Percussing the pneumo

[mshow00]

Agreed with Delta. You don't know if you can hear it until you try. And there is more to it than what you hear. It is also what you feel, which is developed with a lot of practice. It is something that should be attempted until you know for sure that it cannot be done.

If your instructor is saying it's a waste of time, he either isn't very good at it, or else he's been in a crappy urban system for too long. I don't even get what he is saying. Is he saying to just dart every patient bilaterally instead of trying to localise the pneumo? Or is he saying you don't need to dart at all?

He was speaking more about bowel sounds when saying it was a waste of time. He does not want us to be/become protocol monkeys nor does he want us to be "Mother may I?" paramedics. He is teaching/challenging us to use all of our assement skills, teamed with the tools and "tricks" available to be confidant in our Dx and subsequent Tx. Bowel sounds, to do honestly, takes too much time, heart sounds are good but are hard to hear, esp. going 3 down the road; not to mention I have never seen a paramedic check them (not saying they didn't just never seen it). He was attempting to give us a trick to R/O a tension pneumo vs hemopneumo and to tell by resonance (teamed with the rest of the assessment) which side to decompress.

I'm sorry if the explanation above was incomplete.

[rock_shoes]

My rule of thumb has always been to listen, listen, then listen some more. You can get so much more information by putting your ears to work. Whatever the method be it percussion or auscultation your ears can tell you many things your eyes can not see. Is percussion that useful in the pre-hospital environment? Often not strictly due to the ambient noise. Just don't rule it out all together on that basis. There are exceptions to nearly every rule.

[Dustdevil]

Okay, I got a little confused on your original post. I am a little clearer now. I would agree that, in truly emergent cases, where you need to expedite your scene time, that the finer points of the physical exam are not priorities. That would include bowel sounds, and sometimes heart sounds too (although there are situations where auscultating heart sounds are absolutely required). Percussion would fall in there too, assuming that it is environmentally impractical, and you have otherwise absolutely assured beyond a reasonable doubt that your patient needs a dart.

Do not take from his or my opinions that there is no significant value in these signs. Far from it. In fact, they should be a routine part of every physical examination you do, whether it's a medical run or a simple IFT. That is the only way you will ever become proficient at them. And the more proficient you are at them, the more likely you are to be able to make them work for you in real emergencies, even with ambient noise going on.

These skills are just like every other skill. If you do not practise them thousands of times, and regularly as a part of your routine, they will never become second nature to you, and you will always suck at them, forcing you to forever say -- like your instructor -- "oh, don't worry about it."

[mshow00]

Thank you guys that is what I was thinking, I just wanted to make sure I didn't miss the train.

[Arizonaffcep]

A simple question... Do you really percuss the chest of a "suspected" pneumo to determine if/which side the pt requires a decompress? It is a simple enough trick of the trade, but how practical is it? My paramedic instructor is teaching us to do it, but then says stuff like don't worry so much about heart sounds in the back of the rig as they are too hard to hear, don't listen to bowel sounds as it takes six minutes(you would be at the hospital by then here) etc. Just trying to get some impute here, Thank you.

I guess I'm a little curious about decompressing a pneumo. No one has ever died from a pneumothorax, a TENSION pneumo, yes, but not a pneumo[sup:cb7fdb1f98]1[/sup:cb7fdb1f98].

By the time it gets symptomatic, it's a tension (dyspnea, decreased LS, anxiety, JVD, etc. etc.) This, coupled with the application of trauma (since spontaneous pneumos are not that common by comparison), should indicate with a high degree of accuracy if it's a left or right tension. As for percussing them, I was always taught that it was the density difference between a pneumothorax vs a hemothorax is where that comes in handy.

[sup:cb7fdb1f98]1[/sup:cb7fdb1f98] Peter Rhee, MD, http://www.umcarizona.org/body.cfm?id=27&a...ail&ref=799

[p3medic]

Hyperesonance to percussion is consistant with tension ptx, although in the loud out of hospital world may be difficult to appreciate. There are things other than tension ptx that could lead to decreased or absent breath sounds and cardiovascular collapse, however they don't present with hyperesonance. So, if you can percuss, it is a valuable finding, in my opinion. Needlessly sticking needles in someones chest is generally frowned upon.

[AnthonyM83]

Hyperesonance to percussion is consistant with tension ptx, although in the loud out of hospital world may be difficult to appreciate. There are things other than tension ptx that could lead to decreased or absent breath sounds and cardiovascular collapse, however they don't present with hyperesonance. So, if you can percuss, it is a valuable finding, in my opinion. Needlessly sticking needles in someones chest is generally frowned upon.

In what situations would percussion be the determining factor for needling someone?

[p3medic]

I don't think it would be the determining factor, just another finding consistant with the dx. If someone is in hemodynamic collapse, air hungry with absent breath sounds, the presumptive dx of tension ptx is made and a needle thoracostomy is performed. There are many patients with simple pneumo/hemothorax who are not on the verge of hemodynamic collapse who end up with an unnecessary needle in their chest because of an overzealous paramedic. They like to use the arguement that the patient is going to recieve a cx tube anyway, so whats the problem? There are risks involved in the procedure, laceration of lung, intercostal vessels, the heart and the vasculature associated with it, etc...It is not a benign procedure.

Now, with the patient in extremis, the benefit starts to outweigh the risk. Patients in hemodynamic collapse with decreased/absent breath sounds will likely recieve a needle as it is one quick procedure that can truly be life saving. The patient about to die is going to do so quickly.

[Arizonaffcep]

I don't think it would be the determining factor, just another finding consistant with the dx. If someone is in hemodynamic collapse, air hungry with absent breath sounds, the presumptive dx of tension ptx is made and a needle thoracostomy is performed. There are many patients with simple pneumo/hemothorax who are not on the verge of hemodynamic collapse who end up with an unnecessary needle in their chest because of an overzealous paramedic. They like to use the arguement that the patient is going to recieve a cx tube anyway, so whats the problem? There are risks involved in the procedure, laceration of lung, intercostal vessels, the heart and the vasculature associated with it, etc...It is not a benign procedure.

Wow...talk about bad aim.

[p3medic]

You'd be surprised... :oops: