I'm looking to fill in some of the gaps in my files. Any of you have an article and/or protocol for management of iatrogenic pneumothorax? Things such as ED management with serial CXR (how often and how many?) , use of high conc oxygen, etc.
That is so helpful. My motto is "always be prepared"haha "rule number one- if you don't know where you are going, don't put it in"
What ductape said is spot on. The vast majority of ptx do not become tension penumo's, but I couldn't give you a number (guess <5%?). Bagging or any positive pressure ventilation will actually make a tension pneumo worse without a decompression needle. When I've seen it happen, it's pretty obvious. They go from being a little short of breath, to gasping, dying, neck veins distended, hypotensive, shock. You're not likely to ever see it.Interesting discussion. I caused my first ptx a few months ago doing an ICN RFA with 18g RF needles on a guy with intercostal neuralgia following lung resection and radiation for lung CA. The guy had huge emphasematous lungs with blebs as well as scarring in the region due to previous RXT. I was playing with fire. Anyway, he suddenly developed sharp stabbing chest pain worse with inspiration. I got an immediate CXR in the office and sure enough, he had a small ~10% PTX. Sent him to the ER anyway b/c of what emd just said.
Question: Do you know the likelihood of that small pneumo developing into a life threatening tension? And let's say it did turn into that while in the office and he starts gasping for breath with falling 02 sats. What do I do? Stick an 18g 1 1/2" needle into his 2nd intercostal space until EMT arrives? Or just bag him? It's been awhile
keep needle in until transported to ER.
at that point, attach tubing, clamp off tubing. if patient gets short of breath or becomes confused, unclamp. can use 3 way stopcock, but i highly doubt you stock those.
It shouldn't. First you have to know definitively that your patient has a tension pneumo, or at least be confident, by clinical presentation, or see rapid decompensation after a known non-tension pneumo on CXR . But you're right, in that if they didn't have a pneumo, and you needle their chest, they will end up with a pneumo. But the one thing they won't end up with is a tension pneumo. Because they have a decompression needle in their chest now. That's the good thing. Lol. Either way, they end up with a chest tube.Dumb question - if you aren't sure how bad the pneumo is, and you decide to decompress, can you make anything worse?
Bottom line:
Iatrogenic pneumothorax = send patient immediately to an Emergency Physician.
Don't even mess around with observing, watching, and repeating chest X-rays, no matter how small or stable the pneumo may seem. A stable pneumo can go tension pneumo, in a few breaths. Then you have a gasping, dying patient on your hands. If you're ready to decompress the tension pneumo with an 18 gauge angiocath over the second intercostal space at the mid-clavicular line (or 5-6th IC space at mid axillary line), then throw in a quick chest tube, then excellent. Otherwise, don't even mess around with a pneumo, iatrogenic or otherwise.
This is one where you call up the ER attending and say, "Man, I need your help. Can I have you take a look at someone? I just dropped this guy's lung. My bad. Can you look at him and see of he remains stable, needs a chest tube, or needs to be watched overnight? Cool, thanks. I owe you one."
Sure....some small penumo's, ie, 5-10% collapse may absorb on high flow 02 and never get unstable, but a crashing tension pneumo ain't pretty. Trust me. The fact that it's iatrogenic from a tiny needle has a whole lot less to do with anything, than a patients overall stability (is the pneumo getting bigger or smaller?), their co-morbid disease (copd with blebs? asthmatic?) and what's going to happen if it turns into a tension pneumo or not.
So was doing another ICN RFA today on a nice lady who's responded well to ICNBs. I'm on my last nerve and inject dye but no neurogram. Aspiration produces no blood. I start to look around to see where the contrast went and a blob pops up in the lung apex. As I'm internally cursing myself I remove the needle and tell the patient what happened. She remains asymptomatic w/stable vitals and actually feels great from the ablation of the other 3 nerves. I remember back to this thread and end up sending her to the ER anyway for a CXR.
ER doc calls me and tells me there was no pneumo. Can anyone explain what happened. How the hell did the contrast pool up in apex of the lung? Intrapleural space? I'll admit I'm not a lung anatomy guru
unless the ER doc got a CT, you may miss a small pneumo. i vaguely remembe reading that 5% of pneumos are missed on cxr, and of course it is dependent on the dtudy done (and who read it). possibly up to 25% of pneumos are missed in trauma cases with supine views.So was doing another ICN RFA today on a nice lady who's responded well to ICNBs. I'm on my last nerve and inject dye but no neurogram. Aspiration produces no blood. I start to look around to see where the contrast went and a blob pops up in the lung apex. As I'm internally cursing myself I remove the needle and tell the patient what happened. She remains asymptomatic w/stable vitals and actually feels great from the ablation of the other 3 nerves. I remember back to this thread and end up sending her to the ER anyway for a CXR.
ER doc calls me and tells me there was no pneumo. Can anyone explain what happened. How the hell did the contrast pool up in apex of the lung? Intrapleural space? I'll admit I'm not a lung anatomy guru
You may have contrast in the pleural space but no air. That technically would not be a pneumo (pneumo = air in pleural space). Could happen if you punctured the parietal pleura (outer layer) but not the visceral pleura (inner layer around lunch parenchyma itself). Or, like another said above, a small <5% pneumo may not show on a chest X-ray. If so, it likely isn't clinically relevant anyways. CTs now pick up a lot of minor penumo's that in the past were missed and resolved on their own without treatment.So was doing another ICN RFA today on a nice lady who's responded well to ICNBs. I'm on my last nerve and inject dye but no neurogram. Aspiration produces no blood. I start to look around to see where the contrast went and a blob pops up in the lung apex. As I'm internally cursing myself I remove the needle and tell the patient what happened. She remains asymptomatic w/stable vitals and actually feels great from the ablation of the other 3 nerves. I remember back to this thread and end up sending her to the ER anyway for a CXR.
ER doc calls me and tells me there was no pneumo. Can anyone explain what happened. How the hell did the contrast pool up in apex of the lung? Intrapleural space? I'll admit I'm not a lung anatomy guru
Scary ending to day yesterday and I thought of this thread. Last patient of the day doing an intercostal nerve block under fluoro on 64 y.o. woman with pain S/P mastectomy and reconstructive surgeries. Just getting started after touching down on rib and rolling needle off rib when the patient starts coughing. WTF, I am just over top of rib? Pneumo comes to mind and I am anticipating the worst. I inject contrast and flow looks good, patient has pain relief with local and steroid. I get her to roll onto her back and she is coughing but SaO2 98% and she is not tachypnic. I shoot inspiratory and expiratory CXR and lung markings visible to periphery. Patient tells me that she does this all the time due to postnasal drip and her asthma. We watch her for a while and she has no more cough. I warn patient to go to ER if she has any SOB or symptoms because of pneumo risk. I called her last night and again today. No pain, no cough, or pulmonary symptoms. Would you have insisted on patient going to ER?
not really...This technique is looking better every day: http://omicsonline.org/omoigui-diffusion-technique-of-intercostal-nerve-block-2155-6148.1000344.pdf. May try staying on edge of rib instead of center and not advancing.
First of all did you mean "over" rib or "under"?Scary ending to day yesterday and I thought of this thread. Last patient of the day doing an intercostal nerve block under fluoro on 64 y.o. woman with pain S/P mastectomy and reconstructive surgeries. Just getting started after touching down on rib and rolling needle off rib when the patient starts coughing. WTF, I am just over top of rib? Pneumo comes to mind and I am anticipating the worst. I inject contrast and flow looks good, patient has pain relief with local and steroid. I get her to roll onto her back and she is coughing but SaO2 98% and she is not tachypnic. I shoot inspiratory and expiratory CXR and lung markings visible to periphery. Patient tells me that she does this all the time due to postnasal drip and her asthma. We watch her for a while and she has no more cough. I warn patient to go to ER if she has any SOB or symptoms because of pneumo risk. I called her last night and again today. No pain, no cough, or pulmonary symptoms. Would you have insisted on patient going to ER?
First of all did you mean "over" rib or "under"?
Second, no I wouldn't worry about pneumo. It takes time for a pneumo to develop and get symptomatic. The lung doesn't pop like a balloon. Not that it's impossible, but I've never seen a pneumo to present as a "cough." It's almost always shortness of breath or pleuritic chest, back, or shoulder pain.
If you caused a pneumo with a needle and did an X-ray right away you probably wouldn't see anything immediately, as 5% or less pneumos don't show up on plain films lots of times, as it takes a while for lung to deflate through a hole the size of an injecting needle. The only thing that would make me think, "Oh ****, I just caused a pneumo" during an injection would be when I drew back on the plunger, I aspirated air. That = pneumo.
Couldn't give you an exact time but not likely immediate as in a trauma with a gaping puncture in the lung from a busted rib skewering it. Minutes to hours, maybe, or not at all. Some pneumos never get symptomatic and can resolve on their own. Example: any patient who has a chest tube pulled will have a tiny pneumo if only 1% from the space of the tube having been there. Do you go out another tube in? No.Yes, under is more precise. I had just rotated the needle over the inferior border of the rib and thus was just under the rib. No air on aspiration but a patient coughing and gagging a bit still makes me think Oh ****. I prefer my patients still when I am inserting needle near nerves or the lung.
Twenty-five gauge needle, single stick how long would you estimate it takes for pneuma to become symptomatic?
Anyone hazard a guess on the AP diameter of intercostal muscles and ribs? I think it would take the doc coughing and jerking hos arm to get into lung. Not the patient. I remember training and sticking my finger in the chest tube hole. It was pretty far in to touch lung.