This micro lecture is about about tension pneumothorax and needle chest decompression; which forms part of the blended learning materials available to all enrolled students.
Hey guys, my name’s Sam Willis, and I’m a senior lecturer for the Australian Paramedical College. In today’s session we’re going to talk about tension pneumothorax and needle chest decompression.
Now, these two topics really do go hand in hand, even though there are different types of pneumothorax. In this session we’re going to talk about what a pneumothorax is, what it looks like, and how you as a paramedic can actually treat this patient using a large 14 gauge cannula.
Okay, so let’s get going. In this session, to be more specific, we’re going to look at the urgency of decompressing a chest because when you’re dealing with the patient who has sustained significant chest trauma, and they are actually demonstrating the signs and symptoms of a tension pneumothorax, you really do need to be able to act fast.
That includes recognizing the urgency of it, as well as actually using a large bore cannula to decompress, to let the air out of the chest. We’re going to look at the signs and symptoms, and we’re going to looks at the exact skill of decompression.
So let’s try and use this as a case study then. This is a situation you may find yourself in as a state paramedic. It’s a busy Friday night. You’ve been called to a local hotel in the city, where a report of a male who has been stabbed.
On arrival, the male is slumped against the wall of the hotel, struggling to breathe, and is holding the left side of his chest. He has a pale face, blue lips, and a GCS of 12, comprised of E3, V4, and M5.
Let’s go through this case study together. It’s Friday night, so that means that the call volumes go up. The amount of vehicles available to respond go down and, therefore, you are already as a human being, going to be pretty fatigued.
So when you arrive at scene, that it’s outside, it’s a Friday night. People are drinking in the city, therefore there’s clearly safety concerns here. Now it doesn’t mean that you need the police in every situation. However, you’ve got the situation where there’s obviously lots of alcohol involved, somebody’s been stabbed.
This is one of those situations where you are going to need to know where the assailant is, and to get the police on the scene quickly. The reason you need the police is because you don’t know in that crowd of people whether or not the person who stabbed him is actually one of those people.
The male is slumped against a wall of the hotel, struggling to breathe. Now, you know as well as I do that if somebody’s slumped against a wall, hunched over,then that’s not a good sign. Because number one, it will compromise their breathing mechanisms. And number two, if they’re not able to look after themselves, stand up, and get themselves to hospital, or do whatever they need to do, that’s not a good sign, holding the left side of his chest.
Now, the final point here, pale face; sign of hypoxia, lower levels of oxygen. Blue lips; cyanosis, and of reduced GCS. All of these things are not good.
Now, the good news is, with your education and training, knowing that somebody’s been stabbed, knowing that somebody can’t breathe and they’re holding their left side, you now know that you may need to do a tension decompression; in other words, a needle chest decompression, or a chest decompression, or whatever they call it; different names for the same thing.
In other words, you’ve got to get a large 14 gauge cannula, and stick it in the chest. But you’ve got to do some assessments of your patient first before you go off and do that.
A tension pneumothorax is a life-threatening condition. Let’s be clear on that. Now, there are different types of pneumothorax, but when you get to tension, what’s happened is the air inside your chest cavity, not inside your lung, but inside your chest cavity, is pushing everything to one side.What that’s doing is, number one, it’s reducing the amount of oxygen available to the tissues because there’s less oxygen because the lung is not ventilating properly. And number two, you’re starting to quash and squash the other side. In other words, you’re starting to squash the heart and the other lung to the point where, at some point, that patient will go into cardiac arrest.
When you’re faced with a traumatic cardiac arrest, the latest guidelines from the Australian Resuscitation Council tell you to immediately decompress a chest. That’s how serious this. In fact, they don’t just say decompress it. They say treat the tension pneumothorax above beyond doing CPR. Because they say without this, the CPR is going to be pointless anyway, and again, showing you how urgent this situation really is.
Acute treatment involves rapid recognition and decompression of the chest. This is something we are going to talk about but, of course, you’ll have different levels of unconsciousness and consciousness. Of course, you as the paramedic has got to try and work your way through a systematic approach to work out if you are or are not going to do this skill.Let’s take a quick look at this image then. Here you can see a normal lung on this side, whereas on this side you’ve got a smaller collapsed lung that’s being compressed by all the air. Now, what tends to happen is with a tension pneumothorax there’s some kind of mechanism, such as being stabbed in the chest.
Now, the air will either come into the trachea here, go into the lung. And instead of going back out through the trachea and being breathed out, it will actually end up going out through the damaged lung and being stuck in this cavity because it can’t get back through and out through this mechanism.
Every time the patient breathes in it’s really, really painful for that patient. Not only is it painful, but the air’s not going out, so they feel like they’re starting to suffocate as well.
Here you can see at the bottom some symptoms of tension pneumothorax. It includes chest pain, shortness of breath, rapid heart rate, shallow breathing, anxiety, blue or ashen skin. So the chest pain really is caused by … When you’re breathing in, it’s a sharp stabbing chest pain caused by the trauma and the movement of the chest after the trauma.
Shortness of breath is because your lung is being quashed and squashed. Rapid heart rate is a sign of obstructive shock. Shallow breathing, obstructive shock. Anxiety because you’re suffocating, so it will make you anxious. Blue or ashen skin is a sign of hypoxia.
If you were to take an x-ray, this is what a tension pneumothorax would look like on an x-ray. Just be mindful that anything on an x-ray that is white is solid. Here you can see the clavicles. You can see the ribs. You can see all the other bones. This organ here is the heart, and you’ve got the diaphragm down here.
Anything on here that is black is air. Here, quite clearly, you can see that the x-ray has picked up the air around the patient. But what you also notice is that this part here, this, where the tension pneumothorax is, there’s a lot more air in the patient’s left side. This is the patients left. There’s a lot more air in this side than there is in the other side, in the patient’s right.
You can also see that you’ve got this deviation of the trachea, which is normal because it’s being pushed … It’s not normal. It’s pushing everything towards the patient’s right. For me, the biggest thing is it just screams out at you how there’s what we call a hyperinflation of the patient’s chest; in other words, there’s so much more air inside the chest cavity when you compare it to this side.
So the signs and symptoms where we’ve got to really spend a little bit our time, because this is where it all comes down to you being able to recognize. Now I’ve split it down into two main types of signs or symptoms; the key signs and symptoms, and anything else that is really, really important, but it’s not going to help you to identify a tension pneumothorax.
Number one; trauma related mechanisms of injury. That can be stabbed in the chest, shot in the chest, shot in the back, stabbed in the back, fall from height. Maybe you’ve landed on their chest … Maybe they’ve landed on their chest, not you. You and I would be crazy. Maybe they’ve been hit by a moving vehicle. There’s got to be some kind of mechanism of injury that suggests thoracic trauma.
Then there’ve got to be signs of obstructive shock, which just means that there’s an obstruction and it’s causing tachycardia, difficultly in breathing, all the signs and symptoms that you know to be shock. If you can’t remember those signs and symptoms, now is the time to get back into the books, and look at the different types of shock and how they present.
Diminished breath sounds on the side of the injury. So when you have a listen with the stethoscope you’ll hear normal breaths, silent chest, or diminished, normal, silent. So you really are going down and you’re comparing left to right with your stethoscope.
You might also end up with the hyperinflated chest that we saw on the x-ray. Not only will there be more air inside that chest cavity, but there will also be a marked difference in the way the patient sits eventually.
If the injury’s on this side, you’ll see more air in this side. Eventually, the trachea, you’ll get midline shift later on, but it’s really late signs. Everything gets pushed that way.
Of course, you’ll also get this thing called hyperresonance on percussion. Of course, when you percuss, you keep one finger on the chest, and you’re tapping on the finger using the other fingers. Again, you’re comparing left and right. Anything that is solid will sound dull. Anything that is full of air will sound resonant, and when there’s a lot of air it will sound hyperresonant.
So those really are your key signs and symptoms. Then everything else that you see here, reduced level of consciousness; late sign. Signs of hypoxia; pretty late. Pain on inspiration; that’s not late. Aggression and confusion; again, that can happen when there’s hypoxia. All the other signs and symptoms tend to relate around the late stages of tension pneumothorax, including tracheal deviations and other signs of hypoxia.
Now we get onto talking about the actual scale itself. Now, believe it or not, the skill is actually pretty simple to do once you’ve recognized it. Now, just remember when you’re coming to make the decision as to whether or not you are or are not going to decompress the chest, then you can actually do this by talking to your crew mate and discussing the signs and symptoms. Your crew mate might have more experience in this than you.
Remembering that you’re going to be sticking this large 14 gauge cannula through your patient’s chest wall. So, if there’s any doubt or uncertainty, do communicate. Use your non-technical skill.
Now, generally speaking, this it the equipment you need; a large bore 14 gauge cannula or larger. A number of services have a very specialized needle that the armies tend to use, which has got a three-way tap built into it. They’re larger than 14 gauge. But most places, because they are generally a rare occurrence, they won’t invest in the extra items of equipment.
Between service and service, you might see that some services have these huge needles, others just use these 14 gauge cannulas, which are fine. But what you have to remember is once you’ve inserted this needle, that you’ve removed the needle, this is what’s going to be kept in place.
Of course, when your patient’s exhaling all the air is … The purpose of this is to allow all that trapped air to be released. If this cannula is tiny, that’s the only amount of air that will be able to leak out through this tiny catheter, meaning they may have another tension pneumothorax again. So having a 14 gauge isn’t ideal always.
Sharps bin, absolutely, because once you’ve pierced the chest you have to put the sharp in straight away; safety first. You have to put the sharp needle into the sharp bin. Securing device to secure the catheter in place. Now again, some services will give you a special type of dressing. Other’s will just say do your best. Don’t knock it out of place, using securing tape, just to secure it in place.
So there’s weird and wonderful things you can do as a paramedic, but on many occasions, when you work in the metropolitan centers, you’re only 20 minutes away from a hospital. However, when you’re rural, you could be hours away, particularly if the helicopters are off line. Therefore, it really is in your best interest to really reassess, reassess, and reassess using a stethoscope once you’ve actually decompressed the chest.
Now, this is, generally speaking, the process that you will take when decompressing the chest. Now, the landmarks are listed here. Now, it’s the second intercostal space. So these spaces here in between the ribs are called the intercostal spaces. We don’t usually count this one. So this is the first, this is the second, third, fourth, fifth, six, and so on and so forth.
The second intercostal space, mid-clavicular line; so in other words, the middle of your clavicle. They do tend to say just above the third rib because there’s lots of circulation and nerves that sit around the region of the superior portion of the rib. But the reality is it’s not always that easy to identify.
As long as you can go with second intercostal space, mid-clavicular line. Notice how, even if it was on this side, you are way away from the heart, the second intercostal space, mid-clavicular line.
Remembering that if you do have to insert a second one because the tension … because it’s taken so long to get to hospital, you would insert a second 14 gauge cannula laterally, away from the midline. Because you don’t want to be anywhere near the heart.
However, studies have shown that even when you need to do these time and time again, you, generally speaking, don’t even go anywhere near the heart anyway. This has been a very carefully thought out location.
Now there is actually a growing body of evidence to suggest that we should be doing this in the mid-axilla space … Axilla is just the line underneath your arm … in the fifth intercostal space, where they put chest drains. But, unfortunately, there’s not a strong body of evidence to suggest that’s the best place to do it.
Rather, there’s some evidence that says, yes, it still comes with complications. There’s going to be complications wherever do it, but just for now, this is where we do it, second intercostal space, mid-clavicular line, until the guidelines change.
Work together with your crew mates. Reassure the patient. Place them in a comfortable position. Placing them in a comfortable position might mean leaving them where they are, if they’re slumped against a wall and they’re comfortable.
You might need to lay them flat but then you’ve got a problem if you know that to help somebody to breathe, you need to sit them upright to help the mechanics of breathing. But then you’re trying to do this skill where they’re in an upright position, and it’s not always easy.
This is where you use your decision-making communication with your crew mate to try and do what’s best for the situation. We can’t always tell you what to do for every situation because there’s too many factors. But try and get your patient into a comfortable position, and reassure them. Tell them, “Look, we’re going to place this needle into your chest. It will help you to breathe. Stay nice and calm in the meantime.
Make sure you prepare your equipment. Get your needle out. Get your gloves out. Get your decontamination alcohol wipe ready. Get your sharps bin ready. When you’re ready to de-shoot the needle, make sure you shout, “Okay, sharp’s out,” so you can warn everybody around.
span style=”font-weight: 400;”>Introduce the needle into that location. Push it nice and deeply all the way through the chest wall, up to the hilt. Take the needle out, stick it in the sharp bin. Immediately, usually the patient’s that sigh of relief, and then secure it down.
Then, of course, have a listen with the stethoscope, and get the patient to hospital. Be mindful that you also think about possible C spine injuries as well.
What we’ve talked about in this session, guys, is the notion of the time criticality of a tension pneumothorax, and the requirements to decompress the tension pneumothorax. Guys, please remember that we only ever do this in a tension pneumothorax, not in an open pneumothorax, not in a spontaneous pneumothorax, only in a tension pneumothorax, when you’ve see the signs and symptoms and indications that we talked about in this presentation.
Know the signs and symptoms. Keep reading around this. Go on to PubMed. Have a look at the signs and symptoms in all the latest journal articles. Go into the books and have a look, and know how to do the decompression.
Of course, you will get a chance to have a place around with this in the second workshop. You will be able to have a practice on the manikins. You’ll be given more instructions. Certainly, when you do an advanced life support, there’s something called the four Hs and four Ts, which are the reversible causes of cardiac arrest. One of them is tension pneumothorax, so you could save someone’s life by knowing how to do this skill.
Thank you very much for your attention. My name is Sam Willis, and I look forward to talking to you again shortly. Take care.