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Tue Sep 16 14:24:42 BST 2008

It's Ross, to colleagues, LT ;)

The indication for needle decompression is tension pneumothorax.  This is a
clinical diagnosis based, in my mind, on a collection of 'hard' and 'soft'
signs.  The 'hard' signs are decreased breath sounds, ipsilateral
hyperresonance to percussion, and a trachea displaced to the contralateral
side.  The 'soft' signs are chest pain, tachycardia, tachypnoea,
hypotension, distended neck veins, and a notable amount of distress in
concious patients.  Diagnosis is confirmed by perceptible rush of air from
the cannula, resolution of the tracheal displacement and usually an
improvement in the patient's respiratory symptoms.

One should be VERY cautious before performing a needle decompression on a
patient in the field who does not have all three 'hard' signs, especially if
they are not in extremis - decreased breath sounds with hyperresonance
WITHOUT tracheal deviation is likely a simple pneumothorax; dull percussion
implies hemothorax in the presence of penetrating trauma, etc.  To me, the
cardinal sign is mediastinal shift demostrated by tracheal deviation.

R. 

Dr Ross Hofmeyr
Expedition Leader  & Doctor
South African National Antarctic Expedition
ross.hofmeyr at sanae.sanap.ac.za
wildmedic at gmail.com
Tel: +2721 405 9428
Skype:  wildmedic
"Semper Paratus"

> -----Original Message-----
> From: trauma-list-bounces at trauma.org 
> [mailto:trauma-list-bounces at trauma.org] On Behalf Of Larry Torrey
> Sent: 16 September 2008 12:44 PM
> To: Trauma &amp; Critical Care mailing list
> Subject: Re: Needle Decompression
> 
> Dr. Hofmeyr,
> 
> What do you believe the indications to be?
> 
> Best,
> LT
> 
> 
> Dr Ross Hofmeyr wrote:
> > Sahaj, welcome to the inside of the worm can...
> > 
> > My overall opinion is similar to Pret - if you're getting 
> blood back 
> > it is either from the lung (in which case you've just 
> caused a nasty 
> > problem), from the pleural cavity (in which case you have 
> far bigger 
> > problems) or from a vessel (in which case, you've caused ANOTHER 
> > problem).  In the case of the first or third situation, I'd rather 
> > pull it out.  In the second case, it is going to be draining pretty 
> > slowly and will likely clot up anyway, so pull it out.  I 
> remain unconvinced that a 'tension hemothorax' can exist.
> > 
> > Needle decompression remains a thorn in the side of many trauma 
> > doctors (pun intended), because it is used FAR more often than 
> > indicated.  You need to be VERY clear on the indications for 
> > performing a decompression in the first place - hypotension and 
> > decreased breath sounds are NOT the indications, as suggested to me 
> > several times in the past by both pre-hospital personnel 
> and doctors attending ATLS tuts...
> > 
> > R.
> > 
> > Dr Ross Hofmeyr
> > Expedition Leader  & Doctor
> > South African National Antarctic Expedition 
> > ross.hofmeyr at sanae.sanap.ac.za wildmedic at gmail.com 
> ross at wildmedix.com 
> > www.wildmedix.com
> > Tel: +2721 405 9428
> > Skype:  wildmedic
> > "Semper Paratus"
> >  
> > 
> >> -----Original Message-----
> >> From: trauma-list-bounces at trauma.org 
> >> [mailto:trauma-list-bounces at trauma.org] On Behalf Of Sahaj Khalsa
> >> Sent: 16 September 2008 04:48 AM
> >> To: Trauma &amp, Critical Care mailing list
> >> Subject: Needle Decompression
> >>
> >> Hello all,
> >>
> >> Many thanks to all of those who have been keeping all of 
> us updated 
> >> about their situations during this horrible hurricane 
> season.  I have 
> >> lots of family in Houston so I felt like I had a more real 
> and direct 
> >> line to what was going on than the news, which was great.  Our 
> >> thoughts and prayers are with all of you who are still recovering 
> >> from all of the devastation.
> >>
> >> So I am interested in the opinions of anybody on this list 
> who cares 
> >> to share them and has a few spare minutes...
> >>
> >> I am a Paramedic and a paramedic instructor and we are 
> trained that 
> >> when we decompress a chest (usually with a 14 ga
> >> catheter) and get blood flow back, we should pull the 
> catheter.  Why?
> >>
> >> I have discussed this with a number of the ER docs that I 
> work with 
> >> and there is no real clear consensus.  Some of them say 
> that I should 
> >> leave the catheter in the chest as relieving the pressure 
> is a good 
> >> thing, whether that pressure is caused by blood or air.  However, 
> >> most Paramedic textbooks advise us to pull it.
> >>
> >> Assuming that I have put the dart in correctly (and have 
> not hit the 
> >> vessels in the chest wall), understanding that I do not have the 
> >> capability of putting in a chest tube and that I am often 
> times more 
> >> than 60 minutes by ground from the nearest hospital with no 
> >> alternative transport (helo) available, what is your opinion?
> >>
> >> Any replies would be appreciated.
> >>
> >> Sahaj Khalsa
> >> --
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> > 
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> 
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