VFlutter]

I agree, attempt a lateral decompression. If she was peri-arrest and I truly could not get a needle I would consider calling OMC for a finger thoracostomy. We are trained in chest tube insertion but do not carry them.

 

[SpecialK]

This is exactly the reason we're changing to an open finger thoracostomy.

Yes, you can stick a needle in there, and that's what has been done for decades, but they can kink, block, fall out, not reach the pleural space or just in general be a pain in the bum. I personally have never decompressed a chest (and the average ICP is only doing maybe one a year if that?) but I've heard plenty from people who have much more experience than I it's less than 100% reliable.

Both Auckland and London HEMS plus Flight MICA in Vic are doing finger thoracostomy. ICPs are getting them in the next CPG update (soon) but I do not know if this will be for all ICPs, I imagine it will be.

 

[STXmedic]

We have a tremendous obese population down here. If we only darted the patients that we could definitively feel landmarks, our decompressions would be cut by at least half.

As Remi said, it's an approximation anyway and with relatively minimal risk. Dart them in roughly the right spot, err lateral rather than medial, and if you hit a rib slide over the top. To echo others- Risk vs Reward.

This is also a reason we moved to finger thoracostomies. My biggest worry in the above scenario would be not getting deep enough/not penetrating the pleural cavity, which is the most common reason for failure. Cut them and make sure you're in.

 

[NomadicMedic]

I was curious if you had a long enough dart. Think a 3" would have worked?

 

[Tigger]

I was curious if you had a long enough dart. Think a 3" would have worked?

Probably. I am still trying to convince the medical director to let us do finger thoracotomies. If he's ok with periocardiocentesis then he should be with that...

 

[FiremanMike]

While interning I ran a mid 20s female who was ejected during a rollover. She was very combative and required a BVM to prevent her from going apneic, had a variety of orthopedic injuries, and I guess what you could call a flail segment on her left chest, except really her left chest was the flail segment. Pretty much absent breath sounds on that side, and her pressure dropped thirty points between being found in a field by fire and being moved to the ambulance.

In short, she needed to be decompressed and she needed to be RSIed (we also had a significant wait on the helicopter and a much a 45 minute code three ride to a trauma center). I wanted to decompress her prior to intubating for better conditions, but I could not find any landmarks. She was already overweight and most of the ribs were detached from her sternum and shattered everywhere else that I could feel them, which was difficult enough with the adipose tissue and all.

No one was willing to decompress her as a result, not the two paramedics on scene with me nor the flight crew. I have since been told a hand's width down from the axilla is a good enough approximation to the 4th or 5th intercostal space though I have not backed that up yet.

What would you do when faced with this situation?

To be honest, I would have found a soft spot in the general vicinity and went for it.

 

[NomadicMedic]

To be honest, I would have found a soft spot in the general vicinity and went for it.

That's what i was thinking.

 

[MackTheKnife]

While interning I ran a mid 20s female who was ejected during a rollover. She was very combative and required a BVM to prevent her from going apneic, had a variety of orthopedic injuries, and I guess what you could call a flail segment on her left chest, except really her left chest was the flail segment. Pretty much absent breath sounds on that side, and her pressure dropped thirty points between being found in a field by fire and being moved to the ambulance.

In short, she needed to be decompressed and she needed to be RSIed (we also had a significant wait on the helicopter and a much a 45 minute code three ride to a trauma center). I wanted to decompress her prior to intubating for better conditions, but I could not find any landmarks. She was already overweight and most of the ribs were detached from her sternum and shattered everywhere else that I could feel them, which was difficult enough with the adipose tissue and all.

No one was willing to decompress her as a result, not the two paramedics on scene with me nor the flight crew. I have since been told a hand's width down from the axilla is a good enough approximation to the 4th or 5th intercostal space though I have not backed that up yet.

What would you do when faced with this situation?

Yes, Tigger. But if possible, use the patient's contralateral hand, not yours. This is what we teach the military in TCCC. Bottom line is if they need decompression, you need to decompress them. There is usually less adipose tissue in the axillary region. Was the pressure drop associated with a narrowing pulse pressure or pulsus paradoxus? if so, she probably had a TP.

 

[MackTheKnife]

I was curious if you had a long enough dart. Think a 3" would have worked?

SOMA Journal has shown studies that the "usual" 14 gauge, 3.25" needle is not always long enough for a chest tap even in a non-obese pt. And we're talking somewhat fit soldiers.

 

[StCEMT]

SOMA Journal has shown studies that the "usual" 14 gauge, 3.25" needle is not always long enough for a chest tap even in a non-obese pt. And we're talking somewhat fit soldiers.

That is one read I would like to dig through some day.