A very short scenario...

[EMT City Administrator]

Last chance to keep this tread alive. Any deviation from the tread will cause it to be locked.

[spenac]

No discernible lung sounds bilat, no wheezing/stridor, obvious extreme air hunger, cyanosis clearly present at lips, unable to speak, eyes panicked but tracking, PERRL, LOC steadily decreasing. Some diaphoresis, though not dramatic.

Tachy @ 176. Unknown BP though pulse is strong and full.

I'll take easy way since case was solved. But obviously check for airway obstruction. None found. Patient is still moving some air but very limited based on description. Attempt to assist breathing with BVM find very restrictive. Unconscious tube him, positive confirmation. Still restrictive to bagging. Only option is give relief. Bilateral chest decompression. Bilat chest decompression still warranted if he has not gone unconscious. He's broke bad and if you do nothing he will be dead by the time you reach the hospital. Since chest is so tight may want to consider multiple needles bilat, in order to get lungs and heart room to work.

[Ridryder 911]

Rid I am sorry you feel that way. SPO2 below 90 on high flow 02 and a BP below 90 indicates, (not always) that the pt most likely WILL be altered enough to tolarate a needle, possibly 2, going into his chest. If he is not altered and his sats and BP are good enough to get him to a hosp before they can get him a cxr to differentiate the two, I will wait, and refrain from placing a needle into someones chest. WE DO NOT DO PROFILACTIC CHEST DECOMPRESSIONS!!!! IT SHOULD BE DONE IN AN EMERGENT SITUATION WITH UNSTABLE VITAL SIGNS!!! You call me a cowboy medic, but atleast I know when IT SHOULD BE DONE IN THE FIELD!!! It is barbaric to place a needle in a chest without sedation while they are sitting up looking at you!!!! Even if they are altered, with vitals above what I have stated, nobody is good enough to totally differentiate tension from contusion!!! BP less than 90 indicates poor cardiac output, Sats below 90 indicates poor oxygenation !!! Couple those two with a history of chest trauma and a person who is altered, then you may think about placing a needle or two. You NEVER cease to amaze me with your STUPIDITY rid!!!

It is obvious you have limited trauma experience and training. Lower airway obstruction and blood pressure may have no commonality, unless one is hemmorraging or has potentially compromised vessels.

As according to current educational training courses such as sponsored by American College of Surgeons, the American College of Emergency Physicians and many other sponsored trauma care, delay of care to await signs of impending shock, V/q ratio can and may lead to death. This is why, even a chest x-ray should not even be awaited for before a decompression is made in an ER or Trauma Center, if they do they are incompetent.

Obviously as well, you have a misconception that a large pulmonary contusion is made every time a decompression is performed. As well, an understanding about pulmonary contusions. They are not considered an immediate life threatening injury in comparison to a tension pneumothorax.

As far as barbaric, I much rather decompress a conscious patient (if one has time a Lidocaine 2% can be administered) than to have the patient die. Tension pneumothorax is anImmediate Life Threatening injury that should be treated immediately, and any delay (as awaiting for drop in blood pressure, cyanosis, poor sat, tracheal deviation) is and has been proven to be negligent, according to the current standards. These are late and ominous signs. Treatment should have had been performed prior to the development of them. If one awaits for their patient to "be unresponsive" then it has been too late, and should be held accountable for gross negligent care.

Good assessment techniques along with mechanism of injury should be the indicator of immediate treatment. Remember, this is considered an lower airway obstruction and even awaiting a few minutes can be detrimental to the patient.

No, I am not endorsing chest decompression on every simple pneumo and again understanding the differential is why it is important to have in-depth knowledge of trauma care. Prophylactic decompression is made when there is NOT a tension pneumo, again this has nothing to do with vital signs or detectors. Rather it was made upon inaccurate physical findings and assessment. Although, it is not routinely endorced to be productive; many surgeons agree a simple pnuemo produced by a decompression is much better than having a undetected tension that was not treated.

Again, we need to be careful on recommendations. Especially when they are in direct conflict of current medical recommendations made by such organizations I described.

Instead of having argumentative discussion, and if one lacks an understanding I am sure there are plenty that can offer literature recommendations as well as references to course texts.

Again, this is not an personal issue rather poor and misguided advice that was given.

R/r 911

R/r 911

[DwayneEMTP]

CONTENT REMOVED - ADMIN

Good luck to you.

Dwayne

My apologies to all for slinging mud...Back to being a grownup now.. :oops:

[Mateo_1387]

:. Pulse oximetry isn't a diagnostic test that proves or disproves tension. Do you even know how a pulse oximiter works?

A person with a sat of 95 is NOT going to be cyanotic!!! Check your pulse ox my friend!! Lets look this over 95% sats probably meen that each heme molocule is almost full of 02](*,)

I got a pulse ox reading of 86 on my ambulance antenna once..........

[Kaisu]

My apologies to all for slinging mud...Back to being a grownup now.. :oops:

You were way provoked man... I wouldn't have even bothered to try... Your patience amazes me...

[spenac]

I got a pulse ox reading of 86 on my ambulance antenna once..........

Dude don't try and restir up the bull crap that went on earlier. I know you are trying to make light but not time or place. Thanks.

[Mateo_1387]

Dude don't try and restir up the bull crap that went on earlier. I know you are trying to make light but not time or place. Thanks.

certainly not my intention........just a little comedy !

[litteratissimus_medic]

For the sake of argument, I turned up an article from the Journal of Trauma-Injury Infection & Critical Care. Please keep in mind that the author in this context thinks that the current indications for needle decompression are "inappropriately low".

The decision to perform needle decompression in the awake patient must take into account many factors: (1) The patients’ clinical state and particularly its trend is important in deciding whether they are decompensating. The natural history of the disease is that decompensation may very rarely occur in as little as 20 minutes,1 although most take 30 minutes to 60 minutes.2 However, decompensation can take many hours,2 and the longest documented is 4 days.13 (2) Time to more advanced care is a factor as this allows more thorough examination along with abilities to perform chest radiography, chest drainage, and emergency anesthesia. (3) The likelihood of other thoracic injuries is important. The potential coexistence of flail chest and tension pneumothorax is a difficult circumstance, but in severe flail chest the patient may not be able to generate sufficiently negative intrapleural pressures to cause tension.2 Any iatrogenic pneumothorax could significantly worsen the situation if flail is present. (4) The mechanism of decompensation must be appreciated. There are no cases of sudden cardiac arrest in awake tension pneumothorax as it is a hypoxic disease not a cardiovascular one, and the likely end stage is respiratory arrest.2,14 (5) Unilateral or bilateral decompression? Not a single case report exists of bilateral tension pneumothorax in awake patients.2 An attempt must be made to lateralize the disease before performing needle decompression so as to avoid unnecessary bilateral decompressions. The chest signs may be very subtle, however, and require careful examination.2 Very rarely should bilateral needle decompressions be indicated.

The only absolute indication for needle decompression is decompensation:

* Spo2 <92% on high-flow O2

* Systolic blood pressure <90 mm Hg (in absence of other cause)

* Respiratory rate (RR) falling from previous high RR (>35) (in absence of e.g., opiates, head injury)

* Decreased level of consciousness on high-flow O2

However, it is recognized that decompensation is a late stage in the disease and it may be appropriate to decompress earlier. It may be reasonable to consider unilateral needle decompression when the following criteria are met:

* One-way valve dressing (e.g., Asherman chest seal) on open chest wounds

* Oxygen applied

* Extreme respiratory distress

* RR >35/40

* Single words only

* Anxiety excluded as cause of tachypnea (consistent— no drops in respiratory rate)

* Progressive—repeated observation during a 5-minute period

* Chest signs allowing lateralization of the condition

* Pneumothorax signs

* Hyperexpansion and hypomobility

* Tracheal deviation

* Caution exercised in severe flail chest

In summary, although potentially life saving, needle decompression should not be used indiscriminately. The “if in doubt . . .” mentality should no longer be acceptable and future work should aim to refine the indications suggested above.

Citation: Leigh-Smith, Simon MB, ChB, MRCGP, FRCSEd, MSc, Dip IMC, FCEM; Davies, Gary MBBS, MRCP Indications for Thoracic Needle Decompression. Journal of Trauma-Injury Infection & Critical Care. 63(6):1403-1404, December 2007.

[Ridryder 911]

I thought this portion of the articles was interesting ..." Unilateral or bilateral decompression? Not a single case report exists of bilateral tension pneumothorax in awake patients".....Apparently the authors did not investigate very well, I personally seen two this last year. One documented in a response I made and one in a level 1 trauma center, as per radiology report. Unusual maybe, but not that it did not occur. Remember, not all injuries are reported in trauma studies...

As well it is a known fact that when one exhibits the classic symptomology of tension pneumothorax such as tracheal deviation, it is usually found in post mortem. Mediastinal shift to move the trachea has to be so severe it has to move the great vessels. Again, refer to ATLS, IHTLS, PHTLS current standards.

R/r 911