Iatrogenic pneumothorax protocol?

Discussion in 'Pain Medicine' started by NJPAIN, 09.23.14.

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  1. NJPAIN

    NJPAIN 5+ Year Member

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    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.
     
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  3. lobelsteve

    lobelsteve SDN Lifetime Donor Lifetime Donor 10+ Year Member

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  4. SpineBound

    SpineBound Large Member 7+ Year Member

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    haha "rule number one- if you don't know where you are going, don't put it in"
     
  5. emd123

    emd123 5+ Year Member

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  6. NJPAIN

    NJPAIN 5+ Year Member

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    That is so helpful. My motto is "always be prepared"


    Sent from my iPhone using SDN Mobile
     
  7. jonnylingo

    jonnylingo Junior Member 10+ Year Member

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  8. emd123

    emd123 5+ Year Member

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    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.
     
    Last edited: 09.24.14
  9. clubdeac

    clubdeac 7+ Year Member

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    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
     
  10. Ducttape

    Ducttape SDN Lifetime Donor Lifetime Donor 5+ Year Member

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    if he has failing O2 saturation, then decompress. dont wait for EMT. they may not feel comfortable/be trained to use a needle to decompress the tension pneumo.

    you may need longer than a 1 1/2 inch needle. more than likely the pleural space will be 5 cm deep from either approach - more so if they are the typical American.

    100% O2.
    Sit them upright - more readily tolerated. also, from an anesthesia standpoint, there is less shunting and better oxygenation.
    if you have to bag/think about bagging, then you should have already decompressed the lung.

    using an angiocatheter is okay, but best is to just take a 3 1/2 inch spinal needle and enter either the 2nd intercostal space anteriorly or the 5th-6th intercostal space laterally. if you use the angiocatheter, make sure it is at least 16 gauge. if you dont have 16 gauge angiocatheters (the smaller ones kink or can get plugged), use a regular needle.

    Attach tubing and a small syringe with saline if you have time/remember. that way you can see air bubbles knowing you got in. Remember to remove the syringe when it is decompressed. no need to put a stopcock and open/close like they did in "Three Kings" (the movie).

    the major problems occur when one does not decompress or does not get in.
     
  11. emd123

    emd123 5+ Year Member

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    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.
     
  12. bedrock

    bedrock Member 10+ Year Member

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    Appreciate the sage advice from our ER docs.

    Question. If you do as described and the patient is clearly improving, do you remove the needle too or just the syringe?
     
  13. Ducttape

    Ducttape SDN Lifetime Donor Lifetime Donor 5+ Year Member

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    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.
     
  14. lobelsteve

    lobelsteve SDN Lifetime Donor Lifetime Donor 10+ Year Member

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    Saw this on MASH once.
     
  15. Ducttape

    Ducttape SDN Lifetime Donor Lifetime Donor 5+ Year Member

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    The entry wound seems a little low - but obviously bullets have quite varied trajectories once they penetrate. to not have a concurrent liver (or other organ) injury wouldnt have fit the storyline i guess.

    oh and the needle was definitely longer than 1 1/2 inches
     
  16. knoxdoc

    knoxdoc New Member 10+ Year Member

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    Dumb question - if you aren't sure how bad the pneumo is, and you decide to decompress, can you make anything worse?

    The whole idea makes me cringe. You stick a needle in the lung and drop it. The cure? - stick another needle in somewhere else. It never made me comfortable.
     
  17. emd123

    emd123 5+ Year Member

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    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.

    I've seen it happen, actually: a patient needled for what probably wasn't a pneumo at all to begin with. (Wasn't cool).

    If you're "not sure" if someone has a tension pneumo or not, they probably don't. They crash like dogs. It's obvious. Here's how the scenario would play out:

    You do a trigger point to the back. A few minutes after, your patients says, "Doc, my chest feels weird. Am I supposed to feel short of breath?" He looks completely unconcerned.

    You: "Uhh...what? No." Stethoscope to chest (Breath sounds are decreased on the side I did the TPIs on = stable, non-tension pneumo. Damnit!) "Sir, you have to go to the ER. You might have a collapsed lung."

    "No doc. I don't feel that bad really. Is that necessary?"

    "Yes." You look at Joe Patient who all of a sudden starts gasping, gets this crazy nervous look in his face, color turns gray. You look at him and think, Holy crap, their trachea does really push to one side, with distended neck veins in a tension pneumo. Crap. EMS is going to be at least 5-10 minutes. You look and he slumps over turning blue. Oh s--t. I can't sit on this .
    Needle-in-chest-rush-of-air-sound........ wait..... wait....... patient starts pinking up a little bit.... is he opening his eyes?...... holy, crap..... did I just really decompress a tension pneumo? Whoa, that was some crazy s--t. "When the hell is the ambulance getting here!?"

    Honestly, I really wouldn't worry about it, because the chance of seeing a tension pneumo in your pain office is probably 1 in 100,000 to 1 in 1,000,000. I've only seen it a handful of times in 30-40 thousand patients, and it's usually on an intubated trauma patient, intubated copd'er or someone who just got a subclavian from some intern.
     
    Last edited: 09.26.14
  18. knoxdoc

    knoxdoc New Member 10+ Year Member

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    Awesome play-by -play! Greatly appreciated because I never saw one in an ER rotation. Good to know what to look for.
     
  19. Ducttape

    Ducttape SDN Lifetime Donor Lifetime Donor 5+ Year Member

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    okay, most pneumothoraces (sic) will not present in that way, unless you are using a 16 gauge needle for trigger point injections. the rate of development of a pneumothorax logicall should be proportional to the gauge of the needle (and of course if multiple passes were made).

    if the patient is having some chest pain or just short of breath, but doing fine, then just call 911, patient goes to ED, call ED to let them know, without doing the needle decompression, you will be fine 95% of the time.

    knox, think of it this way - you are placing the tip of the needle in air, not "someplace else". the needle pops the balloon that is the pneumo.
     
  20. clubdeac

    clubdeac 7+ Year Member

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    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
     
  21. Ligament

    Ligament Interventional Pain Management Lifetime Donor SDN Advisor 10+ Year Member

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    Yes I believe you are correct. I see this too frequently when doing intercostal nerve blocks. I can't say I've seen contrast in the apex, but I have seen contrast in what must be intrapleural space.

    I'd still rather do this procedure than any type of cervical ESI...
     
  22. Ducttape

    Ducttape SDN Lifetime Donor Lifetime Donor 5+ Year Member

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    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.

    did an ER doc read it? radiologists apparently are more sensitive reading them (and maybe personally).
    was an inspiratory +/- expiratory view done?
    was a CT or (which ties in with the other active thread) FAST scan with US done?

    a pneumo that small probably would not require treatment but does need monitoring, and possibly repeat chest xray.
     
  23. emd123

    emd123 5+ Year Member

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    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.

    No symptoms, plus negative PA/lat CXR with insp/exp view = done.

    You can't CT all these to look for clinically irrelevant penumo's.

    Guess what happens when you pull out a chest tube? Lots of times there's a residual tiny pneumo. You don't go putting a chest tube back in, for a 1-5% pneumo.
     
  24. clubdeac

    clubdeac 7+ Year Member

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    Thanks guys
     
  25. pastafan

    pastafan Interventional Pain Physician 2+ Year Member

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    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?
     
  26. Ducttape

    Ducttape SDN Lifetime Donor Lifetime Donor 5+ Year Member

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    not to be critical.... but this might be one of the situations where you can give yourself a big sigh of relief when using ultrasound - identify the needle tip, look for the pleura, inject a tiny bit of saline if in doubt...

    i would have sat her up, listened to her, had her stay in the office extra long and make sure she did not develop more symptoms, and done the same as you.

    course, in my case, to get her to ER only requires a wheelchair and roughly a minute...
     
  27. pastafan

    pastafan Interventional Pain Physician 2+ Year Member

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  28. SSdoc33

    SSdoc33 7+ Year Member

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    no
     
  29. Ducttape

    Ducttape SDN Lifetime Donor Lifetime Donor 5+ Year Member

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    not really...

    local anesthetic only. short term relief only. (no steroids used, but with a particulate, i cant see it diffusing around like pure local anesthetic. i guess you could try dex...) cant use it diagnostically for possible RFA.

    for chronic pain, i cant see any clinical benefit.
     
  30. DOctorJay

    DOctorJay 10+ Year Member

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    good indication for ultrasound here
     
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  31. emd123

    emd123 5+ Year Member

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    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.
     
  32. pastafan

    pastafan Interventional Pain Physician 2+ Year Member

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    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?
     
  33. emd123

    emd123 5+ Year Member

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    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.

    If the patient jumped and you're worried about a pneumo and you did a chest X-ray (Pa/lat and insp/exp) like you said, you should be okay.
     
  34. lobelsteve

    lobelsteve SDN Lifetime Donor Lifetime Donor 10+ Year Member

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    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.
     
  35. pastafan

    pastafan Interventional Pain Physician 2+ Year Member

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    Good point. I did have a patient get a tension pneumo after surgeon put in a port and left OR. I put a Jelco catheter to decompress and it was a lot deeper than my 25 gauge needle.
     
  36. Ducttape

    Ducttape SDN Lifetime Donor Lifetime Donor 5+ Year Member

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    I don't routinely scan patients but I did for one patient. 2.3 cm to pleural space - within reach of 1 inch needle.
     

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