to needle or not to needle? pneumothorax in the field · to needle or not to needle? pneumothorax...

To Needle or Not to Needle?

Pneumothorax in the Field

Aaron Farney, MD

Livingston County EMS Medical Director

Monroe County Deputy EMS Physician

Faculty, Dept. of Emergency Medicine, University of Rochester

Welcome to IAC 2017!

• Thank you for being here

– Beautiful Lake Placid!

– Lot’s of great stuff today

• Thank you for what you do!

Welcome to IAC 2017!

• Housekeeping items

– Please silence phones

– Feel free to come & go as needed

– Feel free to speak up/ask questions

Introductions

A little bit about me…

• Emergency Medicine physician

• EMS physician

• Faculty, University of Rochester (Rochester, NY)

– Division of Prehospital Medicine

– Dept. of Emergency Medicine

A little bit about me…

• Clinical practice

– Blend of academic & community EM

• UR Strong Memorial Hospital ED (Rochester, NY)

– Level 1 Trauma Center | Comprehensive Stroke Center

– Emergency Medicine Residency (14 residents/year)

– 110,000 patients/year

• UR Noyes Hospital ED (Dansville, NY)

– Rural, community hospital

– No trauma

– 15,000 patients/year

A little bit about me…

EMS Physician

• Fellowship trained in EMS

Rural background

Hometown: Lowville, NY

Fire/EMS Background

10

Where I got started…

Hamilton (NY) FD11

Potsdam (NY) FD

West Brighton (NY) FD

12

Potsdam (NY) Rescue

Brighton (NY) Ambulance

EMS

13

Medical School

University of Rochester (NY) School of Medicine 14

Residency

University of New Mexico Hospitals (Albuquerque, NM) 15

Fellowship - EMS

University of New Mexico Hospitals (Albuquerque, NM) 16

UNM EMS Consortium

17

Introductions

• Show of hands:

– BLS

– ALS

– RN’s

– Providers/Physicians

– Other?

• If you ask a question, please identify name

& locale

A Few Remarks…

What you do matters!

• I went into EMS and Emergency Medicine

because I believe it matters.

– We routinely show up in the most terrifying

moments of other people’s lives

• To intervene when trauma or illness is threatening

health or sometimes, a very life

• To alleviate suffering

• To provide reassurance and a caring hand

– Society values this – you are one of the most

respected professions

But it’s scary as _____!

• What we do matters – so it matters that we

do it right

• Sometimes, it’s literally “life or death”

• Do not have luxury of time to “look it up”

• Must know what to do, how to do it, and

exactly when to do it

• Must be facile with our skills

• This is why we are here today!

Anecdotes vs. Evidence

• Anecdotes

– Stories we tell each other

– Single patients we saw

• Can be good or bad

– Not evidence-based

– Should not shape your practice

– Don’t let anecdotes be how you refine your

craft!

Anecdotes vs. Evidence

• Evidence (aka “the literature”)

– Be familiar with the literature

– Know how to find it

– Read with a degree of skeptism

• What biases & motives do the authors have?

• What are the flaws in the methodology?

• Do the results apply to your patient population?

Evidence-informed Medicine

• No study is perfect

• Few are so good that they alone warrant a

change in practice

• Each study must be interpreted in the context of

the existing literature on the subject

• Practice evidence-informed medicine

– Assimilation of the body of existing literature

with expert analysis

Stepping off the soapbox…

Today’s subject

• Pneumothorax!

• When was the last time you spent any

significant time discussing pneumothorax?

• Questions? Fire away!

• Let’s get to it

Disclosures/Conflicts of Interest

• Easy – none

Two Cases to Get Us Thinking!

Case 1

• 76 yo F with SOB

– C/o sudden onset SOB & sharp right chest pain 1

hour ago. Symptoms ongoing.

– PMHx: COPD, on home O2 @ 2 LPM

– Vitals: HR 110, BP 140/80, RR 24, SpO2 91% on

home O2 (2 LPM)

– Neck exam normal

– Absent right breath sounds

What is the appropriate management of

this patient?

Case 2

• 18 yo M, MVC

– Rollover MVC on interstate, ejected, laying in the

median

– GCS 3, + head injury

– + Chest trauma, absent left breath sounds (full on R)

• no JVD or tracheal deviation

– Firm, distended abdomen

– Left thigh deformity

– BP 60/P

What is the appropriate management of

this patient?

Objectives

• Define & differentiate pneumothorax (PTX) and

tension PTX

• Describe the management of PTX & tension PTX,

and how they differ

• Describe the technique(s) for performing needle

decompression

• Recognize common pitfalls in performance of needle

decompression

Anatomy Review

• Chest wall

– The soft tissues and bones that enclose the upper

torso and its contents

• Lungs

– The organs, located inside the chest, which are

responsible for gas exchange between the

environment and our body

• Mediastinum

– The central part of the chest containing the heart and

great blood vessels

Anatomy

Terminology Review

• Pleura:

– The outer lining of the lungs

– Consists of two layers:

• Parietal pleura

– The layer lining the chest wall

• Visceral pleura

– The layer lining the lungs

• Normally, they are stuck together as one….

Anatomy

Terminology Review

• Pleural space

– The area between the parietal & visceral pleura

– Adheres the lungs to the chest wall

– Pressure is -5 mm Hg to keep layers together

– Is a POTENTIAL space

• Normally, it doesn’t exist

• However, in injury or illness, it can become a REAL space

(always abnormal) and fills with something…

• If connected to lung/airways or environment, pressure

gradient favors filling of pleural space

Pleural space filled with air…

Pneumothorax

Pleural space filled with blood…

Hemothorax

….filled with air & blood…

Hemopneumothorax

Focus on Pneumothorax

• 10-20 cases/100,000 people

• Affects men > women

• Can be primary (no underlying lung disease)

– Trauma

– Spontaneous

• Or secondary (lung disease)

Causes of Pneumothorax

• Trauma

– Blunt chest trauma

• Broken ribs poking holes in pleura & lungs

– Penetrating chest trauma

• Stab/GSW puncture through pleura & lung

– Iatrogenic

• (oops!)

• Secondary causes (underlying lung disease)

– COPD (most common) or asthma

– Cystic fibrosis, interstitial lung disease

– Lung infection, AIDS

– Cancer

Focus on Pneumothorax

What are symptoms of a pneumothorax?

– Chest pain (most common)

• May be unilateral

• Sharp

• Pleuritic

• Sudden

– Dyspnea (not always)

Focus on Pneumothorax

What are some signs of a pneumothorax?

– Sinus tachycardia (most common)

– Unilateral diminished or absent lung sounds

– Tachypnea, increased work of breathing

– Maybe hypoxia

– Subcutaneous emphysema

– Penetrating chest wounds

– Crepitus if blunt trauma/rib fractures

TENSION pneumothorax

• Definition?

“when there is significant ongoing air

accumulation in the pleural space,

increasing pressure, first causing the complete

collapse of the affected lung, and then pushing

the mediastinum into the opposite pleural

cavity…preventing blood from returning to

the heart…(then) shock…. (then) cardiac

arrest.”

Pollak, AN. “Emergency Care & Transportation of the Sick and Injured.” Chapter 27 Chest Injuries.

2005.

TENSION pneumothorax

TENSION pneumothorax

What are some signs of tension PTX?

– Distended neck veins (JVD)

• May not be present if lots of blood loss

– Tracheal deviation?

• Maybe, but rare.

– Probably hypoxic & tachycardic, narrowed pulse pressure

– Absent breath sounds

– Hypotension (ALWAYS)

– Hemodynamic shock & collapse

– Eventually….cardiac arrest

Tension PTX?

JVD

Tension PTX?

NO

PTX: BLS Management

PTX: BLS Management

HIGH FLOW OXYGEN

PTX: BLS Management

Occlusive dressing (for sucking chest wound)

PTX: ALS Management

Needle Decompression

Who to Needle?

• Tension pneumothorax!

– Is an immediate life threat

– Is a TRUE emergency

– Requires EMERGENT intervention to save

the patient’s life

– Is an indication for prehospital needle

decompression of the chest

Who NOT to Needle?

• Uncomplicated pneumothorax:

– Is an URGENT condition

– Is not an immediate life threat

– Does NOT require needle decompression in

the field (or in the ED)

– May or may not require a chest tube in the ED

(depends on size, etc.)

Equipment

18 GAUGE X 1.5” ANGIOCATHETER

Equipment

14 GAUGE X 3.25” ANGIOCATHETER OR LARGER

Technique?

Technique #1

Technique #1

Technique #1

Technique #2

Technique #2

Albuquerque EMS Protocol

Errors in Technique

Errors in Technique

Complications

• Performed when NOT indicated

– May commit patient to unnecessary chest tube who

otherwise would not get one

• Improper placement

– Not in pleural cavity (i.e. chest wall, blood vessel)

• Failure to decompress tension cardiac arrest

Post-decompression

• Continue routine BLS/ALS

• High flow O2 via NRB

• Initiate transport without delay

• Be ready for potential recurrence!

– Repeat needle decompression if tension PTX

recurs

Emergency Dept. Care

• Chest tube placement

• Post chest tube X-ray to confirm

placement

• Admission

Questions?

Scenario #1

• 76 yo F calls EMS for SOB

• Has h/o COPD

• C/o sudden onset SOB & sharp right chest

pain 1 hour ago

• Vitals: HR 110, BP 157/98, RR 24, SpO2

92% on home O2 (2 lpm)

• No JVD or tracheal deviation

• Absent right breath sounds

Scenario #1

• What would you do?

– High flow O2

– IV access

– Analgesia

– Transport to hospital

– NO needle decompression

Scenario #1A

• 76 yo F calls EMS for SOB

• Has h/o COPD and “collapsed lung”

• C/o sudden onset SOB & sharp right chest

pain 1 hour ago

• Vitals: HR 120, BP 70/50, RR 24, SpO2

92% on home O2 (2 lpm)

• + JVD no tracheal deviation

• Absent right breath sounds

Scenario #1A

• What would you do?

– High flow O2

– Needle decompression!

– IV access

– Transport to hospital

Scenario #2

• 18 yo M, s/p rollover MVC in I-40, ejected, laying

on side of road

• GCS 3

• Is breathing 16x/min but sonorously

• HR 140, BP 72 by palp

• Obvious chest trauma, absent left breath

sounds, no JVD or tracheal deviation

• Firm, distended abdomen

• Broken left femur

Scenario #2

• What would you do?

– Protect c-spine

– Open airway & insert adjunct?

– High flow O2

– Needle decompression!

– IV access x 2, IV fluids

– Transport urgently to Trauma Center

Scenario #2A

• 18 yo M, s/p rollover MVC in I-40, ejected,

laying on side of road

• GCS 3

• Is in cardiopulmonary arrest

• Obvious chest trauma, absent left breath

sounds, no JVD or tracheal deviation

• Firm, distended abdomen

• Broken left femur

Scenario #2A

• What would you do?

– CPR

– Protect c-spine

– Open airway & insert LMA

– High flow O2

– BILATERAL needle decompression!

– IV access, IV fluids

– Epi? Meh.

In Summary…

• Tension PTX is a life-threatening

complication of pneumothorax, resulting in

hemodynamic and respiratory collapse

• Tension pneumothorax is an indication

for emergent needle decompression.

• Pneumothorax withOUT tension is NOT an

indication for needle decompression

In Summary…

• Needle decompression is performed with a 14

gauge, 3.25” angiocatheter (or larger) in one of

two locations:

– 2nd intercostal space, mid-clavicular line

– 4th-5th intercostal space, mid-axillary line

• Common pitfalls include inadequate depth and

improper site selection

Parting words….

Keep reading, keep learning.

What you do is just too darn

important not to.

References

• Nicks BA, Manthey D. Chapter 68: Pneumothorax.

Tintinalli’s Emergency Medicine, 8th edition; 2016: p.

464-468.

• Pollak, AN. “Emergency Care & Transportation of the

Sick and Injured.” Chapter 27 Chest Injuries. 2005.