Overview of EMS Pneumothorax Identification Without Ancillary Testing
First responders, like paramedics, have a critical job of identifying and treating various health emergencies that require immediate attention. Pneumothorax is one such condition – it’s dangerous and can be life-threatening. Pneumothorax occurs when air accumulates in the ‘pleural space’, an area between the lung and the chest wall, causing the lung to partially or entirely collapse. When the buildup of air inside the chest becomes too high, it can result in a severe type of pneumothorax known as tension pneumothorax. This critical condition occurs in 1 out of every 20 patients with severe injuries.
Treating pneumothorax can be fairly straightforward. However, possible complications like injuries to the heart or major blood vessels can happen. Identifying a pneumothorax quickly out in the field can be quite challenging for first responders. They don’t have access to the medical equipment and experts available in a hospital emergency department, like x-ray machines or chest specialists.
Moreover, other health conditions that affect the lungs or heart such as chronic obstructive pulmonary disease (COPD), asthma, congestive heart failure, and the accumulation of fluid in the chest cavity (pleural effusion) can mimic the symptoms of a pneumothorax. However, by understanding the subtle differences in symptoms, first responders can better pinpoint a pneumothorax quickly and initiate treatments more effectively.
Anatomy and Physiology of EMS Pneumothorax Identification Without Ancillary Testing
The pleurae are essentially protective coverings for your lungs and also line the interior surface of your chest wall. They work as a barrier and stick closely together, due to a certain negative pressure. This design ensures that whenever you take a deep breath and your chest wall expands, your lungs inflate accordingly. Think of the gap between these coverings as a potential space that only appears when there is a rise in pressure between them, which happens if there’s an unexpected collection of air or fluid in the chest cavity.
Pneumothorax is a health condition that occurs when air accumulates in this space between your lung and chest wall. It’s often due to an injury but can also happen spontaneously without any clear cause. Sometimes, a spontaneous pneumothorax happens due to a rupture (a “blow-out”) in the pleura or because of an unexpected reaction to changes in barometric pressure. If you have certain health conditions like COPD, cystic fibrosis, interstitial lung disease or Marfan syndrome, you might be more prone to spontaneous pneumothorax.
Traumatic pneumothorax, on the other hand, arises due to blunt or sharp injuries to the chest and is something doctors may suspect if someone has been exposed to a blast or concussion. When this happens, the affected lung collapses and can’t take in oxygen from the air, leading to low oxygen levels or hypoxia. In some serious cases, called tension pneumothorax, the pressure inside your chest becomes so high it makes the structures inside your chest, including the blood vessels and heart, shift to the other side. This in turn puts pressure on them and compromises blood flow and heart function.
This type of pneumothorax is a medical emergency. To treat this, doctors will have to release the trapped air to restore the normal pressure within the chest and allow the lung to re-expand. Healthcare professionals should be well-acquainted with this potentially life-saving procedure and informed about its possible complications and when it should not be used.
Why do People Need EMS Pneumothorax Identification Without Ancillary Testing
When a person has a traumatic pneumothorax, also known as a collapsed lung, it’s common practice for them to be treated at the hospital. They typically receive a procedure known as thoracostomy tube placement, which involves inserting either a small catheter or a larger tube into the chest. This is often done immediately upon arrival at the hospital, leading some to think that every case of a collapsed lung needs this kind of intervention.
However, research indicates that this isn’t always necessary. Many people with a collapsed lung do not need treatment right away, and doctors usually opt to monitor their condition with regular CT scans. Careful evaluation allows healthcare providers to decide whether they need to perform a procedure on site or in the field. When this decision process is used correctly, it can prevent unnecessary surgery and hospital stays. For those selected for treatment in the field, a procedure called needle decompression can reduce the risk of death within the first 24 hours after trauma.
People with a collapsed lung who are critically ill, or at risk of becoming so while still in the field, should receive needle decompression. Common symptoms of a collapsed lung include feeling short of breath and having pain on one side of the chest. Even if the patient’s vital signs are normal, they may still have a collapsed lung; these signs typically don’t change until pressure builds up in the chest cavity.
Doctors or EMTs often notice that there are no breath sounds on the impacted side. Other signs can include air in the soft tissues, causing a condition known as subcutaneous emphysema, and swollen neck veins. If not treated quickly and effectively, the patient can become hypoxic, or low on oxygen, and hypotensive, or low on blood pressure. Some authorities recommend aggressive field treatment for suspected collapsed lungs based on how the injury occurred and how much trouble the patient is having breathing. Ideally, needle decompression should be used for those who show signs of shock, low blood pressure, poor blood flow, trouble breathing, or altered mental state.
Patients who are suspected to have a collapsed lung due to receiving positive pressure ventilation, a procedure where air is forced into the lungs, should be strongly considered for needle decompression.
When a Person Should Avoid EMS Pneumothorax Identification Without Ancillary Testing
If a person has burns or infections, or is of a particular physical build, using a needle to release pressure from a certain part of the body may not be advised. Patients who are stable should be watched closely. However, if their heart or lung functioning gets worse, releasing the pressure using a needle might be needed to make them feel better. Avoiding procedures that aren’t necessary can help prevent unnecessary stays in the hospital or having to have more procedures done.
Equipment used for EMS Pneumothorax Identification Without Ancillary Testing
Choosing the Right Catheter
Most medical guides suggest using a 14-gauge 3.25-inch catheter for relieving pressure in the chest, a procedure known as “needle decompression,” for adults. Some studies, based on CT scan measurements, indicate that many people have a chest wall thickness that’s more than this needle length, suggesting that thicker needles of the same length might be more suitable. It’s often preferred to insert the catheter in the side of the chest, rather than the front, because the side typically has less soft tissue. To check if the catheter has been placed correctly, devices that change color according to the amount of carbon dioxide (known as “colorimetric capnography devices”) and one-way valves can be used. A standard catheter, like those used for IV drips, is usually enough and more cost-effective.
Using Ultrasound at the Point of Care
The usefulness and effectiveness of using ultrasound at the point of care, also known as Point-of-Care Ultrasound (POCUS), is well documented. To use POCUS effectively for a collapsed lung, or pneumothorax, it’s crucial to have a structured training program that includes supervised exams and reviewing of the ultrasound images.
The healthcare provider uses a handheld ultrasound device to observe the usual movement of the pleura (the thin membrane that surrounds the lungs), during heart contraction or breathing, this is called “lung sliding”. Patients with a pneumothorax do not show lung sliding.
Different views can be taken for each lung, allowing for an estimated size of the pneumothorax. Depending on the skill of the user, a POCUS lung assessment can be more sensitive than a traditional chest x-ray. Ultrasound can also help identify which patients may need needle decompression, provide evidence of a pneumothorax, and confirm that the lung has reinflated. As portable ultrasound devices become more common, healthcare providers should know how to do a basic lung assessment using POCUS.
How is EMS Pneumothorax Identification Without Ancillary Testing performed
If a patient is suspected to have a pneumothorax, which is a condition where air leaks into the space between the chest wall and the lung, the first step is to ensure that they can breathe and that their heart is functioning normally. This is a standard part of emergency medical treatment. It’s important to give oxygen to those experiencing symptoms to help remove some of the excess air around the lung.
Patients who have mild symptoms may not need high levels of oxygen. If there’s an open wound on the chest, it should be covered with a special dressing that allows air to escape but not enter, to avoid build-up. This can be made by applying a dressing and only using tape on three sides. It’s like a one-way valve for air, and it’s found to be more effective than ones that don’t allow air to escape.
If a patient is showing signs of poor blood circulation or there’s a risk of their condition worsening, additional steps should be taken. One such step is needle decompression, which involves inserting a needle into the chest to release trapped air. This can be done via two main methods: an anterior (front) approach or a lateral (side) approach.
The anterior approach involves inserting the needle in the area around the collarbone, in between the 2nd or 3rd ribs. But sometimes this area has too much soft tissue or is not available for inserting a needle. If so, the lateral approach is an alternative. This is done along the armpit line, around the 4th or 5th ribs.
A 14-gauge or 10-gauge catheter, which is a type of tube, should be inserted along with the needle. It’s preferable to place it above the rib to avoid hitting any nerves or blood vessels located underneath. After inserting the needle and catheter for about 5 to 10 seconds, they can be removed and disposed of. If air is heard escaping and the patient’s breathing and vital signs improve, this means the treatment was successful. The catheter should remain in place during transportation. Some places recommend putting a one-way valve over the catheter, just like the dressing used for an open chest wound.
Similar steps are taken in children, though different sized catheters are used. The smallest size is appropriate for very young children, while a slightly larger size is recommended for older children. Generally, a regular-sized intravenous catheter is sufficient for most pediatric patients.
Possible Complications of EMS Pneumothorax Identification Without Ancillary Testing
After a procedure called needle decompression, which is used to relieve pressure in the lungs, it’s crucial for the doctor to listen to your lungs to check your condition. Remember that needle decompression is only a temporary solution. It’s still vital to put a chest tube in when you get to the emergency room. Potential side effects of this treatment might include the lung condition getting worse, bleeding, infection, and injury to the lung tissue.
Most emergency medical workers feel ready to do needle decompression. But, research shows that only about a third of these procedures are done correctly, inserting the catheter in the correct space around the lungs. Also, up to 20% of these procedures might not have been needed. It’s crucial to place the needle accurately since misplaced needles might harm nearby blood vessels or solid organs, like the heart.
If you have a simple lung condition called a spontaneous pneumothorax and only received oxygen treatment, you need to be observed for 3 to 6 hours. Longer monitoring times might be needed if your case is more complicated. Remember, your condition can recur, especially when you’re in high altitude areas or deep underwater. Therefore, you’re advised to avoid traveling by air or doing activities like scuba diving for about a week or two after treatment.
What Else Should I Know About EMS Pneumothorax Identification Without Ancillary Testing?
Pneumothorax is a medical term for when air gets trapped in the space between your lung and chest wall. If you have a pneumothorax, you might experience sudden chest pain, shortness of breath, rapid heart rate, and you might feel like you’re not getting enough oxygen. On the affected side, there might be less sounds from breathing and a unique, hollow sound if the chest is tapped.
In some cases, this condition can progress to a more severe form called tension pneumothorax. This might cause similar symptoms, but can also lead to low blood pressure, poor blood flow, swelling in the neck veins, and the windpipe shifting to the opposite side.
At the very beginning, if tension pneumothorax is suspected, a procedure called needle decompression may be done. This can help improve heart function for a short while but it’s a temporary solution. The sure-fire way to treat pneumothorax is by inserting a chest tube. This is a procedure usually done in the emergency rooms where a tube is placed between the ribs into the chest space to release the trapped air.
