tension pneumo + hypotension

[zzyzx]

Several EMS systems here in California have adjusted their protocols for needle decompression by saying that the medic can only decompress (w/o an order) when hypotension if present.

It's been my understanding that hypotension in a tension pneumo is a very late sign. Isn't this correct?

Apparently these protocol changes have been made because there's been a large percentage of needle T's done on patients who didn't in fact have a pneumo.

 

[DallasFireRescueMedic]

Since your question is related to hypotension, I think you mean a Hemothorax as opposed to a Pneumothorax. Anyway, I'm with you. Although the thoracic cavity can hold a substantial amount of blood, I would think a person with a hemo or hemo/pneumo is likely circling the drain even prior to presenting with hypotension.

Let's visualize what they are asking... You've got an 18yr old PT drowning in his own blood and by all indications, he has pneumo. They want you to stand over him with a needle waiting for his BP to drop low enough for you to stick him? Heck, why not just wait until he goes into cardiac arrest so you can be 100% certain he even needs medical attention.

My insignificant opinion would be to train on how to better diagnose the problem rather than wait until you have multiple problems on your hands, i.e. - hypotention.

 

[Akulahawk]

I would say it more like this: in those systems, a Paramedic may only decompress a tension pneumo on standing order in the presence of hypotension.


Yes, it's a late sign, but probably not so late as tracheal deviation...

For example, Sacramento's protocol is (under Trauma)

If all the following are present in a patient:
1. Severe respiratory distress.
2. SBP less than 90 mmHg or loss of radial pulse due to shock.
3. Unilateral decreased breath sounds with a history of chest trauma.

 

[mycrofft]

Welcome back!
Read this (Merck Manual):

http://www.merckmanuals.com/profess...tinal_and_pleural_disorders/pneumothorax.html

"Tension pneumothorax is suspected in patients with sudden, unexplained hypotension and dyspnea or some risk factor, particularly positive pressure ventilation. If such a patient also has signs of pneumothorax, such as decreased breath sounds and hyperresonance to percussion, tension pneumothorax should be assumed".

Tx: immediate needle decompression, oxygen admin, and stuff better done in hospital (chest tubes, observation and CXR).

 

[Handsome Robb]

Since your question is related to hypotension, I think you mean a Hemothorax as opposed to a Pneumothorax. Anyway, I'm with you. Although the thoracic cavity can hold a substantial amount of blood, I would think a person with a hemo or hemo/pneumo is likely circling the drain even prior to presenting with hypotension.

Let's visualize what they are asking... You've got an 18yr old PT drowning in his own blood and by all indications, he has pneumo. They want you to stand over him with a needle waiting for his BP to drop low enough for you to stick him? Heck, why not just wait until he goes into cardiac arrest so you can be 100% certain he even needs medical attention.

My insignificant opinion would be to train on how to better diagnose the problem rather than wait until you have multiple problems on your hands, i.e. - hypotention.

A tension pneumo most definitely can cause hypotension, doesn't have to be a hemopneumo or hemothorax.

If they do have the hemo or hemopneumo do you think a 14g angiocath is going to actually do anything for that person's condition?

I'm sure you know that since I'm assuming you've been around longer than me.

 

[usalsfyre]

The defining characteristic between a large, but still simple pneumo and one that has tensioned tends to be hypotension, as a tension pneumo will kink the IVC.

Since your question is related to hypotension, I think you mean a Hemothorax as opposed to a Pneumothorax. Anyway, I'm with you. Although the thoracic cavity can hold a substantial amount of blood, I would think a person with a hemo or hemo/pneumo is likely circling the drain even prior to presenting with hypotension.

First, there's no such thing as a "tension hemo". It would take more blood than is currently circulating in the body.

Let's visualize what they are asking... You've got an 18yr old PT drowning in his own blood and by all indications, he has pneumo.

If it's a hemothorax, they won't be "drowning in their own blood". A hemothorax is in the pleural space which is outside of the lung parenchyma and therefore not subject to blood entering the alveolar space. A pulmonary contusion, where there is blood in the alveolar space, is not helped by a needle because the needle stays in the pleural space. They need suction and PEEP.

They want you to stand over him with a needle waiting for his BP to drop low enough for you to stick him? Heck, why not just wait until he goes into cardiac arrest so you can be 100% certain he even needs medical attention.

Needle decompression is not indicated for hemothorax, it won't help. A tube thoracostomy is, but that's clamped after so much blood return is noted because as you note, the thoracic cavity holds a decent amount of blood. It's very possible for (and I've seen) a patient exanguante on to a trauma room floor post thoracostomy.

My insignificant opinion would be to train on how to better diagnose the problem rather than wait until you have multiple problems on your hands, i.e. - hypotention.

As I said before, hypotension is the hallmark sign between simple vs tension pneumo. When decompressed, they get instantly better in most cases.

 

[mycrofft]

How about auscultative signs? Blood doesn't sound like air, and mechanism suggests diagnosis. (Ditto other clinical signs, since haemo by itself won't progress to a deviated cryc, it tends to kill first, right?).

Maybe a good assessment could one day be considered basis for a needle decompression, except it is really more of a "recon in force"; if it's a pneumo, good start. If it's a haemo, then withdraw the needle and go for Alternative 2.
In those cases a portable ultrasound does start to sound good, even to me.

 

[Shishkabob]

Several EMS systems here in California have adjusted their protocols for needle decompression by saying that the medic can only decompress (w/o an order) when hypotension if present.

It's been my understanding that hypotension in a tension pneumo is a very late sign. Isn't this correct?

Late sign? Sure... but that's really the only time it needs to be done anyhow (usually seen along with severely increased ventilatory effort and crappy sats). Not all pneumos become tension pneumos, and having a pneumothorax without the tension aspect isn't that big of a deal. All they'll get at the hospital is a chest x-ray and a lookey-loo.

 

[mycrofft]

Yeah. In fact, a not-uncommon sequelum to a pneumothorax is other, usually smaller, pneumothoraces. ("-thoraxes"?).

 

[MSDeltaFlt]

Several EMS systems here in California have adjusted their protocols for needle decompression by saying that the medic can only decompress (w/o an order) when hypotension if present.

It's been my understanding that hypotension in a tension pneumo is a very late sign. Isn't this correct?

Apparently these protocol changes have been made because there's been a large percentage of needle T's done on patients who didn't in fact have a pneumo.

Yes, zzyzx my friend, it is a late sign. And, unfortunately, you are in the same boat as myself. You are apparently a victim of the weakest link(s). Because some of your colleagues have been promoted beyond their abilities, everyone must suffer the consequences.

 

[FLdoc2011]

Honestly that's how I think it should be pre-hospital. Certainly risks to it and if hemodynamically stable then supportive care until you can get them to an ER to verify a PTX where a tube thoracostomy can be performed.

I've had to do a few needle decompressions here in the hospital even before X-ray has a chance to get there only because they were hemodynamically unstable with other risk factors so it was pretty obvious, but even then it was a little nerve wrecking.

Like others have side, it's not the tx choice for hemothorax. And if they're not actively crashing/unstable then they can prob wait a little for the hospital. If unstable/hypotension then it can be life saving, go for it, if not then it would extremely poor form to do it and hit an artery and add to the problem.

 

[Smash]

I have no real issue with waiting for hemodynamic compromise or respiratory distress. I wouldn't necessarily wait for frank hypotension per se, but deteriorating hemodynamics in the setting of presumed pneumothorax is not unreasonable (assuming other factors are taken care of, or are being taken care of)

The trouble with the traditional signs of pneumothorax is that they are all either late or very subtle. Auscultation is unreliable and tracheal deviation is usually very subtle.
If respiratory/hemodynamic compromise is present we are pretty aggressive with decompressing, but there does have to be suspicion first, and some compromise second.

If the patient has a simple pneumothorax that has not converted to a tension pneumothorax, I don't see the benefit in poking more holes in them. Wait until a proper chest tube can be placed (unless extenuating circumstances such as aeromedical evacuation are present) Like FLdoc says, it's pretty bad when someone without a tension gets a needle through their internal mammary for no reason.

 

[Doczilla]

Anyone remember the saying "people don't suddenly crash, people suddenly notice"?

Hypotension takes the back burner to airway in this case. You'll see low sats, poor compliance, and shallow end-inspiration before you see hypotension in my experience. If hypotension if your "clue", then you've been missing a whole lot before that. Also,with cocominant injuries, the hypotension may be completely unrelated.

 

[Veneficus]

Tracheal deviation as a late sign drives me nuts

The trouble with the traditional signs of pneumothorax is that they are all either late or very subtle. Auscultation is unreliable and tracheal deviation is usually very subtle. .

Thank you...

Everytime I see somebody claim tracheal deviation as a late sign makes me want to manually deviate their trachea.

I have tried to hunt down the source of this misinformation and nearly a decade ago actually figured I narrowed down to where it comes from.

In many US paramedic texts, there are quotes out of context from actual medical textbooks. (with the language usually dumbed down) In this particular case, "tracheal deviation" as a sign was kept, but the definition was not, from surgical textbooks of the 70s and 80s.

Tracheal deviation is defined as 3mm or more from an imaginary line between the mental symphysis and the center of the suprasternal notch. It is not a late sign.

Even under the best of circumstances is difficult to detect and assumes normal fusion of the mandible and no variation in sternal position. However, using a piece of suture (I was taught how to look for it by an old school surgeon in the US) or another type of plane can help greatly in measuring.

The gross deviation which everyone imagines as "tracheal deviation" is a late sign, but by the time you actually see it, you really missed many earlier signs or you didn't get to the patient in time to really help. This seems to be what is passed down through EMS education but it is definately not the full story.

Perhaps the people who perpetuate it thought they figured out an obvious error that surgeons overlooked?

 

[Akulahawk]

Anyone remember the saying "people don't suddenly crash, people suddenly notice"?

Hypotension takes the back burner to airway in this case. You'll see low sats, poor compliance, and shallow end-inspiration before you see hypotension in my experience. If hypotension if your "clue", then you've been missing a whole lot before that. Also,with cocominant injuries, the hypotension may be completely unrelated.

Unfortunately, until recently (past 10 years or less), the protocols I saw for treating tension pneumo were all keyed to tracheal deviation... Never mind that we were also taught those other signs for pneumothorax. We just weren't allowed to do a needle thoracostomy unless/until those signs and tracheal deviation occurred. The other thing that "they" drummed into our heads is that if we do a needle thoracostomy and the patient didn't have a pneumo or it wasn't bad enough yet, we just put the patient right down the path to a chest tube if the patient wasn't going to need one...

 

[medicsb]

Thank you...
Tracheal deviation is defined as 3mm or more from an imaginary line between the mental symphysis and the center of the suprasternal notch. It is not a late sign.

I'd like to meet a physician who can reliably detect a 3mm deviation of the trachea without a radiograph.

 

[Dwindlin]

I'd like to meet a physician who can reliably detect a 3mm deviation of the trachea without a radiograph.

Or one that cares about 3mm. . .

 

[medicsb]

Or one that cares about 3mm. . .

Hah, or that.

 

[OzAmbo]

Pneumothoracies will always have a degree of tensioning, whether they have enough to be clinically significant is a different story but its not possible to have free air in the pleural space without it being equal ot or greater than the atmosphere as the drawn in by negative pressure and then not allowed to escape.

Im surprised that you would have to wait for them to become so compromised before you intervene, toying with a respiratory arrest after they become hypoxic or intervening when the signs of poor perfusion are becoming evident i would have thought earlry intervention would be better than chasing the eight ball once they are ready to drop their bundle.

 

[Veneficus]

I'd like to meet a physician who can reliably detect a 3mm deviation of the trachea without a radiograph.

Since I was taught to do it by a surgeon, I would say it is rather easy, without a radiograph. But does require something to measure with.

While radiographs are a great tool, it is important to be able to function and make decisions when they are not available. (austere environments, disasters, etc.)

Doctors who don't care?

They are found everywhere, that is a problem beyond my ability to solve.

Doctors who require large amounts of technology to function because of their lack of knowledge should probably not advertize that too loudly.

But it does not excuse the perpetuation of inaccurate teaching.