All posts by TheTraumaPro

Advanced Needle Thoracostomy

In the past, I’ve written about the merits of needle vs finger thoracostomy. One of the arguments against needle thoracostomy is that it may not reach into the chest cavity in obese patients. As I mentioned yesterday, use the right needle!

Obviously, the one on top isn’t going to get you very far. The bottom one (10 gauge 3 inch) should get into most pleural spaces.

But what if you don’t have the right needle? Or what if the patient is massively obese and the longer needle won’t even reach? Pushing harder may seem logical, but it doesn’t work. You might be able to get the needle to reach to the pleural space, but the catheter won’t stay in it.

Here’s the trick. First, make the angiocatheter longer by hooking it up to a small (5 or 10cc) syringe. Now prep the chest over your location of choice (2nd intercostal space, mid-clavicular line or 5th intercostal space, anterior axillary line) and make a skin incision slightly larger than the diameter of the syringe. Now place the syringe and attached needle into the chest via your incision. It is guaranteed to reach the pleura, because you can now get the hub of the catheter down to the level of the ribs. Just don’t forget to pull out the catheter once you’ve placed the chest tube!

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The Right Way to Treat Tension Pneumothorax

Tension pneumothorax is an uncommon but potentially lethal manifestation of chest injury. An injury to the lung occurs that creates a one-way valve effect, allowing a small amount of air to escape with every breath. Eventually the volume becomes so large as to cause the lung and mediastinum to push toward the other side, with profound hypotension and cardiovascular collapse.

The classic clinical findings are:

  • Hypotension
  • Decreased or absent breath sounds on the affected side
  • Hyperresonance to percussion
  • Shift of the trachea away from the affected side
  • Distended neck veins

You should never diagnose a tension pneumothorax with a chest xray or CT scan, because the diagnosis is a clinical one and the patient may die while these procedures are carried out. Having said that, here’s one:

image

The arrow points to the completely collapsed lung. Note the trachea bowing to the right.

As soon as the diagnosis is made, the right thing to do is to “needle the chest.” A large bore angiocath should be placed in the second intercostal space, mid-clavicular line, sliding right over the top of the third rib. The needle should then be removed, leaving the catheter.

The traditional large bore needle is 14 gauge, but they tend to be short and flimsy. They may not penetrate the pleura in an obese patient, and will probably kink off rapidly. Order the largest, longest angiocath possible and stock them in your trauma resuscitation rooms.

image

The top catheter in this photo is a 14 gauge 1.25 inch model. The bottom (preferred at Regions) is a 10 gauge 3 inch unit. Big difference! 

The final tip to treating a tension pneumothorax is that a chest tube must be placed immediately after inserting the needle. If the patient is on a ventilator, the positive pressure will slowly expand the lung. But if they are breathing spontaneously, the needle will change the tension pneumothorax into a simple open pneumothorax. Patients with other cardiovascular problems will not tolerate this for long and may need to be intubated if you dawdle.

Related post:

How Big Should Your Trauma Bay Be?

Trauma resuscitation rooms vary tremendously. They can range from very spacious…

to very tight…

Most trauma bays that I have visited were somewhere between 225 and 300 square feet (21-28 sq meters), although some were quite large (Rashid Hospital in Dubai at nearly 50 sq meters!).

Interestingly, I did manage to find a set of published guidelines on this topic. The Facility Guidelines Institute (FGI) develops detailed recommendations for the design of a variety of healthcare facilities. Here are their guidelines for adult trauma bays:

  • Single patient room: The clear floor area should be 250 sq ft (23 sq m), with a minimum clearance of 5 feet on all sides of the patient stretcher.
  • Multiple patient room: The clear floor area should be 200 sq ft (18.5 sq m) with curtains separating patient areas. Minimum clearance of 5 feet on all sides of the patient stretcher should be maintained.

The FGI “clear floor area” corresponds to my “Trauma Bay Working Area”, which is the area that excludes all the carts, cabinets, and countertops scattered about the usual trauma room. California’s guideline of 280 sq feet seems pretty reasonable as the “Trauma Bay Total Area”, if you can keep your wasted space down to about 30 sq feet.

Bottom line: Once again, don’t try to figure out everything from scratch. Somebody has probably already done it (designed a trauma bay, developed a practice guideline, etc). But remember, a generic guideline or even one developed for a specific institution may not completely fit your situation. In this case, the FGI guidelines say nothing about the trauma team size, which is a critical factor in space planning. Use the work of others as a springboard to jump start your own efforts at solving the problem.

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July Newsletter Released!

The July newsletter is now available! Click the link below to download. This month’s topic is “Malpractice and Trauma, part 2”.

In this issue you’ll find articles on:

  • Does open discussion at M&M increase lawsuits?
  • Is family presence during trauma resuscitation risky?
  • EMS liability litigation
  • Basics of nursing malpractice
  • Forensic nursing

Subscribers received the newsletter last weekend. If you want to subscribe to get early delivery in the future (and download back issues), click here.

Click here to download newsletter.