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Needle VS Chest Tube?

Discussion in 'Emergency Medicine' started by jbod34, Aug 1, 2006.

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  1. jbod34

    jbod34 Member

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    When do you use a needle for decompression of a pneumo vs just putting in a chest tube? I was under the understanding that the needle was used to buy time while other problems are asessed and until you have the time to put the chest tube in but I have also heard that the needle should be skipped and you should go right to the chest tube b/c it is going to have to get done anyway. ???
    Thanks
  2. DropkickMurphy

    DropkickMurphy Removed

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    It's really a matter of which is quicker and how critical the patient happens to be. Most of the time, if the patient is crashing (rapidly dropping BP, etc) and there is a strong suspicion that it is tension pneumo that is behind it, it's a lot quicker to put a 14 gauge Angiocath into an intercostal space than to delay while setting up for a chest tube. Granted if the patient isn't in extremis (not a tension pneumo, just a simple pneumo) then there is no need to needle decompress the chest....just go for the chest tube.

    BTW, on a somewhat related note. there are some trauma docs who believe too many people are being unnecessarily needle decompressed, particularly by overzealous paramedics.
  3. MirrorTodd

    MirrorTodd living life

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    That's funny. We, meaning the medics in my unit while deployed, were directed to needle decompress anyone with these criteria: open chest wound, chest pain, difficulty breathing. Granted, a chest tube wasn't even part of our training and this was supposed to be while being engaged by an enemy.
  4. DropkickMurphy

    DropkickMurphy Removed

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    Well, I got an earful from Ken Mattox once over this topic so it's something I have an interest in. Personally I tend to agree that it is done far more often than is clinically necessary or beneficial.
  5. leviathan

    leviathan Drinking from the hydrant Moderator Emeritus

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    There is a thread SOMEWHERE on SDN about this, but I can't remember where. At any rate, I remember reading about a study on it and they did find they were done way more than was necessary. There were also medics that said they heard "hissing of air" after the needle on their PCRs, when hospital CXR found no pneumo. It sounds like they cause more damage most of the time than what they prevent. However, you will always hear anecdotal stories of medics decompressing chests of crashing patients and getting instantaneous improvement, so I guess in some rare cases it does help. Perhaps more research needs to be done in the protocols for decompression to help make the criteria more sensitive.
  6. DropkickMurphy

    DropkickMurphy Removed

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    Yeah, if you hit a bronchus, I'm pretty sure air will hiss out....this might even happen with just getting the catheter into the lung parenchyma.
  7. BKN

    BKN Senior Member

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    My very first publication was a letter to the editor pointing out that if you try needle decompression in somebody with a tension pneumo occurring during CPR (we did it pretty hard in those days), it fails. Even with three 14 ga you can't keep up with the air entering the pleural space under PPV.

    So the answer is, tension pneumo under PPV, get a knife and enter the space.

    I do find needle decompression useful for apparent tension pneumo, hypotensive, not intubated. As suggested, that's not as common as sticking a needle in the chest because you don't know what else to do.
  8. DropkickMurphy

    DropkickMurphy Removed

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    So what do you suggest for paramedics in the setting of a long transport time, with an intubated patient with tension pneumo? :confused: It's not like letting medics put in chest tubes is the best choice.....
  9. southerndoc

    southerndoc life is good Moderator Emeritus Lifetime Donor

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    Ken Mattox doesn't think any pre-hospital patient should be needle decompressed.
  10. DropkickMurphy

    DropkickMurphy Removed

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    Yes, I was on the receiving end of a very acerbic rant about that. *shudders*
  11. BKN

    BKN Senior Member

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    The doctor says you're gonna die. (Old snake bite joke).

    No good answer. You've got to know some anatomy to make an incision into the chest. I also find that the paramedics are more often wrong than right when they think they have a tension.

    This is perhaps why Ken feels that you shouldn't even do a needle in the field. He's had that opinion ever since Norm McSwain introduced the dart.

    Fair sized egos both sides.
  12. DropkickMurphy

    DropkickMurphy Removed

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    I like Ken, and I respect him a great deal, but he is your "typical" surgeon (although he's got good reason to be packing that ego of his; he's the one I want treating me) and I tend to agree with him that paramedics are largely poorly trained compared to other health care providers when it comes to the science underlying what we do.

    Personally I abhor the rote approach of education that is utilized in EMS and this is why I feel that I can't in good faith recommend a lot of the more advanced procedures that might be potentially beneficial. Honestly, I can't seem to see an end to it other than to be more selective about our selection of potential EMS personnel (particularly at the ALS level) combined with more stringent education, preferably akin to what we see in physician assistant programs. Sorry for the rant.....
  13. corpsmanUP

    corpsmanUP Senior Member

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    One jurisdiction I worked as a medic had a protocol that any traumatic arrest got bilat needles. I know they don't do it that way anymore there and my guess is that they did not save many patients with this protocol.
  14. DropkickMurphy

    DropkickMurphy Removed

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    In 7 years as an ALS provider, I have done so few needle decomps that I can count the cases on one hand. One case was the traumatic arrest of my best friend. I violated my own rule to never do anything I didn't have clear clinical indications to do (I did everything I had at my disposal).....I've second guessed myself over that case so many times..... :(
  15. corpsmanUP

    corpsmanUP Senior Member

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    Most former medics probably can think back to all the medics they worked with and think of maybe a handful that you would want taking care of your family personally. Unfortunately many medic programs just push out medics who have the cash to pay for the program even if they did not even have much EMT experience prior. Some places have "time in rate" requirements but that time is usually pretty short.

    I can think of 3 medics I worked with who are now physicians and in looking back I can definitely see the traits they had that led them to further their education. But that is also the problem. When most of your best medics move on to bigger and better things, then it continues to leave a vacuum. This happens because unlike the PA profession where salary and job satisfaction is stellar, the medic profession always seems to get crapped on when it comes to these things.

    I don't know the solution unfortunately.
  16. Apollyon

    Apollyon Screw the GST Lifetime Donor

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    That's what it was where I was paramedic, too - I'm out of that area so long, though, that I don't know if it's still in there.

    In the relatively few traumatic arrests I had, the penetrating were the only ones who survived (including Marvin Quince - whose name I can use because...well, about 8 years ago, he got shot 3 times, was a trauma code, and we got a save out of him - only so that he could get shot and killed - AGAIN - 3 years ago).
  17. leviathan

    leviathan Drinking from the hydrant Moderator Emeritus

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    Honestly, I think you answered your own question: better pay, and more education for paramedics. That's the way it is up north here, and although we too have some pretty piss-poor medics, there are just as many stellar ones who stick around for life. The BC Ambulance Service just won at an international medic competition, but I don't know much about the competition or if it has any credibility to it.
  18. corpsmanUP

    corpsmanUP Senior Member

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    I do agree that there seems to be better EMS infrastructure in the NE. I trained outside DC at NOVA if any of you remember that place, with Pam Dacarmo and Larry Newell. Every EMS system there was part of fire and it just seemed to make more sense for the careers of the EMS guys and gals. I did all my ride alongs in Fairfax County and eventually joined the Dale City VFD where I rode when I wasn't working on base in Quantico (was active duty then).

    The volunteer stations and training in Prince William County, as well as Prince George's County Md were just hard to fathom unless you have worked there. I left in the mid 90's to come back home down south and go to PA school and never have I EVER worked or been associated with an EMS agency that came close to the level of care and knowledge as the guys and gals of N. Va and Md. They just have some major budgets up there and I have no clue where it comes from. And the crazy thing is the skill level of the mostly volunteer medics in this region! They were far better than most of the paid medics I have interacted with down south.
  19. jbod34

    jbod34 Member

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    Thanks all I needed to know was the criteria for a needle decomp vs chest tube. Didn't mean to start a conversation about EMS and Medic salary and how they are poorly trained....
  20. Tiger26

    Tiger26 Senior Member

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    So anyway, this is kinda messed up, but . . . I was at Ft. Lewis, WA to get commissioned as an Army officer before med school starts this fall, while my other ROTC colleagues were there between their junior and senior years of college. Anyway, we were 'learning' first aid (put on a field dressing, stop someone from choking, put on a tourniquet) when we get a station about needle decompression. Yeah, that's right, now they're apparantly teaching every Joe in the Army how to do needle decompression. I don't know if it was some over zealous training officer watching Three Kings or what, but even ROTC cadets were learning it. Of course I apply the term "learn" loosely since it was an Army Reserve unit doing the training, and the occupation of the instructors included jobs like 'horse breeder, amateaur fighter, machinist, and admin secretary"
  21. psychbender

    psychbender Cynical Member

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    Ahh, you were taking Combat Lifesaver. The Army wants at least 1 in 10 soldiers to be CLS certified in case the medic goes down, or is otherwise occupied. And yes, the curriculum does cover needle decompression, tourniquets, and IVs...and it can technically be done as a self-study course with physician-witnessed test-out. A couple us HPSP folk at my school just tested out for CLS. Twas funny watching some of them get their (obviously) first human sticks on each other.
  22. MirrorTodd

    MirrorTodd living life

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    God that's scary. I can almost picture someone trying to put the needle in, "Eh doc, the needle won't go down." "That's because you're trying to put it through the rib." I don't think the Army understands the concept of "perishable skills."
  23. DropkickMurphy

    DropkickMurphy Removed

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    The Army does not understand that. When I helped teach CLS, I refused to teach needle decompression and explicitly told any troop I came in contact with that it was NOT a basic skill and should not be used except by someone with a minimum of EMT-Intermediate level training.
  24. MirrorTodd

    MirrorTodd living life

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    I feel exactly the same way.
  25. CaptainCaveman

    CaptainCaveman SDN Bronze Donor Bronze Donor

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    Few issues with that:
    1) There is a horrible shortage of Paramedics. Increasing the education would only make it worse.

    2) If you want us to become PA trained then pay us as PA trained. 50k/yr starting (or around). Too many places pay medics $12/hr starting.
  26. CaptainCaveman

    CaptainCaveman SDN Bronze Donor Bronze Donor

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    I am trained as an I-85 (plus many modules, but not quite I-99) and we don't do decompression. To tell the truth I am scared to even consider it.
  27. DropkickMurphy

    DropkickMurphy Removed

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    Seeing as there is sketchy evidence to support that paramedics are necessary in most cases..... :laugh:

    So, more money or we keep the status quo of marginally effective operations and quite possibly worsened outcomes....I didn't realize we were allowed to resort to making demands like we're negotiating for the release of hostages :laugh:
  28. DropkickMurphy

    DropkickMurphy Removed

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    Good to know....
  29. Jeff698

    Jeff698 Chief Resident

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    I think you already defined your crappy save rate when you said 'traumatic arrest'. Needles or not, they're dead and likely to stay that way.

    Take care,
    Jeff
  30. DropkickMurphy

    DropkickMurphy Removed

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    FDASTW- Found dead and stayed that way.
  31. Chronic Student

    Chronic Student So Fresh, So Clean

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    Don't forget the infamous radio call... "Dispatch, he was DRT!"

    Dead Right There in reference to a traumatic decapitation.

    -Mike
  32. Jeff698

    Jeff698 Chief Resident

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    In Texas, we pronounce that "Dead Raht Thar". :)

    Take care,
    Jeff
  33. Chronic Student

    Chronic Student So Fresh, So Clean

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    Hey, I'm from Texas. I guess the accent doesn't come across in the e-mail.

    -Mike

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