I'll start off by saying this.... true tension pneumothorax is rare, but when present, it must be treated promptly without delay. If not treated the patient may quickly progress from respiratory distress -to- shock -to- cardiac arrest. Don't wait for the presence of tracheal deviation and/or JVD as they may never "show their face"
Furthermore, non-tension (simple) pneumothorax is relatively common, is not immediately life threatening and should not be treated in the field. While most tensions are caused by trauma this is not a hard fast rule. Some causes can be iatrogenic, for example, a sequela from lung cancer surgery -- I have seen this firsthand, when a large hematoma was visible in the patient neck area 1 day after hospital discharge. Additionally, we may cause this if we get overzealous with our artificial or mechanical ventilations. OR maybe your open chest wound dressing has become occluded and needs "burped"
When choosing your site - keep these helpful tips in mind.
To reduce failure rates (with needles alone - they will fail), consider using needles that have a minimum length of 3.25" inches for adults to ensure you actually enter the pleural space. In smaller children standard 14g-18g angio catheter may be all that is called for.
In many cases when the gold standard finger thoracostomy can't be performed or isn't allowed by current pre-hospital protocols - repeated needle decompressions may be needed - odds are they will kink, occlude, or compress. Of note, finger or tube thoracostomies in the field should only be reserved for and performed by highly trained EMS providers who have the proper medical oversight
Maneuver over the top of the desired rib to avoid the neurovascular bundles
Most traumatic arrest protocols have agencies perform bilateral decompression as the standard of care if any blunt of penetrating trauma to the torso is appreciated on the physical exam as part of the MOI. The procedure can usually be repeated if PEA > 40 bpm or VF/VT is persisting. Many also consider PEA < 40 bpm to be an asystolic equivalent rendering further resuscitation efforts futile. Some argue today that this should NOT be automatic, and you should have definitive clinical indications present before attacking both sides of the chest as a reflexive action.
For the anterior axillary (preferred) or mid axillary approach:
IF YOU HAVE TO CHOOSE, going too HIGH is a small issue while going too LOW has tremendous complications as you get too close to vital solid organs like the spleen or liver. Remember, solid organs have a likely tendency bleed..... a lot.
For the mid-clavicular approach:
IF YOU HAVE TO CHOOSE, going too LATERAL is a small issue while going too MEDIAL has tremendous complications as you get too close to the cardiac box. The true length of the collarbone is longer than you think.
Some manufacturers have cited that fenestrated catheters have outperformed non-fenestrated catheters and prevented distal needle occlusions -- something to ponder when making that purchase.
To supplement my quick down and dirty review above, it is very timely that NAEMSP just published a position paper on this important topic, and it can be found here:
Lyng, J. W., Ward, C., Angelidis, M., Breyre, A., Donaldson, R., Inaba, K., … Bosson, N. (2024). Prehospital Trauma Compendium: Traumatic Pneumothorax Care – a position statement and resource document of NAEMSP. Prehospital Emergency Care, 1–35.
**Disclaimer ** As with any topic we discuss on our blog entries -- our content will never supersede your own local protocols -- please continued to be aligned with your medical direction and relevant department policies above all else.
November 11, 2024
Author: Joshua Ishmael, MBA, MLS(ASCP)CM, NRP
Pass with PASS, LLC
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