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

- Rogue Medic

Knowing When To Hold ‘Em

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.

Footnotes:

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

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

[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]

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Comments

  1. Isn’t this really just one example of how our paramedic education is lacking? First and foremost it shows a lack of patient assessment abilities, and rapidly drops off of the cliff from there.

    On a side note, do they not teach to use a 10cc syringe filled roughly halfway with NS attached to the decompression needle in order to observe positive air evacuation?

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