Pleural Decompression

So today's topic, we want to talk about pleural decompression. And we want to look at the diagnosis, the indications, the appropriate procedure to perform a pleural decompression, but also to discuss some of the pitfalls involved in pleural decompression. And we're going to look at two aspects of it. We're going to look at the needle decompression, but we also want to touch a little upon finger throatostomy as well, which are two separate indications. So first, let's talk about why pro decompression. So the whole issue of pluric compression, both penetrating or blunt traumatic injuries, is for patients that are unstable and have decreased or diminished breath sounds on one side or the other.

So most of the times, if the patient is unstable and they are diminished breath sounds, the first thing that comes to mind is attention pneumothorax. And remember that I'm going to emphasize it again, the patient should be unstable before you consider even doing a pro decompression. Of course, there's other issues that could make the patient be unstable and have decreased breath sounds on one side or the other. For example, it could be blunt chest trauma with rib fractures, pulmonary contusions, and just dysfunction of the chest wall itself with diminished breath sounds. Or also it could be a very large hemothorax, which would not be a pneumothorax. But likewise, you will have diminished breath sounds on the side. And then the other issue also that you could find where there may be decreased breath sounds on one side other than blunt chest trauma with rib fractures, a hemothorax or a pneumothorax, is if the medics in the field have intubated the patient prior to you listening. Then one of the scenarios obviously that we encounter is a right main intubation, which will give you diminished breath sounds on the left side. So that being said, those are the four issues that we're dealing with. That being said, let's give a scenario of a patient that has diminished breath sounds on the left side. How will you make the diagnosis to see if you have a pneumothorax or a hemothorax in an unintubated patient that's unstable? Well, then you need to use a couple of other clinical assessment tools that are available to you. And that would be, number one, you listen, you have decreased breath sounds. Number two, you want to look and see if there's any evidence of distended neck veins. If there's any shifts of the trachea or is there any shift of the mediastinum? And then basic. And then finally you want to be able to feel or percuss and percussion, even though I know that you guys are in a total different situation that we're in. But even in the field, percussion could be helpful to you so that if you patient has diminished breath sounds, there's no distended neck veins.

There'S no crepitance or any issues to indicate rib fractures. But then you percuss and you hear resonance sound more like a drum and not doll. The most likely you have a pneumothorax in that situation. The other thing that would help you is to look and see if you could tell if there's any deviation of the trachea whatsoever. And if there is, if you have a tension pneumothorax, you would expect the mediastinum to shift to the opposite side of the of the pneumothorax the same way as it will if you have a hemothorax. But the big difference between the hemothorax and the pneumothorax is that when you percuss, you're going to have resonance instead of dullness. If you have dullness, then most likely it's not a pneumothorax. And that indication the needle decompression would not be sufficient to evacuate a hemothorax or to help the patient. So in that situation you wouldn't be doing it. The other situation is the final situation is if you have a right, if the patient has been intubated and you have a right main intubation, then likewise in this situation, you're going to have diminished breath sounds on the left side. You're going to percuss and it's going to be dull. And it's going to be dull because Dalan is collapsed. It's totally atelectatic. Now, in this situation, however, the mediastinum will shift to the left because as the lung collapses on the left, it pulls the mediastinum. It's called traction atelectasis. It pulls the mediastinum to the left side. And now you have to be really, really careful because in this situation, obviously all your major structures are going to be close to the chest wall on the left side.

So once you have done, you have gone through that process, you have made the right diagnosis, then you have decided to do the procedure and how to do the needle decompression appropriately. I will just tell you quickly, but I want to show you also on a student a little bit, because there are little. There are some things that make it easy to do on anyone. The needle decompression has now for the adults, as per the ATLS guidelines, has changed from doing it in the second intercostal space, midclavicular line, to the mid axillary line between the fourth and fifth intercostal space.

In the adults. In children, it's still the second intercastal space, midclavicular line where you were doing the needle decompression. But there's some issues with that. And what I see is not easy, especially I'm sure that it's much more difficult for you guys in the field to find exactly that location. And the way that I do it, which has kept me safe for many, many, many years, is that I try to find, especially in men, which is most of you, my patients remember, I'm men anyways. But in men, it's very simple to feel the latissimus dorsi. If you're feeling the muscle fibers of the latissimus dorsi, then you're going too posterior. And if you get posterior, the ribs come at an angle. You know, they don't go straight like this, but an angle like this from anterior to posterior and from also superior to inferior. So if you go posterior, actually that angle of the. Of the ribs deflects your needle. And your needle is not going to go straight. It won't take the straight path that you think it will take. And the further posterior that you get, the more that deflection is going to be. So you want to make sure that you stay regardless of where you think you found the mid axillary line. Always stay anterior to the latissimus dorsi. And this becomes more critical in a male who has a lot of muscle. This latissimus dorsi may come a lot more anteriorly than you think. And it will be very simple for you to go too posterior and get into trouble that way. So what I do is that I feel the fibers of the serratus anterior and I make sure that I don't go too far anterior. But normally I'm just either right at the anterior axillary line or, or just a slightly bit posterior to the anterior ciliary line. And in that position, in the fourth to fifth intercastal space, you'll be able to feel the ribs on just about anybody. Even in a person that may be a little bit, you know, thicker or obese or anything like that, you still will be able to feel the ribs, which is what you want to do. You want to feel the ribbon. And even if you've got a design yourself, it's very simple to feel the ribs right where the serratus anterior muscles are and not if you go more posterior to the latissimus dorsi. It's a lot difficult. Now. There's multiple ways of doing it, obviously, and this is just a comfort issue. And maybe if the student could come, I could show this. This is a 10 gauge needle with a catheter, obviously, and it's a good size. It's what, like three inches? Yes, three inches long. So you can see that even an equal. And this will penetrate very, very deeply. And that's why you want to make sure that you have the right diagnosis. Because if you don't have the right diagnosis and the mediastema has shifted to that side, then it's very easy to hit the lung or hit any other structure. One of the ways to do it is to hook it up to us. And you guys may not have the capability to do that in the field, I don't know. But if you put a syringe with fluid in it, saline, and you aspirate as you go in, immediately, the minute you see air coming to the syringe, then you thread your catheter in, you thread your catheter, take the needle out. If you're doing it blindly, also without the syringe, the minute that you see anything, bubbles, a little bit of bubbles, bloody bubbles or anything like that, it means that you are already in the chest. And at that point I would try to thread the needle and remember that it's like everything, it shouldn't take a lot of force. So if you can't push it, if you can't push it for some reason and there's resistance, then back out and do it again. Because most likely you're not in the right spot. If it's a pneumothorax or a hemothorax, this is going to go really easy. There's no lung there. You don't have a lot of space between the lung and the chest. Also, it should be really, really easy. And this is what I'm talking about here. So if you see, you know, his is latissimus dorsi, here's the mid axillary line, but right there I could still feel his lat. Now, even in somebody who's more built than he is, not that he's not built, but somebody who is, this muscle will come up even a little higher. Up to here. So I like to stay until I come to the nipple line. And you could see the ribs going like this. See, it's not a straight thing. The ribs are not like this. This ribs coming like this. So it's very easy to you when you come up here to get deflected. And your needle might go up or it might go down like this, where you don't want it to go. You want to try to get the needle to come straight in like this. So you want to come at least at the fifth intercostal space, right here or right here, see? And then you feel the rib easily on him, even if he puts his lung there, his arm down, like that, which is anatomical, let's say that he has a shoulder that's busted, the arm is broken. You don't want to be doing this to a patient that has that. It's going to create more pain and more problems. Even in that situation. If you come a little more anterior, here's the anterior axillary line right there. Then if you come to, they tell you mid axillary line. But if you come a little more anterior to that, then you're going to have a much easier time in putting the needle. And in fact, for 31 years that I've been putting chest tubes, that's where I put my chest tubes. And this is the same thing that if you're going to do a needle decompression and you do get a pneumothorax, then your next step is to do. I don't know if your training is there yet or not, but the next step will be to do a finger thoracostomy, which is what I've been trying to show the medics when they come to the trauma center, to a trauma bed, they bring me patients with a compression. I'm trying to show them how to do the finger thoracostomy, which is for right now, is for patients that are in cardiac arrest. So that's one step further. So you have a patient with diminished breath sounds, and once it has been intubated, he's in full cardiac arrest. Then you want to do a finger thoracostomy on that patient. And you're going to do the same thing. You're going to come there and you will feel the rib and the whole thing. The reason why I say go a little anterior, because I want you to feel the rib. I want you to really feel the rib. Because that once you feel the rib, you know exactly what you're doing. You feel the rib, you Want to stay on top of that rib. You make an incision over the rib. You have to put your finger through it. That's what's called a finger thoracostomy. So it needs to be at least 2 inches, you know, 1 1/2 to 2 inch long incision. And then you make an incision above the ribbon. You cut through the muscle or you spread it with a clamp. Whatever you have, you poke into the chest and you want to put your finger in and spread that muscle with your finger and feel inside and feel the chest wall, feel the diaphragm and feel the heart and also feel the lung. And then obviously, if you do, patient gets vital signs back. You want to put a little dressing that goes on three sides. You want to leave it like a flap. You don't want to occlude it because the whole purpose is to open it, not occlude it. Now, there's some other pitfalls with that also. One of the pitfalls with a thoracostomy is if you go inferior to the rib, you could hit intercostal vessels and that could cause bleeding in and of itself. Honestly, I'll tell you that that's not going to be a big deal if the patient's arrested. If the patient's arrested, you do need to save to bring them back. And if you put your finger in, you're going to evacuate a pneumothorax. It doesn't really matter. But to be appropriate, you want to be on top of the rib. And then the other thing that's key about it is to make sure that you insert your finger all the way in. Don't be afraid to put your finger in. And also to spread the muscle so you make it big enough so that it stays open. Because even when we put a chest tube in, the minute that you put the chest tube out, the muscle closes again right away. So you want to spread and spread the muscle.

So those are the issues. So just to summarize it.

The diagnosis has to be made appropriately. You need to use all your clinical assessment. Listen, look, listen and feel. You want to look for tracheal deviation, distended neck veins. You want to look for any asymmetry of the chest, any asymmetrical movements. And you want to also then subsequently feel. And the feel part, when it comes to this, is to be to percuss. And I know how difficult it is for the medics in the field. It's going to be much, much, much tougher than for us when we're In a controlled environment. But even like that, I still recommend to Percuss always before you do a needle decompression. And then finally when the patient is intubated, always suspect that it's a main stem intubation if it's a right main instubation. If the patient is intubated, you don't hear breath sounds on one side. The first thing you do is pull the tube back, Pull the tube back and then you reassess, you look, listen and feel once again to see the breast sounds came back. If they did, then you don't have to do the needle decompression in that situation. And then for the finger thoracostomy, it's the same position, the same right exactly where you took the needle out. Then you want to do your finger thoracostomy right there. And the pitfall or that procedure is to make sure that you go on top of the rib, spread the muscle big enough so it stays open, put your finger in, feel the diaphragm, the lung, the heart and the chest wall. And then finally put a three sided dressing so you don't totally occlude it once again, after you have successfully resuscitated the patient. Just one going away message that I like to put out there is for the medics to know that us working as a team together to provide the best possible care to the patients that we both care for together, is that we want to be able to help as much as possible. So whenever you guys bring us a patient that you have done a needle decompression, I would encourage you to stay for a few minutes longer because we already have to put a chest tubing in those patients. We like to at that time tissue the anatomy when we put in the chest tubing. So you could actually put your finger in the chest, feel the ribs, feel the angle of the ribs that I'm talking about. Feel how you have to disrupt the muscle and make the opening bigger and also be able to feel where the diaphragm is, the heart and the lung. So just a couple of extra minutes, I think that we are working together on a whole bunch of projects. Whole blood, needle decompression, finger thoracostomies, fast out in the field. And I think that the more we collaborate and work together, the better that our patients will do.