Overview of EMS Pneumothorax
A traumatic pneumothorax is the second most frequent kind of chest injury, with about 50,000 cases occurring each year in the United States alone. A pneumothorax is when air enters the area between the lung and the chest wall, which can cause the lung to collapse.
It’s important to catch and treat a pneumothorax early, as it can lead to serious complications like difficulty in breathing or even shock. This is why emergency medical service (EMS) providers need to be able to quickly recognize and treat a pneumothorax. In fact, most EMS workers in the United States follow protocols that help them do just that.
There are numerous treatments for a pneumothorax, and the one that is chosen can depend on the care provider’s training and where the patient is located geographically. It’s worth noting that there isn’t one widely accepted method used nationwide.
Anatomy and Physiology of EMS Pneumothorax
The area around and inside the lungs, known as the pleural space, plays a big role in understanding what happens when someone gets a pneumothorax, or collapsed lung, from an injury. Normally, there’s a small space between the tissue covering the lung and the tissue lining the chest wall, which makes it easier for the lungs to move when you breathe. But if these tissues get hurt, blood and air can start to fill this normally empty space.
As more and more air fills the space, it puts pressure on nearby tissues, which can disrupt the normal pressure inside the chest. This disruption can interfere with blood flow and make it hard to breathe, leading to various health problems.
There are three main types of pneumothorax caused by injury: simple, tension, and communicating. A simple pneumothorax happens when an injury to the lung or the lung lining allows air to collect in the pleural space. Most often, this happens in the case of blunt injury that breaks the ribs, which can hurt the lung or the lung lining. Unless a lot of air and pressure build up, the air in the space usually doesn’t affect the nearby tissues.
A tension pneumothorax could be seen as a more serious simple pneumothorax. This is when so much air collects in the pleural space that it compresses, or squeezes, important structures in the chest. This can lead to the lung collapsing, making it hard to breathe and get enough oxygen. The buildup of pressure can also squeeze blood vessels, which decreases the amount of blood flow and can cause a drop in blood pressure. If too much of this happens, it can lead to shock, an emergency condition that can result in a fast heart rate and eventually, if not treated rapidly, can cause the heart to stop.
Lastly, an open or communicating pneumothorax is a pneumothorax that is caused by an injury that breaks through the chest wall. This lets air move back and forth between the outside and the pleural space. This injury disrupts the normal vacuum-like effect inside the chest that helps us breathe. But unlike a simple pneumothorax, it can’t lead to a tension pneumothorax because the opening lets excess air escape. Still, this kind of injury can cause breathing problems and needs to be corrected quickly.
Why do People Need EMS Pneumothorax
When a person suffers a chest injury, it could lead to a condition known as a pneumothorax. A pneumothorax happens when air accumulates in the space surrounding the lungs, collapsing the lung and causing serious issues such as difficulty in breathing or reduced blood flow. Signs of this could include low oxygen levels, crackling sensations under the skin, decreased breathing sounds, rapid breathing and heart rate, low blood pressure, abnormal movement of the windpipe, and what is sometimes referred to as a “sucking” chest wound.
These signs are usually looked for by first responders or medical professionals during their initial examination of the patient. However, it’s important to note that not all of these signs are completely reliable and some might appear late.
Two primary emergency procedures are administered in cases of suspected pneumothorax. For a tension pneumothorax – an emergency condition where air continues to build up with each breath, causing severe problems – a needle is used to release the trapped air. This is often considered if there is chest trauma, absence or reduced breathing sounds on examination, and significantly low blood pressure or oxygen levels.
If there’s an open and “communicating” chest wound that allows air to freely move in and out of the chest cavity, applying a three-sided dressing is usually the appropriate response. While this kind of injury might have been open before treatment started, the application of the dressing could unintentionally cause a build-up of air, leading to a tension pneumothorax.
A “sucking” chest wound suggests the possibility of a communicating pneumothorax, and should prompt the medical professional to apply an occlusive dressing, which covers up the wound to prevent outside air from entering the chest cavity. This is done regardless of the person’s breathing condition at the moment, as they can quickly worsen. If the person isn’t displaying any serious symptoms or signs of difficulty in breathing, it might be more useful to quickly transport them to a hospital instead of applying the dressing. However, this decision is at the discretion of the first responder or other medical professionals at the scene.
When a Person Should Avoid EMS Pneumothorax
There aren’t any hard and fast rules against using two emergency treatments for a certain type of collapsed lung. One treatment is called a needle thoracostomy, which is simply a fancy way of saying ‘popping the lung with a needle’ to let air out and fixed the collapsed lung. The other method is using a special type of dressing to cover a puncture or hole in the lung. This is used in cases where the lung is ‘communicating’ (meaning the air can go back and forth between the lung and the outside of the body).
A health professional will decide what’s best to do by considering a few things – like the overall health of the patient, how long it will take to get to a hospital, and any unique things about the patient’s health. For example, if the patient is on long-term blood thinners, the health professional has to think about this before carrying out a treatment. Whether or not to do something more serious or wait till they’re in hospital (where they can carry out more complex treatments such as a thoracostomy, a procedure to fix a collapsed lung) is a careful decision.
Ultimately, these lung injuries can have serious outcomes if not treated properly, and often it’s very necessary to act quick and treat the patient, especially if they’re in a critical condition. Therefore, treatment usually should not be postponed just because of these considerations.
Equipment used for EMS Pneumothorax
There’s still some debate about the best tools for treating a tension pneumothorax, or air pressure on the lungs, with a procedure called needle thoracostomy. Medical responders outside of a hospital setting might use special commercial devices or typical catheters called “angiocatheters”. People are still weighing up how much these different options cost and how effective they are, and there isn’t a single widely accepted choice yet. A major concern that has been looked into is how often needle thoracostomy is successful and which method works best.
Because people are gradually having a higher body mass index, which is a measure of body fat, medical emergency services are increasingly using devices that are bigger and longer. This is to get through the distance needed to reach the space around the lungs. There have also been several studies suggesting different places to insert the needle, which we’ll cover later.
As a medical first responder, you should make sure you know the equipment available and how to use it.
Traditionally, dressings that can be closed on three sides were used to let out air from a pneumothorax. However, people started worrying about how long it took to put the dressing on and how hard it was to tape it to the chest properly. This led to new techniques and devices being developed. Other devices that have been invented include ones that seal off an area, have a valve, suction ports, and ventilated paths.
Up until now, there haven’t been any trials on humans comparing these devices, but many studies have been done on pigs. Among the devices tested, the best ones were ventilated dressings that could be closed off, because they were less likely to get blocked with blood clots and stuck better to the patient than traditional tape methods. These engineered ventilated dressings cost a lot more than simple dressings with tape. Medical first responders need to know what equipment is available and how to use it in their system.
Who is needed to perform EMS Pneumothorax?
These two methods can be performed by any emergency healthcare provider, as long as they have the necessary tools. Most emergency healthcare systems have certain rules outlining who can carry out these procedures and when they are needed. It’s very important that these healthcare providers know these rules well.
As technology continues to advance, there’s potential for some hospital techniques to be used in pre-hospital or emergency settings in order to more quickly and accurately identify health issues. The use of ultrasound, for example, has been proven on many occasions to be a fast and effective way to detect pneumothorax (a collapsed lung) immediately. This is now a standard part of treatment for patients with serious injuries.
What was once a large and complicated piece of technology has become lighter and more user-friendly. It may soon be a tool that emergency healthcare providers can use. An ultrasound probe can be connected to lightweight electronic devices, which means it can be used as a portable tool to help examine patients in the field. Although more research is needed, this could potentially become the new standard care for pre-hospital providers, leading to better patient outcomes.
Preparing for EMS Pneumothorax
If a patient is suspected of having a pneumothorax, which is a collapsed lung, the focus is on preventing any additional strain on their breathing. Using extra oxygen can help with both their overall oxygen levels and the ability of the collapsed lung to recover. Pain relief may also be provided if there are suspected rib injuries, which can affect the patient’s ability to breathe properly. If the patient is in shock, other possible causes should not be overlooked, since there may be more than one reason for their condition if they have been injured.
Patients should not be put under positive pressure ventilation unless it becomes absolutely necessary due to problems with their breathing. The medical staff should always be ready to detect signs of a worsening condition and step in to relieve pressure on the lung if needed.
For patients with a suspected chest injury, it’s important to fully examine the chest area as soon as possible. This includes the underarm and back areas, where injuries might not be easily visible if the patient is lying down. Sealable dressings may be used on ‘sucking’ chest wounds, where air is being drawn into the chest cavity. However, these dressings can sometimes be difficult to keep in place, so it’s recommended to try to dry out the application area before sticking them on, if possible.
How is EMS Pneumothorax performed
Needle decompression is a procedure where a large catheter – a flexible tube – is inserted through the chest wall into a place called the pleural space, allowing trapped air to escape. To correctly perform this procedure, certain landmarks on the chest are identified by touch and sight, with the goal being to insert the needle just above a rib to avoid puncturing the larger blood vessels in the chest. Sometimes, when the needle is inserted correctly, you can hear a distinctive ‘whoosh’ as the air escapes, but this doesn’t happen every time. Often, the signs of a successful needle decompression are improvements in the patient’s vital signs like heart rate and blood pressure.
There’s been a lot of discussion and research on the best place on the chest to insert the needle for this procedure. Traditionally, it’s been recommended to place the catheter in a location called the second intercostal space, which is just below the collarbone. However, there have been many cases where this approach fails. Recent research suggests that it might be better to place the catheter in an area between the fourth and fifth rib (the fourth or fifth intercostal space) on the side of the chest, about halfway between the front and back. This is because this area has less soft tissue, meaning the catheter can penetrate deeper into the pleural space, reducing the likelihood of failure. However, this approach does have one primary downside — the patient’s body might cause the catheter to kink or bend, which could block it. This is something that needs to be watched for, especially during long transport times, as it has been noted happening in military transportation scenarios.
For a certain type of chest wound called a ‘sucking chest wound’, a specific dressing procedure is needed to prevent more air from entering the pleural space. The goal is to create a sort of one-way valve over the wound, allowing air to escape but not to re-enter. Conventionally, this is done by using an occlusive dressing, which is a type of adhesive dressing that is attached to the chest on three sides. The fourth side is left open to allow blood and air to escape the wound. There are also commercially available devices that work in a similar way and can be quickly placed over the wound. In military settings, the three-sided dressing is often replaced with a completely sealed four-sided adhesive dressing. This is combined with the needle decompression procedure if the chest pressure increases.
Possible Complications of EMS Pneumothorax
Needle thoracostomy is a medical procedure used to release air or fluid pressure from the chest. Despite its usefulness, it might come with complications, being a somewhat invasive and painful process for the patient. There are incidents where it has caused harm to the chest blood vessels, lung substance (lung parenchyma), and heart tissues, leading to significant health problems and even death. Hence, in placing the needle, the closeness to these chest organs should be carefully considered.
In addition to this, cases of infection entering the chest during this procedure have been reported too. So, it’s important to assess the patient’s condition and the risk of infection before proceeding with this treatment. Considering these factors, using needle thoracostomy should be limited to necessary situations only.
It’s also essential to note that needle thoracostomy is a temporary solution. Usually, when patients reach the hospital, they may need to undergo a procedure called tube thoracostomy, which involves installing a chest tube to drain fluid or air. Some emergency medical service systems, particularly in the United Kingdom, have trialed placing chest tubes on-site before reaching the hospital. The findings showed similar success rates in terms of reducing pressure, but it resulted in more significant delays in patient transportation.
As for occlusive dressings—bandages that completely seal a wound—the complications are not so much related to the procedure itself, but rather to failure to effectively cover the wound to prevent air from entering or escaping. The most common issues are the dressing not sticking properly to the patient, which can lead to a continued leaking of air from the chest (communicating pneumothorax), or the bandage blocking the wound, causing air to be trapped in the chest (closed pneumothorax). This in turn could potentially create high pressure in the chest, known as tension pneumothorax. The possibility of these issues may increase if there’s also internal bleeding (hemothorax) involved, as blood may obstruct the path for air to leave the chest cavity, and blood clots could prevent the dressing from sticking to the chest wall. There have been other infrequent complications, like localized allergic reactions to certain adhesives.
What Else Should I Know About EMS Pneumothorax?
Quick evaluation and treatment of a patient with a chest injury has been proven to be very effective in dealing with serious, life-threatening issues such as breathing difficulties or unstable blood pressure. Paramedics can use established steps in assessing and treating a condition known as a traumatic pneumothorax, which is a collapsed lung caused by trauma. As we continue to develop new methods and technologies in hospitals, paramedics will be able to further improve this skill and apply it to the patients who need it most.