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July 16, 2015
Teaching points: EMS needle decompression of a tension pneumothorax
By Ryan Jacobsen
The video "Tension Pneumothorax and Needle Thoracostomy" claims to show the needle decompression of a large tension pneumothorax from the “inside” of the patient’s chest cavity by using a thoracoscope. After viewing my first thoughts were, “This is very cool,” but as I thought about this video as an EMS education tool I wanted to urge caution.
Video-Assisted Thoracoscopic Surgery (VATS) is a minimally invasive way to perform surgery inside the chest while the patient is under general anesthesia. It uses multiple ports (think laparoscopic surgery inside the thorax). VATS contains a camera, light source and several ports to let tools enter to perform tasks such as: incising, grasping, and removing tissues.
Tension pneumothorax pathophysiology and treatment
A tension pneumothorax occurs when enough air enters the pleural space (typically due to trauma, but can occur spontaneously) and the resulting increase in intra-pleural pressure causes compression of large vascular structures in the mediastinum, chiefly the right heart and caval system resulting in the classic findings of jugular venous distention, hypotension, and tachycardia, tracheal shift away from the affected side and diminished or absent breaths sounds.
The emergent EMS treatment for a tension pneumothorax is to decompress the pleural space by inserting a large angiocath between the second intercostal space (midclavicular line) or the fifth intercostal space (midaxillary line).
What the video shows
The video is very high-quality, is less than two minutes long and was apparently recorded by a Dr. Oleksandr Linchevskyy, described as a Thoracic Surgeon who practices in the Ukraine. At about 20 seconds the glistening parietal pleura lining the inside of the thoracic cavity is clearly visible. A small blob of lung collapsed in the bottom portion of the screen is rising up and down with ventilation, glistening with its own visceral pleural covering, is discernable.
Immediately following a typical, white angiocath, enters the anterior chest wall between the ribs (top/center of the screen), advances, followed by the needle being withdrawn, leaving just the catheter resting in the pleural space. So far, this is an amazing video of the correct placement of an angiocath to decompress a tension pneumothorax.
The rest of the video demonstrates extremely rapid expansion of the lung with the angiocath impacting the anterior surface of the lung as it expands seemingly to full size and the video ends. The entire process from needle entry to near full expansion took approximately 60 seconds!
EMS should NOT expect similar results
This rapid lung expansion is NOT what EMS providers should expect when they needle decompress a tension pneumothorax in the field for the following reasons:
1. EMS environment is less controlled with less resources
This video was likely filmed in an operating room, which is a well-controlled environment, on a patient who was likely intubated and a thoracoscope was used for recording purposes. This environment does not mimic the prehospital world and likely has resources that most EMS services do not have available.
2. Field decompression is a lifesaving, but temporary treatment
The goal of needle decompression in the field is to emergently relieve a large amount of pressure that has become trapped in the pleural space. While it can be lifesaving, it is only a temporizing measure and still needs definitive care which typically involves a tube thoracostomy.
3. Pneumothorax resolution is much slower
EMS providers should NOT expect rapid and complete resolution of the pneumothorax or full re-expansion of the lung when placing an angiocath to decompress a tension pneumothorax. After watching this video one might get the idea that all you have to do is place an angiocath and within 60 seconds the lung is completely inflated again and all is well.
Recall the description of how thoracoscopy works. The large port holes through which the thoracoscope is inserted would have immediately decompressed the pleural space upon entry into the thorax and immediately relieved any tension. This appears to be more of a manufactured tension for demonstration purposes (which is still pretty amazing). VATS is not the treatment for a tension pneumothorax, nor is waiting to go to the operating room, but could provide (as this video did) a reasonable facsimile of what needling a chest looks like from the “inside.”
4. Pneumothorax resolution is frequently incomplete in the ED
We frequently do not see complete resolution of pneumothoraces even after tube thoracostomy is performed in the emergency department (think small garden hose diameter compared to angiocath). Often times we see persistent small pneumothoraces on post-procedure chest x-rays; even when placed to wall suction. Chest tubes are typically left in place for several days to up to a week to ensure pneumothoraces have resolved completely.
This video provides a great visual demonstration of what the inside of a chest looks like when the lung is collapsed and a needle enters the anterior chest wall. It gives a glimpse into the ideal scenario and pertinent anatomy. EMS educators need to ensure that when using this video as a teaching aid of what happens when a needle decompresses a tension pneumothorax to make some important disclaimers so that no EMS providers erroneously feel that “their needle” accomplished what this video appears to accomplish.
About the Author
Ryan Jacobsen MD, EMT-P, FACEP is the medical director for the Johnson County EMS System, which has over 850 EMS providers and serves a population of approximately 600,000. Dr. Jacobsen served from 2009-20013 as the Associate EMS Medical Director for the Kansas City Fire Department as well as the Associate Section Chief of EMS at Truman Medical Center/University of Missouri-Kansas City (UMKC) School of Medicine. He also served as the Medical Director for the EMS Education Program at the UMKC School of Medicine EMT/Paramedic Training Program. Dr. Jacobsen is involved in numerous research endeavors resulting in multiple publications in various Emergency Medicine/EMS periodicals and continues to mentor Emergency Medicine Residents regarding EMS and EMS research.