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

- Rogue Medic

When Should EMS Use Needle Decompression

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.

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? 😯

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.


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

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]

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]


Click on the image to make it larger.

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]

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.

Footnotes:

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.

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

[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.

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

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Comments

  1. For the record, I wrote this post, not Fern. Fern is a friend who has a wonderful blog at http://www.fire-rescue-newbie.blogspot.com

    Also, there were details about the call that I left out to protect patient privacy, and to keep a long post from getting longer. As I remember, the patient had deteriorated even in the short time we had him. When the doc put the needle in, he honestly didn’t have much of a reaction as far as pain or fear goes. He was far more preoccuppied with his other injuries and fears.

    I’ll say that I felt the patient needed the treatment, but, I’m also placing a lot of trust in my paramedic as we.

    Regardless, thanks for the awesome post. It’s a good thing to think about….prevent us from getting over excited and treating unnecessarily.

    • MK,

      For the record, I wrote this post, not Fern. Fern is a friend who has a wonderful blog at http://www.fire-rescue-newbie.blogspot.com

      I don’t know how I did it, but I goofed. I apologize.

      Also, there were details about the call that I left out to protect patient privacy, and to keep a long post from getting longer.

      That is usually the case.

      As I remember, the patient had deteriorated even in the short time we had him. When the doc put the needle in, he honestly didn’t have much of a reaction as far as pain or fear goes. He was far more preoccuppied with his other injuries and fears.

      That sounds more appropriate for needle decompression, but who carries a decompression needle on them just in case?

      I used to carry naloxone (Narcan) in a pocket on the 1st and 15th of the month when I worked on trucks that covered areas with a lot of drug use, and used these a lot, but I soon realized that this was more for show, than for the benefit of the patient. Narcan doesn’t save lives, it just saves us from getting experience managing airways.

      I’ll say that I felt the patient needed the treatment, but, I’m also placing a lot of trust in my paramedic as we.

      Trust can be important, especially when things do not go as planned, but we should ask why something unusual is being done/was done, when we have the opportunity and it does not interfere with care.

      Sometimes/often we forget that others on scene do not see the same things that we see.

      Regardless, thanks for the awesome post. It’s a good thing to think about….prevent us from getting over excited and treating unnecessarily.

      Thank you.

      TOTWTYTR and others will often make the point about knowing when not to treat being more important than knowing when to treat. Too many of us start a treatment, that may not be indicated, then get caught up in having to complete the treatment, and we forget that we never really needed to do it when we started. RSI (Rapid Sequence Induction/Intubation) is one of these that can lead to a dead/disabled patient, who would have survived without disability if only the medic/nurse/doctor had decided not to intubate.

      We want to use our skills. Our bias is toward treatment. We need to work on controlling our biases and focus on what is best for the patient.

    • Mr. Rogue Medic,

      I appreciate the compliment that I could write a blog like M K’s, but alas, ’tis not mine. My blog is but another dunce blog written by some monkey who thinks he knows a thing or 2. My blog post quality is nowhere close to M K’s. I wish I could write half as well as her. (But I’m just another kid who wants to be a hose jockey.)

      And thanks for the explanation. It explains things really well.

  2. While I agree with you about needle decompression being over used, I didn’t specifically write about it in my post. I think I’ve decompressed about four patients in the past 20 or so years, not one of them was alive and not one of them survived.

    At least in my area it’s rarely used. YMMV, as the saying goes.

    • Too Old To Work,

      While I agree with you about needle decompression being over used, I didn’t specifically write about it in my post.

      It came up in the comments.

      I think I’ve decompressed about four patients in the past 20 or so years, not one of them was alive and not one of them survived.

      EMCrit covers Traumatic Arrest and encourages the use of diagnostically popping the chest. Finger thoracotomy is a more effective equivalent of needle decompression (also known as needle thoracotomy or needle thoracostomy).

      Dr. Weingart points out that, in trauma, compression (chest compressions) won’t help, while decompression (decompression of a tension pneumothorax) will help much more often.

      I did one on a pulseless guy with a pulverized side, but only blood came out. Not a surprise, but it wasn’t going to make anything worse and had the remote chance of making things better. We also did chest compressions and gave drugs which will not make anything better and may make things worse, but the ACLS guidelines refuse to recognize the futility of futility.

      At least in my area it’s rarely used. YMMV, as the saying goes.

      YMMV? Low mileage. Not much point in driving far with a pulseless trauma patient. 🙂

      It would be interesting to track this, but so many of the patients are put in helicopters because the trauma center is more than 10 minutes away. The flight services are not likely to provide feedback about the EMS screw ups, because they depend on them to call for a helicopter, which is an EMS screw up they encourage.

      .

  3. The only time I perforated a chest was on a man who was recently discharged home after having a chest tube removed. He most certainly had a pneumo. Stabbing him worked.

    Ides of March? I thought this was November?

    • CCC,

      The only time I perforated a chest was on a man who was recently discharged home after having a chest tube removed. He most certainly had a pneumo. Stabbing him worked.

      It is helpful when the patient’s history tells us what treatment to use. I take advantage of that information as much as possible.

      This has happened before? What helped you to get better then?

      Then people at the hospital tell me I am brilliant and ask how I ever thought of X. I say, I am not so brilliant – the patient told me.

      Ides of March? I thought this was November?

      As in, Brutus, put that stabby thing away. You have to wait 4 more months!

      He gets less respect than Rodney. The brainless, overpaid Roland Emmerich is the latest, and possibly the worst, conspiracy theorist ridiculing Shakespeare.

      .

  4. Great post Rogue Medic. The Victorian (Australia) Ambulance clinical practice guidelines state decompression should only be performed when the patient is deteriorating with decreased LOC and/or poor perfusion (avalable on their website). As a student, its good to be reminded to use big needles with caution.

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