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Mon Apr 10 20:22:18 BST 2006

My post was specifically aimed at procedures such as chest tubes.  Even 
emergency surgical airways are of benefit.  As for the needle: You'll not 
get much of an argument from me there.  Let the air out.  It might help.

But, I have been a field medic in a busy urban setting.  Under the best 
circumstances you really can't appreciate a tympanitic chest or even 
diminished breathsounds, unless nearly absent.  The ambulances these days 
are, by and large, disel engines (loud) and scenes are controlled chaos.  
The patient is lying on a board, next to a car...jaws of life motor in the 
back ground, light generators, 20 EMS, fire, police and media people...all 
talking/yelling...helicopter ready for hot load in down the road... a couple 
of fire trucks, ambulances and police cars running...traffic going around 
you...and you expect me to believe that a definative dx of tension ptx can 
be made?  Dubious at best.

So, let's look at the question posed:  Distened neck veins and tracheal 
deviation.  Be honest with yourselves out there: how many have you really 
seen?  Before you answer, consider this months J of Trauma.  A retrospective 
study of lethal tension ptx in strictly penetrating chest trauma found only 
3-4% in combat (Vietnam).  Can we assume this number would go up in the 
civilian setting with the addition of blunt numbers?  Most likely.  
Significantly...unlikely.  Dr Mattox's book (well, my 2nd ed) quotes an 
overall prevalence of 20% in chest trauma patients.   That's all 
pneumos...not tension.  Tension makes up a much smaller number.  Most simple 
ptx do not progress to tension.  Hell, before everyone got CTs, we missed 
50% of the ptx that were there (on plain x-ray):

So, here's my answer: it's a question.  Can you honestly say to yourself 
"THIS IS A PROVEN, HELPFUL PRE-HOSPITAL INTERVENTION".  If you can, stick 
the needle.  If you can't...haul ass.

Getting blood out of the chest (ie: tube thoracostomy) is as much diagnostic 
as it is therapeutic.  Take an isolated GSW to the right chest.  These 
happen in young people who can safely "one-lung" ventilate for some time.  
Getting the blood out quantifies the volume loss and decreases the risk of 
empyema.  Tension hydrothorax is rare.

It's true that this doesn't fit every scenerio, but it covers most.  The 
rest, we play by ear.  Obviously a COPD'er isn't going to do as well with 
one lung dropped.

EMS folks:  Keep up the good work.  Don't get caught up in interventions of 
dubious benefit and don't be offended by the "scoop and run" mentality.

By all means, please give Dr. Mattox the respect he is entitled to.  If 
nothing else, he makes us think.  I wish I would have been trained by him.

RD

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