Professional Documents
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Pneumothorax
Musculoskeletal Pain
Rib Fractures
MI
Acute Pulmonary Embolism
Physical Examination
Vital Signs: Tc= 98.7 BP= 98/60 HR=115 RR= 26 Sat 89% RA
Tension Pneumothorax
Rib Fractures
Laboratory
Supplemental O2
Decompression Needle Thoracostomy
Needle Thoracostomy, Discussion
Procedure
1. Use a large bore needle w/ catheter (14-16 gauge)
2. Identify 2nd intercostal space at midclavicular line (1-2 cm lateral to the
sternal angle). This will minimize likelihood of IMA injury
3. Prepare area with Betadine
4. Insert needle directly superior to the 3rd rib. This prevents injury to
neurovascular bundle located on the inferior aspect of each rib.
5. Insert needle perpendicular to the chest wall, approximately 3-6 cm in
depth
6. Stop advancement of needle upon hearing opening hiss/pressure release
of pleural space.
7. Remove needle; leave catheter in place
What next?
What next?
Tube Thoracostomy
1. Identify and prepare the area w/ Betadine at ICS 4 or 5 along the mid-axillary
or anterior axillary line
2. Anesthetize the area (subcutaneous tissue, intercostal muscles) with Lidocaine.
Some physicians use opioid analgesia or a combination of an opioid + Benzo.
3. Make a 2 cm incision
4. Insert a large blunt clamp over superior aspect of rib (preventing damage to the
neurovascular bundle that lies on the inferior border of the rib). Apply gentle
pressure until the parietal pleura is pierced.
5. Open clamp to establish a tract for the chest tube.
6. Bluntly dissect w/ finger.
7. Clamp proximal end of tube tangentially w/ Clamp. Insert tube over superior
aspect of rib into pleural space.
8. Insert the chest tube past the last hole. Note the last hole disrupts the continuity
of the radiopaque line—this facilitates radiographic placement confirmation.
Suture chest tube w/ Silk sutures.
What next?
What next?
Complications:
ABG: 7.32/50/60/24/ 89 % RA
138 102 18
Chem 7 110
3.7 25 1.2
Cardiac Enzymes: TnI: 0
TnT: 0
CKMB: 1.2
Lab Results, Discussion
ABGs: Often seen in tension pneumothorax is a varying
degree of acidemia, hypercarbia, and hypoxia. Note in acute
respiratory acidosis increases in PaCO2 by 10mmHg will
decrease pH by 0.08 (i.e. PaCO2 40->50 lowers pH 7.4-
>7.32). The reduction in PaO2 is caused by alveolar
hypoperfusion secondary to atelectasis, low
ventilation/perfusion ratios, and anatomic shunts.
Chem 7: Principally used for the CO2 value. More
accurate for calculations of compensated respiratory
acidosis than HCO3- values in ABGs which represents an
average of computed PaCO2 levels.
Cardiac Enzymes: necessary to r/o acute MI and
resulting cardiogenic shock, must have serial reading to
accurately r/o acute MI
Discussion