Tension Pneumothorax

Without evidence of benefit, an intervention should not be presumed to be beneficial or safe.

- Rogue Medic

Knowing When To Hold ‘Em

Fri, 28 Sep 2012 08:00:18 -0400 by Rogue Medic

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Bob Sullivan wrote an article about an EMS Office Hours episode that we were on several weeks ago.

What is the right way to deal with a tension pneumothorax? He describes a patient who was assessed and treated in a hospital. the patient did have a simple pneumothorax and was uncomfortable, but there was no rush to decompress the chest, even after the diagnosis was made by X-ray.

The patient’s condition did not change. Approximately 30 minutes after the diagnosis was made, more pain medication and Versed were given, and the tube was placed without incident.^[1]

Why are we in such a rush to put needles in chests based on limited information – when the patient is not unstable?

Click on the image to make it larger.^[2]

This image shows how many of the patients in a hospital study of EMS needle decompression never had any kind of pneumothorax – 26%.

57 patients had a needle decompression.

Ultrasound examination prior to chest tube showed that these patients never had any kind of pneumothorax and therefore did not need any kind of chest tube.

The paramedic’s needle(s) never even reached the pleural space, so there had never been any decompression. Many of the medics still had documented that there was a rush of air when they provided this intramuscular injection, or is it intra-something else, because the needle wasn’t where it was supposed to be.

How do we get a rush of air from an intramuscular injection?

We see what we want to see.

We feel what we want to feel.

We hear what we want to hear.

We confirm our beliefs, rather than objectively assess the patient.

The only reason we know that these patients did not have any kind of pneumothoraces is that the needles were too short to reach the pleural spaces of the patients. Maybe the sites used were not well chosen, but why use a short needle?

The same people who teach us how to identify a tension pneumothorax should be teaching us to only use a long needle to attempt to decompress a suspected tension pneumothorax.

Do they teach us the right assessment?

Do they teach us to use a long needle?

Maybe some instructors do not. Maybe some students forget a lot. Maybe we need refreshers on all of the rarely performed procedures we might use.

How many of the rest of the patients also did not have the paramedic’s needle reach the pleural space, but did have a tension pneumothorax?

We do not know.

How many of the rest of the patients also did not have the paramedic’s needle reach the pleural space, but did have a simple pneumothorax and never had any tension pneumothorax?

We do not know.

How many of the rest of the patients DID have the paramedic’s needle reach the pleural space, but did not have a tension pneumothorax or simple pneumothorax before being stuck with the needle?

We do not know.

What we do know is that when size matters, we seem to be coming up short.

Are the patients faking it to get us to stop sticking needles in them?

If the cause of the pneumothorax is the paramedic, are we doing any good with needles?

If we can’t figure out the differences among a simple pneumothorax, a tension pneumothorax, and no pneumothorax, are we doing more harm than good?

If we only stick patients who have worsening respiratory distress or who are hypotensive and getting worse, then we should not be sticking harpoons in so many of the wrong people.

Longer catheters have been suggested to increase the likelihood of successful needle decompression.^7,8 This is a matter of debate secondary to the argument that the use of longer catheters may lead to more injuries.^[3]

With a 2 inch needle, there was a high failure rate.

If we are using standard 14 gauge 1 1/4 inch catheters, what are the chances that the needle is reaching the pleural space, when many 2 inch needles will not reach?

Maybe we are trying to do such a bad job with needle decompression that people will stop paying attention to our intubation problems.

How benign a procedure is needle decompression if the patient does not have a pneumothorax of any kind? I will have to ask advocates of aggressive needle decompression to let me practice on their chests.

Where’s the harm? It’s just a tiny 14 gauge needle. I let students stick me with them for IVs.

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Footnotes:

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^[1] Knowing When To Hold ‘Em
August 31, 2012
EMS Patient Perspective
Bob Sullivan
Article

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^[2] Inadequate needle thoracostomy rate in the prehospital setting for presumed pneumothorax: an ultrasound study.
Blaivas M.
J Ultrasound Med. 2010 Sep;29(9):1285-9.
PMID: 20733183 [PubMed – in process]

Free Full Text from J Ultrasound Med.

When Should EMS Use Needle Decompression
Rogue Medic
Thu, 10 Nov 2011
Article

Inadequate needle thoracostomy rate in the prehospital setting for presumed pneumothorax: an ultrasound study – Full paper
Rogue Medic
Mon, 14 Feb 2011
Article

Inadequate needle thoracostomy rate in the prehospital setting for presumed pneumothorax: an ultrasound study – abstract
Rogue Medic
Tue, 07 Sep 2010
Article

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^[3] Anterior versus lateral needle decompression of tension pneumothorax: comparison by computed tomography chest wall measurement.
Sanchez LD, Straszewski S, Saghir A, Khan A, Horn E, Fischer C, Khosa F, Camacho MA.
Acad Emerg Med. 2011 Oct;18(10):1022-6. doi: 10.1111/j.1553-2712.2011.01159.x. Epub 2011 Sep 26.
PMID: 21951681 [PubMed – indexed for MEDLINE]

Filed Under: Assessment, Heresy, Tension Pneumothorax

Low quality is identified by inability to use critical thinking

Mon, 20 Aug 2012 17:30:31 -0400 by Rogue Medic

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The title is a variation on a sentence written by David Givot.

You will notice that the “substandard” providers in your area are chiefly characterized by their inability to “handle” some situations through critical thinking.^[1]

Do some of the people you work with seem to treat a lot more unstable patients than most?

Do some of the people you work with seem to need to use a lot more life saving treatments (intubation, needle decompression, crichothyrotomy, cardiversion, et cetera) than most?

Are they dealing with more unstable patients, or are they just over-reacting?

Needle decompression may be an excellent way to identify some of those who have the patient assessment skills that are ~~deadly~~ substandard.

Click on the image to make it larger.^[2]

The chart is for all patients treated with needle decompression for suspected tension pneumothorax.

Many patients never had any kind of pneumothorax.

Did any patient have a tension pneumothorax?

We do not know.

Are we providing this kind of oversight on EMS needle decompressions anywhere?

26% of patients did not have any pneumothorax at any time – not even after a paramedic stuck them with a large needle that is supposed to cause a pneumothorax.

This should have caused us to reassess our needle decompression assessment and treatment, but has anything changed?

Do any of our needle decompression patients have tension pneumothorax?

Do we care?

Back to the article –

In far too many cases, training programs offer the minimum legal subject matter required for accreditation as a training facility, usually little more than glancing over some EMS statutes and local rules.

“Don’t mess up, or you will get sued” seems to be the extent of the preparation new providers (who grow to be old providers) ever get with respect to protecting themselves legally.^[1]

In the study, 26% of paramedics messed up in a very big way.

Did any of them get sued?

Did any of them receive any remediation?

Did the EMS service do anything to try to cut down on inappropriate needle decompressions?

In each case, a paramedic stabbed the patient in the chest.

How many of the rest of the patients only had a pneumorax because a paramedic stabbed the patient in the chest?

How representative is this study?

We don’t know.

We used to pretend that paramedics are great at intubation, but then we studied paramedic success rates and realized that only some rare paramedics seem to be good at intubation.

If we do not measure what we do, we do not know how bad we are.

If we do not measure what we do, how can we improve?

Our patients deserve excellent care, but we don’t even know what we are doing.

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Footnotes:

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^[1] If providers save lives, then the law saves providers
Providers who combine solid skills with knowledge and understanding of how law applies will be both good and safe
The Legal Guardian
by David Givot
August 13, 2012
EMS1.com
Article

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Free Full Text from J Ultrasound Med.

When Should EMS Use Needle Decompression
Rogue Medic
Thu, 10 Nov 2011
Article

Inadequate needle thoracostomy rate in the prehospital setting for presumed pneumothorax: an ultrasound study – Full paper
Rogue Medic
Mon, 14 Feb 2011
Article

Inadequate needle thoracostomy rate in the prehospital setting for presumed pneumothorax: an ultrasound study – abstract
Rogue Medic
Tue, 07 Sep 2010
Article

Filed Under: Critical Judgment, Heresy, Risk Management, Tension Pneumothorax

Will spontaneous pneumothorax progress to tension pneumothorax?

Mon, 04 Jun 2012 08:00:32 -0400 by Rogue Medic

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This paper gets right to the point.

Spontaneous pneumothorax must rank high in the list of common medical conditions where conventional teaching and management either make no physiological sense or are based on inadequate evidence and trials which have failed to address the most important points.^[1]

make(s) no physiological sense?

based on inadequate evidence?

based on . . . trials which have failed to address the most important points?

What does he say in the rest of the paper?

Textbooks and guidelines are unanimous in attributing the mechanism of tension pneumothorax to ‘the operation of a one-way valve system, drawing air into the pleural space during inspiration not allowing it out during expiration’.¹ ^[1]

If the conventional teaching were true, then why do so few spontaneous pneumothoraces progress to tension pneumothoraces?

Why is tension pneumothorax is rare.

Treatment of presumed tension pneumothorax appears to be much more common than tension pneumothorax.^[2]

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Click on the image to make it larger.

The chart is for all pneumothoraces (not just spontaneous pneumothoraces) treated as tension pneumothoraces, even if there really was no pneumothorax, but this suggests just how easily we can find what we are looking for, even when it is not there.

Did any patient have a tension pneumothorax?

We do not know.

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Tension pneumothorax can only occur by generation of supra atmospheric pressures within the chest – either through positive pressure ventilation (invasive or non-invasive) or through forced expiratory manoeuvres, commonly coughing.^[1]

That is not what I was taught.

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A couple of studies in 1966 had conflicting results. One suggested aggressive treatment, but had no conservative treatment arm, so this was based on assuming that aggressive treatment is the best treatment. The other study showed that patients did dramatically better with conservative treatment, but almost everybody ignored that study in favor of the fatally flawed study.

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In 1993 the British Thoracic Society carried out the first randomized controlled trial of treatment of spontaneous pneumothorax but unfortunately in this, as in all succeeding trials, there was no arm of conservative management with observation.¹² ^[1]

One of our problems is the tendency toward the unproven treatment, while ignoring the possibility that lack of intervention may be a better treatment.

In cardiac arrest, we only have two interventions that have been demonstrated to improve outcomes – chest compressions and defibrillation.

A sensible approach to finding out what works would be to add only one intervention at a time and compare it with these treatments. However, even the current ROC (Resuscitation Outcomes Consortium) trials are biased by not including a treatment arm limited to treatments that have been demonstrated to improve outcomes. The proponents of the treatments that are being studied will always be able to use the excuse that these studies were biased by including treatments that do not work. Treatments that will probably be demonstrated to worsen outcomes, if we ever start following ethical research practices.

In spite of an absence of good evidence supporting aggressive treatment, the Standard Of Care has been aggressive treatment.

As we should be accustomed to by now, the Standard Of Care was based on very biased research that ignored the scientific method and put patients at risk for no real benefit.

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What then is the case for doing nothing in spontaneous pneumothorax? First, the risk of death is extremely low. British figures from 1991 to 1995 show hospital admission rates for pneumothorax at 16.7/100 000 per annum,¹ whereas deaths from pneumothorax (including all high risk cases) were less than 1% of this figure at 1.26/1 000 000 per annum.^[1]

One in a million?

Either the aggressive treatment made a huge difference in saving lives or there was not a need for aggressive treatment to begin with.

Would it be unethical to find out if conservative treatment works?

In Cairns we have had a policy of non-intervention wherever possible for 15 years. Even with large pneumothoraces, symptoms resolve to a low level by the following day following adequate analgesia and although the patients may be breathless on moderate to vigorous exertion, they are fully capable of carrying out their daily activities and returning to work, confirming Stradling and Poole’s observations in the 1960s.¹⁰ ^[1]

Would many patients make an informed decision to have an invasive treatment that would lead to extended hospitalization, rather than conservative treatment?

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In fact, all of the current experts in the field seem to concentrate on treating the chest X-ray appearance rather than the patient.^[1]

Treat the patient, not the machine.

When will we learn?

In cardiac arrest, many of the current experts focus on obtaining ROSC (Return Of Spontaneous Circulation), while ignoring the lack of improvement in neurologically intact survival with this focus on ROSC.

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But at least some of what we were taught must be true!

What causes pneumothorax? Traditionally, blebs and bullae (emphysema-like changes or ELCs) have been blamed. Smoking is in fact the predominant risk factor with a lifetime risk in male smokers estimated at 12% compared with 0.1% for lifelong non-smokers.²¹ ^[1]

Even the blebs, the mean old blebs, are not the cause. What next, no Santa Claus?

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But if there is a recurrence, that is proof that the patient should have had aggressive treatment!

The risk of recurrence after a first primary spontaneous pneumothorax is estimated between 30% and 50%, smoking markedly increasing the risk.¹ Once there has been one recurrence, the risk of further recurrence rises exponentially and it is certainly sensible to recommend some procedure to prevent further recurrences after the second pneumothorax on the same side. However, as primary spontaneous pneumothorax is essentially a nuisance rather than a dangerous condition it may not be necessary to go to heroic measures to prevent a recurrence which will also be merely a nuisance.^[1]

This would ordinarily be a nuisance, easily managed with pain medicine, but we prefer to stick a large catheter in your chest and sometimes leave the trochar in the catheter leading to fatal outcomes. 😳

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What is crucially needed here is what should have been done 40 years ago, which is a randomized controlled study of conservative observational management of primary spontaneous pneumothorax against what is currently the best evidenced intervention which is pleural aspiration.^[1]

The same is true for the various superstition-based treatments that are Standards Of Care for cardiac arrest.

Maybe, someday we will learn.

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Footnotes:

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^[1] Spontaneous pneumothorax: time for some fresh air.
Simpson G.
Intern Med J. 2010 Mar;40(3):231-4. Review.
PMID: 20446970 [PubMed – indexed for MEDLINE]

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^[2] When Should EMS Use Needle Decompression
Rogue Medic
Thu, 10 Nov 2011
Article

Inadequate needle thoracostomy rate in the prehospital setting for presumed pneumothorax: an ultrasound study – Full paper
Rogue Medic
Mon, 14 Feb 2011
Article

Inadequate needle thoracostomy rate in the prehospital setting for presumed pneumothorax: an ultrasound study – abstract
Rogue Medic
Tue, 07 Sep 2010
Article

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Simpson, G. (2010). Spontaneous pneumothorax: time for some fresh air Internal Medicine Journal, 40 (3), 231-234 DOI: 10.1111/j.1445-5994.2009.02155.x

Filed Under: Assessment, Critical Judgment, Heresy, Mythology, Research Blogging, Tension Pneumothorax

When Should EMS Use Needle Decompression

Thu, 10 Nov 2011 06:30:24 -0500 by Rogue Medic

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It seems as if everyone is writing about tension pneumothorax this month. Too Old To Work, Too Young To Retire writes “The First 150 Are Exciting”. He seems to be channeling Vin Diesel in Knockaround Guys.

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Then there is ~~Fern~~ MK ^♦ at Probie To Practitioner writing More Training Does Not Equal A Better Provider. There is an important lesson in there for those who think that because they have more training, they are the tough guys/gals who can go around and spit tobacco on everyone else. Does that mean everyone is now channeling Vin Diesel? 😯

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Back to EMS, this is what ~~Fern~~ MK was writing about needle decompression –

Our medic grabbed a needle to decompress his chest when a woman on the flight crew burst through the ambulance door. The medic began briefing the flight crew as he prepared to decompress his chest. The woman from the flight crew (who later introduced herself as a doctor), literally stepped in front of our medic, whipped a needle out of her flight suit, and stabbed him in the chest, decompressing his chest. The flight doctor never spoke a word with the patient, never addressed any of his fears or concerns.

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Picture credit. The doctor is here. It is time for your needle decompression!

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I commented –

When a needle decompression is indicated, the patient should generally not be aware of what is going on.

On the other hand, what kind of idiot doctor does a needle decompression without an assessment?

and Fern (really Fern, this time) responded with –

So, you’re saying the patient should have a reduced LOC if needle decompression is to be performed? Or are you saying that they shouldn’t know what’s coming to them?

Not trying to stir the pot, just an honest question.

I oversimplified.

Neither decreased LOC (Level Of Consciousness) nor should we sneak up on the patient for an Ides of March kind of surprise. The patient should be sick enough that the patient does not care about being stabbed in the chest with a big needle. If the big needle is a problem for the patient, the patient probably is not sick enough to need it. If we can wait and the patient is not getting worse, should we be engaging in aggressive perforation of the chest?

Penetrating injury to the chest is usually an indication for a trauma alert. That is supposed to be from a penetrating injury provided by someone other than EMS. Should the patient become a trauma alert because of our treatment?

One day, I was writing charts and my partner was watching one of the EMS reality shows (I think it was “Paramedics”). On the show, the medic was explaining to the patient that he believed the patient had a tension pneumothorax and what was coming. The announcer began to describe, in hushed tones, how the medic was saving the life of the patient.

Then you hear the patient scream – a long loud scream – as the medic starts pushing the needle into the patients chest. A blood curdling scream is not the rush of air that we are told we will hear when we decompress a tension pneumothorax. The patient should not be able to scream. Whimper, yes. Scream, no.

It is kind of like the patient yelling at you that he cannot breathe. If he can yell, he can probably score a better FEV₁ than you.

There are two important indicators for decompressing a tension pneumothorax – increasing difficulty breathing and a bad blood pressure that is getting worse.

Not tracheal deviation. If a patient with a goiter is treated by EMS, he will have needles poking out of everywhere – neck, chest, and veins.

Not decreased breath sounds. Those might be present or they might not or they might be due to something that is not a tension pneumothorax. That something might not benefit from a large needle that might reach the pleural space, but probably will not reach the pleural space.

Think about this as if you are the patient –

OK, I’ll breathe more deeply, just stop stabbing me!

Would you be showing more signs of life because of the pain from the needle or because the harpoon was the right treatment?

We assume that a change after a treatment is because the treatment worked. Maybe the treatment just caused a lot of pain, but did not provide any benefit to the patient.^[1]

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In one study of whether a needle decompression meant that the patient had any kind of pneumothorax, 57 patients were scanned in the ED. Fifteen patients (26%) had no signs that they ever had any pneumothorax, even when they checked with CT scans.^[2]

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Click on the image to make it larger.

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From this study we cannot tell if the number that should be in the place of the double question marks is 42. Maybe it is 32. Maybe it is 22. Maybe it is 12. Maybe it is 2. Maybe it is zero. We don’t know and this study cannot tell us, which is not a fault of the study.^[3]

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I treat these patients with pain medicine and have not needed to perforate any chests. This has led to satisfied patients and satisfied trauma surgeons.

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Footnotes:

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^♦ In the comments, MK writes that Fern did not write this. MK wrote this. I don’t know how I made that mistake, but I did. I apologize. 😳

Eventually I figured out where I went wrong. MK wrote the post, but Fern wrote the response to my original comment. It doesn’t take much to confuse me.

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^[1] Placebo vs Belief vs Neither – Part II
Rogue Medic
Article

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Free Full Text from J Ultrasound Med.

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^[3] Inadequate needle thoracostomy rate in the prehospital setting for presumed pneumothorax: an ultrasound study – Full paper
Rogue Medic
Article.

Filed Under: Heresy, Mythology, Research, Tension Pneumothorax

Inadequate needle thoracostomy rate in the prehospital setting for presumed pneumothorax: an ultrasound study – Full paper

Mon, 14 Feb 2011 13:30:23 -0500 by Rogue Medic

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Also posted over at Paramedicine 101 (now at EMS Blogs) and at Research Blogging. Go check out the rest of the excellent material at these sites.

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When I wrote Inadequate needle thoracostomy rate in the prehospital setting for presumed pneumothorax: an ultrasound study – abstract, I was only looking at the abstract. Now that I have seen the entire paper, I have not seen anything weaken the results of the study. There are plenty of points to discuss.

On the EMS Research Podcast Harry Mueller, Patrick Lickiss, Dr. Bill Toon, and I discuss this paper. In about half an hour, we go into the details. Here I will present the highlights. First, go listen to the podcast. Prehospital Needle Thoracostomy: EMS Research Episode4

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During the podcast, I suggested that Dr. Blaivas is a radiologist, or some other specialist in imaging medicine, as opposed to being an emergency physician. That is not correct. Dr. Blaivas is Professor of Emergency Medicine in the Department of Emergency Medicine at Northside Hospital Forsyth in Cumming, Georgia. Dr. Blaivas is also either the world’s first or second emergency ultrasound fellowship graduate. Therefore he is very well qualified to examine all aspects of emergency medicine and ultrasound.

Let’s look at the paper.

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An unstable trauma patient who is not oxygenating well or is hypotensive and has decreased breath sounds unilaterally on auscultation may be assumed by paramedics to have a PTX.² Not unreasonably, with lack of a more definite way to rule in or rule out the presence of a PTX, needle thoracostomy is opted for to relieve the tension that is assumed to be present.^[1]

Previous experience and this study lead me to the doubt this not unreasonable conclusion.

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In the prehospital setting where external noise and distractions may be overwhelming, release of air is frequently not audible.^[1]

This focus on decreased breath sounds may be one of the important factors in the misdiagnosis of tension pneumothorax.

How many medics are good at assessing lung sounds?

How many medics can tell the difference between the diminished lung sounds that are indicative of a tension pneumothorax and the diminished lung sounds that are consistent with any of the normal variations of lung sounds?

I would also change part of a sentence –

In the prehospital setting where external noise and distractions may be overwhelming, release of air is frequently ~~not audible~~ imaginary.

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Typically, in such critically ill patients, the chest tube is placed before review of a chest radiograph to confirm that the tension PTX has improved. The natural assumption is that regardless of whether a PTX was present, proper penetration of the chest wall would lead to a PTX even if it were not originally present.^[1]

Should any doctor be using this logic to decide to place a chest tube without assessing the patient?

Should any doctor be placing a chest tube without assessing the patient?

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However, if the needle did not penetrate the lung and no PTX was initially present, a chest tube could be avoided.^[1]

In the absence of a pneumothorax, a chest tube ~~could~~ should be avoided.

What justification is there for placing a chest tube in a patient with no indication for a chest tube?

Maybe the needle is in the chest because the medic has really scary IV skills. In this study, at least a quarter of the medics treating these patients (unless some are repeat offenders) have really scary needle decompression skills.

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The main outcome measure was whether a PTX was present. The secondary outcome measure was whether a PTX developed after catheter removal.^[1]

There does not appear to be any discussion of whether a pneumothorax developed after catheter removal.

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Physicians performed the ultrasound examinations during the secondary survey. Chest radiographs were obtained immediately after the ultrasound examinations. Examiners were not blinded to physical findings or on which side needle thoracostomy was performed.^[1]

blinding would have been nice, but this study seems to be more to demonstrate the concept that needle decompression may not even produce a simple pneumothorax. This can be left for a later study.

It would also be nice to follow up on the patients to find out if any showed any of the no pneumothorax patients showed any signs of pneumothorax later on, which could cast doubt on the ultrasound findings.

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A total of 57 patients were enrolled in the study over a 3-year period. Fifty-six patients had 1 needle thoracostomy performed, and 1 patient had 3 needle thoracostomy procedures on the same side for hypotension and persistent unilateral decreased breath sounds.^[1]

It should not surprise anyone that the patient with the ~~multiple stab wounds~~ 3 attempts at needle decompression did not have any kind of pneumothorax.

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A tension PTX is a life-threatening process that must be treated immediately either through needle thoracostomy or tube thoracostomy. Despite frequent use of chest radiography on patient arrival to emergency departments, many PTXs are initially missed.^[1]

It seems that a lot is missed.

Needles misses lungs.

Medics miss the absence of a tension pneumothoraces.

Doctors miss the presence of pneumothoraces.

If there is an important point to this, maybe it should be that we all need to improve our assessment for pneumothoraces and be more conservative in our treatment in the absence of unmistakable signs of a tension pneumothorax.

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The combination of unilateral decreased or absent breath sounds with instability is justifiably interpreted as the presence of a PTX. There is no way to verify or refute such a finding.^[1]

Maybe.

Maybe not.

Should we assume that a tension pneumothorax is subtle?

I don’t think so.

Why do we teach about tension pneumothorax as if it is the same as an easily missed simple pneumothorax?

I think it is because we don’t realize just how unsubtle a tension pneumothorax is.

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This study had several limitations. The first was the small sample size. Second, the sonologists were not blinded to the side on which needle decompression was attempted. Third, it is possible that some patients did in fact have a PTX that was completely relieved by needle decompression, and no more air leaked after catheter removal. Thus, the CT scan would not show even a trace PTX. Although this is possible, it is clinically very unlikely.^[1]

There are limitations, but are these results consistent with what we know about the shortcomings of EMS education and understanding of infrequently done procedures?

Absolutely.

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Click on the image to make it larger.

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The same problem exists for trying to figure out the number that should be in the place of the single question mark.

We know that of the patients treated for claimed tension pneumothorax, 26% were treated by paramedics so poorly that the needle never even made it to the lung.

Should we assume that all of the patients treated with needles that actually reached the lung did have tension pneumothoraces?

There is nothing in this paper to suggest that.

There is no good reason to assume that all of the medics who missed the diagnosis also missed the lung. 26% missed the lung and missed the diagnosis.

It is reasonable to assume that some of the medics missed the diagnosis, but used a long enough needle to hit the lung. What we do not know is how many of those who hit the lung with a needle missed the diagnosis.

Another possibility is that the patient had a pneumothorax, most likely a simple pneumothorax, and the medic missed the lung with the needle, but since it was not a tension pneumothorax there was no dramatic deterioration of the patient. The needle decompression would be no more indicated for these patients than for those without any pneumothorax.

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Also covered at EMS Research Podcast Episode 4 at 510Medic.

Go listen to the podcast. Prehospital Needle Thoracostomy: EMS Research Episode4

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Footnotes:

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^[1] Inadequate needle thoracostomy rate in the prehospital setting for presumed pneumothorax: an ultrasound study.
Blaivas M.
J Ultrasound Med. 2010 Sep;29(9):1285-9.
PMID: 20733183 [PubMed – in process]

Free Full Text from J Ultrasound Med.

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Blaivas M (2010). Inadequate needle thoracostomy rate in the prehospital setting for presumed pneumothorax: an ultrasound study. Journal of ultrasound in medicine : official journal of the American Institute of Ultrasound in Medicine, 29 (9), 1285-9 PMID: 20733183

Filed Under: Critical Judgment, Education, EMS Research Podcast, Heresy, Paramedicine 101, Research Blogging, Tension Pneumothorax

Inadequate needle thoracostomy rate in the prehospital setting for presumed pneumothorax: an ultrasound study – abstract

Tue, 07 Sep 2010 17:22:22 -0400 by Rogue Medic

Also posted over at Paramedicine 101 (now at EMS Blogs) and at Research Blogging.

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Go check out the rest of the excellent material at both sites.

Over at 510 Medic, there is an interesting abstract of a new article on treatment of tension pneumothorax. Frequency of Inadequate Needle Decompression in the Prehospital Setting.

CONCLUSIONS: In this study, 26% of patients who received needle thoracostomy in the prehospital setting for a suspected PTX appeared not to have had a PTX originally, nor had 1 induced by the needle thoracostomy. It may be prudent to evaluate such patients with bedside ultrasound instead of automatically converting all needle thoracostomies to tube thoracostomies.^[1]

I have not read the full text. ~~I do not have access to this journal. If anyone can send me the full text, I would like to address some of the details, rather than just speculate about them.~~ Late entry – I have received the article. Thank you to Jeff Williams and Jeremy Blanchard. I will write more about the full text later on.

510 Medic makes some important points and asks some good questions. Then 510 Medic asks –

So if we subscribe to the goal of “first do no harm” and those 15 patients didn’t have a pneumothorax induced by the procedure, is their discomfort worth proper treatment for the remaining 42 patients?^[2]

I think that there is a more important question.

Should we assume that the presence of a pneumothorax is an indication for needle decompression?

A pneumothorax is not the same as a tension pneumothorax. Even the definition of a tension pneumothorax is not easy to agree on. I tend to treat with opioids what many others would treat with needle decompression. I have not had any of these patients deteriorate, while in my care. They received chest tubes in the trauma center.

Should we assume that the presence of a pneumothorax is an indication for needle decompression?

57 patients with a prehospital diagnosis of tension pneumothorax. Yes, EMS does diagnose, but that is a discussion for elsewhere. Yes, these patients were diagnosed by EMS with tension pneumothorax, unless we are suspecting acupuncture, because what other prehospital indication is there for sticking a needle into a patient’s chest?

Out of 57 patients diagnosed with tension pneumothorax, only 42 patients had a pneumothorax.

How many patients had a tension pneumothorax at the time the needle was stuck into the chest wall?

How many of those patients would have been better off if treated with something other than a needle?

How many complications were there from the needle decompression?

Am I wrong to use italics to highlight the word decompression, since so many of the patients did not have anything to decompress?

We rush to perform procedures that we have little experience with. Isn’t this a situation likely to lead to misdiagnosis?

Isn’t the infrequent use of needle decompression for suspected tension pneumothorax likely to lead to operator error?

The actual occurrence of tension pneumothorax appears to be much less frequent than the prehospital diagnosis of tension pneumothorax. Isn’t that an indication of a failure to properly educate medics?