Critical Procedure - Tension pneumothorax
For all procedures, ask yourself, 'does this need to be done 'now vs later'? And should this be done by 'me vs someone else?' Very often the answers will be 'now' and 'me' - so read on!
Emergency decompression of a tension pneumothorax using an
- intravenous catheter
- bespoke/dedicated catheter device
- open/finger thoracostomy (see footnote for this)
This procedure is somewhat controversial, it has been much promoted in the past and there has been a lot of discussion about its safety and efficacy.
The consensus currently seems to be:
1. Needle decompression can be associated with complications (may create a pneumothorax if there wasn't one, in an already compromised patient, lung laceration, air embolism)
2. It should not be used lightly.
3. It should never be used just because we don't hear breath sounds on one side.
4. In extremis with any of the following, dyspnoea, shock with distended neck veins, reduced breath sounds, deviated trachea, it could be life saving.
In the absence of haemodynamic compromise and clear signs of a tension pneumothorax it is prudent, if possible, to confirm the diagnosis with emergency x-ray or ultrasound, providing you monitor the patient throughout and are prepared to intervene if the situation worsens.
Traumatic cardiac arrest where tension pneumothorax is a possibility.
A patient not in extremis.
No clear evidence of tension pneumothorax.
14 or 16G IV cannula - longer is better
20ml syringe (not essential)
Optional - Heimlich valve or improvised Heimlich valve
Select site (ease, speed, chance of success)
5nd intercostal space in the anterior or mid axillary line (possibly higher chance of success than the traditional site, below)
2nd intercostal space in the mid-clavicular line (the second rib joins the sternum at the Angle of Louis) - failure rate up to 50%
- brief skin preparation (if time allows), insert the cannula, perpendicular to the skin. Advance until you hear air escape.
- Remove the needle from the cannula
- Monitor for patency and re-occurrence
Cannula too short and thus not reaching the pleural space.
Creation of a pneumothorax.
Obstruction of the cannula by tissue leading to failed decompression.
Failure to follow up this procedure with formal chest tube insertion.
If needle thoracostomy fails:
- open/finger thoracostomy ie. the first part of standard chest tube insertion - can be Plan A sometimes if can perform quickly
- formal chest tube