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Tue Sep 16 23:09:05 BST 2008

Pre-hospital needle thoracocentesis is probably the most over-used unnecessary skill in the EMS tool box. 
 All to often we see an RTC casualty with a minimal degree of respiratory compromise 'needled just in case'!!
Many of them have iatrogenic problems related to this action

However, I do agree with Tim, that in some rare cases that I have seen, pre-hospital throacocentesis (with a 14G cannulae) can be life saving. When it has been necessary, I actually remember that the 'hiss' has been genuinely loud, unlike the many innappropriate ones that I have seen with little if any postive sign or improvment.

As for diagnosis, the last pre-hospital one that I decompressed was the driver of a car in a high speed RTC who I was asked to see as he was very distressed with his breathing. From the backdoors of the ambulance I could see the hyperinflation, grossly unequal movement of his chest and his oxygen saturation of 75% on high flow oxygen! The paramedics actually heard the decompression 'hiss' outside the ambulance. He rapidly stabilised and was transported the short distance to hospital for an x-ray and a drain.

If you want to see 'real'clinical signs of tension then try the ICU. When these patients tension on IPPV they have some of the most barn door signs that you will ever see....including mid-line shift, which I have never seen pre-hospital.

Dr Mark Forrest
Consultant in Anaesthetics & Critical Care
Medical Director of Cheshire Fire & Rescue Service
Medical Director of ATACC

----- Original Message ----
From: Robert Waddell II <bobwaddell at bresnan.net>
To: "Trauma & Critical Care mailing list" <trauma-list at trauma.org>
Sent: Tuesday, 16 September, 2008 8:11:16 PM
Subject: Re: Needle Decompression

Thanks Tim, I'll try to get the paper.  Your comments have a greater  
volume than some may see in that the classic signs, especially those  
listed in most of the text, include deviated trachea.  I believe it  
was Lee in the 80's who showed through a large post evaluation  
analysis that tracheal deviation occurred in non-viable (dead)  
patients and was an extremely late sign and demonstrated that looking  
for the deviation wasted time and aided in the practitioner loosing  
focus of the treatable injuries.  Maybe it is time for main stream EMS  
to re-think the "why we do what we do" and get back to a stronger  
focus on the patient we're caring for and their positive outcomes.  
Thanks again.

Take care,

Bob
bobwaddell at bresnan.net
307 920 2020

On Sep 16, 2008, at 12:53 PM, Coats Tim - Professor of Emergency  
Medicine wrote:

>
> Several posts on this thread have mentioned the 'classic' signs of  
> tension pneumothorax. However there is a very good paper from the  
> Emergency Medicine Journal in 2005 that should make you rethink and  
> question. See:
>
> Leigh-Smith S, Harris T. Tension pneumothorax—time for a rethink?
> EMJ 2005;22:8–16.
>
> What SImon and Tim showed was that 'classic' signs of tension  
> pneumothorax are based on operative experience in an anaesthetised  
> patient, where compensatory mechanisms have been reduced. In the non- 
> anaesthetised patient there may be a number of compensatory  
> mechanisms which means that the 'classic' signs may well not be  
> present. My experience is that in a non-anaesthetised patient the  
> 'classic' signs of tension pneumothorax only occur periarrest.
>
> On the issue of 'does field needle thorocostomy work?' my experience  
> is yes, but only very occasionally. It is certainly not as important  
> an intervention as some prehospital trauma courses make out.
>
> Tim Coats.
> Professor of Emergency Medicine.
> Leicester University, UK.
>
>
>
> -----Original Message-----
> From: McSwain, Norman E Jr. [mailto:nmcswai at tulane.edu]
> Sent: Tue 9/16/2008 4:14 PM
> To: Trauma &amp; Critical Care mailing list
> Subject: RE: Needle Decompression
>
> See my comments from the two previous postings this morning. I would
> only add that I have used it several times in the field myself with
> apparent success. I say apparent because there were no radiographs to
> prove a anatomical pathophysiological improvement. General improvement
> in the patient's condition that made me believe that something had  
> been
> accomplished by it
>
> Norman
>
> Norman McSwain Jr, MD FACS
> Trauma Director Charity Hospital
> Professor of Surgery
> Tulane University School of Medicine
> 504 988 5111
>
>
> -----Original Message-----
> From: trauma-list-bounces at trauma.org
> [mailto:trauma-list-bounces at trauma.org] On Behalf Of kmattox at aol.com
> Sent: Tuesday, September 16, 2008 9:23 AM
> To: Trauma &amp; Critical Care mailing list
> Subject: Re: Needle Decompression
>
> I for one have never been impressed, nor seen real benefit from needle
> decompression of the chest.
>
> K
>
>
>
> ------Original Message------
> From: Dr Ross Hofmeyr
> Sender: trauma-list-bounces at trauma.org
> To: 'Trauma &amp; Critical Care mailing list'
> ReplyTo: Trauma &amp; Critical Care mailing list
> Sent: Sep 16, 2008 9:04 AM
> Subject: RE: Needle Decompression
>
>> You put
>> in in for proper indications ( decreased breath sounds,
>> decreased oxygenation) then is doing its job allowing the
>> lung to expand (blood or air they both can compress the
>> lung).
>
> *Screeches to halt*
>
> Holdonamminit - how, pray tell, does a cannula in the chest help the
> lung
> expand?  Do you mean a cannula PLUS non-return valve of some form?
>
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