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Wed Sep 17 01:24:47 BST 2008

Hi Larry,
We don't see as many as we used to, but we still see far to many , with very little justification. I am afraid that there is still an element of 'have a skill so use it' and I am convinced that many individuals are confused by their training into thinking that this is a very common problem in RTCs and to miss one would be shameful, so they stick a needle in just in case!

As for genuine tensions, I see more in the ICU then pre-hospital. In the last 20 years Pre-hospital work, I can count on only two hands the number that have been 'real' tensions. clinically.
Mark F
UK

----- Original Message ----
From: Larry Torrey <LTorrey at maine.rr.com>
To: "Trauma & Critical Care mailing list" <trauma-list at trauma.org>
Sent: Wednesday, 17 September, 2008 12:58:05 AM
Subject: Re: Needle Decompression

Do you see a lot of these procedures?  I work in a teaching hospital in 
a major US city, and see one, maybe two per year come in the door from EMS.

LT

MARK FORREST wrote:
> 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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