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