**4. Needle decompression**

Needle decompression is a lifesaving procedure used to decompress the chest when there is tension pneumothorax. Tension pneumothorax is the accumulation of air in the pleural cavity under pressure. Progressive buildup of pressure in the pleural space leads to mediastinum shift to the opposite side, lung collapse, and tracheal deviation to the unaffected side and obstructs venous return to the heart. This results in a hemodynamic instability and can lead to cardiac arrest [4, 11] (**Figure 5**).

#### **4.1. Basic principle**

The routine practice is to preoxygenate the patient for 5 minutes. If it is not possible, then preoxygenate for 3 minutes. However, four maximal inspirations are equally effective in the cooperative patient [4, 8]. Administering oxygen using noninvasive positive pressure ventilation has the ability to improve the process of oxygenation much faster than by using the face mask. All the equipment should be prepared before the intubation and should be checked. The laryngoscope handles and light should be checked if they are working or not. ETT cough should be checked for any air leaks. Connect the patient at the same time to a monitor including pulse oximetry, cardiac monitor, and NIBP. The nurse at the same time should prepare the required medication and label them and get an intravenous access. Record and observe

The patient should be positioned in the sniffing position if no cervical spine injury is suspected. If cervical spine injury is suspected, manual in-line immobilization should be main-

Premedicate the patient as indicated by the condition. Lidocaine (1.0–1.5 mg/kg) or fentanyl (2–3 μg/kg) both can be given to blunt the intracranial pressure response, transient hypertension, bronchospasm, and tachycardia associated with intubation. Phenylephrine (50 μg) can be used to lessen the hypotensive effect of intubation. Administer an appropriate induction agent as indicated by the clinical setting and patient's hemodynamic status followed by a non-depolarizing agent, if no contraindication. Flush the intravenous line after each drug to ensure delivery [10]. A cricoid pressure (the Sellick maneuver) should be applied immediately and maintained till

Intubate the patient after administration of succinylcholine (or rocuronium) and the patient's muscles are relaxed. Confirm the correct placement of the ETT by visualizing the tube passing

auscultating breath sounds at the midaxillary lines and epigastric area. Release cricoid pressure. After successful intubation, secure the tube and connect to a ventilator and adjust the sitting according to patient condition. Administer additional sedative hypnotics and analgesics as indicated by clinical scenario. Obtain a chest radiograph to confirm proper placement of

wave on the capnography, and

patient physiologic parameters.

66 Essentials of Accident and Emergency Medicine

tained during the intubation.

oral endotracheal intubation is completed.

the endotracheal tube [2, 4, 6, 7, 9, 10].

*3.4.3. Complications of RSI*

• Hypoxia

• Death

• Cerebral anoxia

• Myocardial ischemia

• Difficult or failed intubation

• Hypertension or hypotension

• Airway injury and dental trauma

• Tachycardia and bradycardia mainly in children

through the vocal cords, monitoring continuous end-tidal CO<sup>2</sup>

The main idea is to insert a catheter into the pleural space, thus creating a pathway for the air to escape and release the built-up pressure. It is an emergency procedure when there is tension pneumothorax and should be followed by the chest tube insertion as a definitive management [14].

Indication for emergent needle decompression.

Traumatic cardiac arrest with chest involvement

• Tension pneumothorax

That is evident clinically in patients with tachypnea, hypoxia, tachycardia, hypotension, tracheal deviation to the unaffected side, diminished breath sound, hyperresonance chest, and increased percussion note.

**Figure 5.** Radiograph of a patient with a large spontaneous tension pneumothorax.

Whenever there is deterioration in the patient's oxygenation or ventilatory status, the chest should be reexamined and tension pneumothorax should be excluded. Failure to suspect and pick it clinically will result in death.

**4.6. Tips**

length needed for the procedure.

**4.7. Complications**

mothorax[15, 16].

• Hemothorax

Complications include

• Cardiac tamponade

thorax is present)

**4.8. Chest Tube**

• Hemothorax

Indications

• Abscess

• Empyema

Failure of the procedure can be due to a short needle, especially in obese patients with a thicker chest wall, so a longer needle should be used for a successful procedure [13].Ultrasoundguided procedure can be an excellent option, and at the same time, it will confirm the presence of pneumothorax by the loss of lung's sliding movement or lung point sign which is more specific for pneumothorax. Ultrasound also can help choosing the appropriate needle

Resuscitation Procedures in Emergency Setting http://dx.doi.org/10.5772/intechopen.76165 69

Needle thoracostomy is not a simple procedure with no complications, and it should be done when patient scenario and clinical assessment support the clinical diagnosis of tension pneu-

• Arterial air embolism (when needle thoracostomy is performed and no tension pneumo-

• Indication for main theater: >1200-ml drainage immediately after insertion or continuous

• Pneumothorax (with potential to later tension pneumothorax)

• Failure of the procedure or ineffective drainage of pneumothorax

• Hemorrhage (which can be life-threatening)

• Pain to the patient due to procedure itself

• Thoracic and abdominal organ injury

• Traumatic pneumothorax (some) • Spontaneous pneumothorax (some)

150–200 mL/hr. for 2–4 hours (**Table 1**)

• Loculatedintrapleural hematoma

• Atelectasis and pneumonia

#### **4.2. Contraindications**

There is absolute contraindication for needle decompression, but in patients with polytrauma, if the injury is not salvageable, then it should be avoided [16].

#### **4.3. Equipment**


#### **4.4. Patient preparation**

The procedure should be explained to the patient or family and he should be placed in supine position. 100% oxygen through the face mask should be administered if the patient not on mechanical ventilator. Also the patient should be connected to a monitor including cardiac monitor and pulse oximetry.

#### **4.5. Technique**

The procedure should be done under aseptic technique. The EP should wear the gown, sterile gloves, mask, and cap. The anatomical landmark should be identified which is the second intercostal space at the midclavicular line on the affected side.


Then the catheter-over-the-needle should be advanced till reaching the pleural space. A rush of air will be heard escaping from the syringe. At this point the catheter should be advanced and the needle should be withdrawn at the same time. The catheter then should be secured in place and should be left open to air. The patient should be prepared for tube thoracostomy as needle decompression is a temporary procedure. Post insertion patient should be reevaluated and continued to be monitored, and chest X-ray should be requested. Successful placement of the catheter will be confirmed by the improvement of patient symptoms and hemodynamic status [11–14].

#### **4.6. Tips**

Whenever there is deterioration in the patient's oxygenation or ventilatory status, the chest should be reexamined and tension pneumothorax should be excluded. Failure to suspect and

There is absolute contraindication for needle decompression, but in patients with polytrauma,

The procedure should be explained to the patient or family and he should be placed in supine position. 100% oxygen through the face mask should be administered if the patient not on mechanical ventilator. Also the patient should be connected to a monitor including cardiac

The procedure should be done under aseptic technique. The EP should wear the gown, sterile gloves, mask, and cap. The anatomical landmark should be identified which is the second

• Insert a large-bore (i.e., 14 gauge or 16 gauge) needle with a catheter into the second intercostal space, perpendicular to the skin and above the superior border of the third rib at the midclavicular line, to prevent damage to the neurovascular bundle located at the second

Then the catheter-over-the-needle should be advanced till reaching the pleural space. A rush of air will be heard escaping from the syringe. At this point the catheter should be advanced and the needle should be withdrawn at the same time. The catheter then should be secured in place and should be left open to air. The patient should be prepared for tube thoracostomy as needle decompression is a temporary procedure. Post insertion patient should be reevaluated and continued to be monitored, and chest X-ray should be requested. Successful placement of the catheter will be confirmed by the improvement of patient symptoms and hemodynamic status [11–14].

• Use iodine-based solution (Betadine) to clean the area that should be punctured.

pick it clinically will result in death.

68 Essentials of Accident and Emergency Medicine

• Povidone-iodine or chlorhexidine solution

• Sterile gloves, gown, and face mask

if the injury is not salvageable, then it should be avoided [16].

• 12- to 16-gauge catheter-over-the-needle, 4.5 cm in length

• Ultrasound machine (optional) with sterile gel and probe

intercostal space at the midclavicular line on the affected side.

**4.2. Contraindications**

**4.3. Equipment**

• Syringe 5 or 10 ml

**4.4. Patient preparation**

monitor and pulse oximetry.

rib inferior border.

**4.5. Technique**

Failure of the procedure can be due to a short needle, especially in obese patients with a thicker chest wall, so a longer needle should be used for a successful procedure [13].Ultrasoundguided procedure can be an excellent option, and at the same time, it will confirm the presence of pneumothorax by the loss of lung's sliding movement or lung point sign which is more specific for pneumothorax. Ultrasound also can help choosing the appropriate needle length needed for the procedure.

#### **4.7. Complications**

Needle thoracostomy is not a simple procedure with no complications, and it should be done when patient scenario and clinical assessment support the clinical diagnosis of tension pneumothorax[15, 16].

Complications include


#### **4.8. Chest Tube**

Indications


#### **4.9. Relative indications**

Penetrating thoracic injury and need for positive pressure ventilation. Profound hypoxia/hypotension in patient with penetrating chest injury **3.** Expose insertion site by moving the upper extremity above the head on the affected side.

○ Place 1–3 intercostal spaces higher in pregnant patients (especially those in the third

Resuscitation Procedures in Emergency Setting http://dx.doi.org/10.5772/intechopen.76165 71

**5.** Confirm rib space and anesthetize with up to 5 mg/kg of lido with or without epinephrine.

• Must anesthetize the skin, soft tissue, muscle, periosteum, and pleural space.

**7.** Use curved clamp to bluntly dissect through the muscle until you reach the rib.

**9.** Open the clamp and pull it out with the clamp still open to create a larger tract.

**8.** Angle the clamp to go above and over the rib and push until enter the pleural space.

**10.** Premeasure chest tube from skin incision to ipsi clavicle to avoid advancing chest tube

**11.** Clamp the proximal end of the chest tube and pass it along the tract into the pleural

• It helps to have your finger in the tract and pass the tube along your finger, particularly

• Insertion site = mid- to ant axillary line at fourth/fifth intercostal space.

○ ~Nipple line in men and inframammary crease in women.

**6.** Incise along the upper border of the lower rib of the intercostal space.

• Ensure that inner tract/incision can fit your finger and tube.

**13.** Feed the chest tube until all the holes are inside the thoracic cavity.

○ Controversial as to whether this is important.

• Aim superoanterior for pneumothorax; aim posteriorly for hemothorax.

• If tube rotates easily, it can help indicate correct location inside pleural cavity.

O suction).

**15.** Attach distal end of tube to the Pleur-evac and place on suction (20–30cmH<sup>2</sup>

**16.** Secure tube with silk suture and cover with gauze and cloth tape.

trimester) due to elevated diaphragm.

**4.** Clean with Betadine and drape.

too far.

cavity.

in obese patients.

**14.** Rotate the tube 360 degrees.

**17.** Obtain CXR position of tube.

**12.** Once in the space, remove the clamp.

• Reduces likelihood of tube kinking.

• Profound hypoxia/hypotension and signs of hemothorax

#### **4.10. Contraindications**

• No absolute contraindications when performed for emergent indication

#### *4.10.1. Relative contraindications*


#### **4.11. Equipment needed**

	- 14–28F for pneumothorax
	- 32–40F for hemothorax

#### Procedure

	- Insertion site = mid- to ant axillary line at fourth/fifth intercostal space.
		- ~Nipple line in men and inframammary crease in women.
		- Place 1–3 intercostal spaces higher in pregnant patients (especially those in the third trimester) due to elevated diaphragm.

**4.9. Relative indications**

70 Essentials of Accident and Emergency Medicine

**4.10. Contraindications**

*4.10.1. Relative contraindications*

• Overlying skin infection

• Multiple pleural adhesions

○ 14–28F for pneumothorax ○ 32–40F for hemothorax

• Syringes and needles for anesthesia

**4.11. Equipment needed**

• Coagulopathy

• Chest tube

• Scalpel

• Kelly clamp • Sterile drapes • Silk sutures

• Lidocaine • Betadine

• Face shield • Pleur-evac

Procedure

• Sterile gown/gloves

Penetrating thoracic injury and need for positive pressure ventilation. Profound hypoxia/hypotension in patient with penetrating chest injury

• No absolute contraindications when performed for emergent indication

**1.** Consider antibiotic (e.g., cefazolin) dose 1–2 gm intravenously before procedure.

injury to the diaphragm/intra-abdominal organs.

**2.** If possible, elevate head of the bed to 30–60 degrees to lower diaphragm-decreasing risk of

• Profound hypoxia/hypotension and signs of hemothorax

	- Must anesthetize the skin, soft tissue, muscle, periosteum, and pleural space.
	- Ensure that inner tract/incision can fit your finger and tube.
	- It helps to have your finger in the tract and pass the tube along your finger, particularly in obese patients.
	- Aim superoanterior for pneumothorax; aim posteriorly for hemothorax.
		- Controversial as to whether this is important.
	- Reduces likelihood of tube kinking.
	- If tube rotates easily, it can help indicate correct location inside pleural cavity.


○ Give prophylactic antibiotics (e.g., Ancef) to decrease rate of empyema.

Resuscitation Procedures in Emergency Setting http://dx.doi.org/10.5772/intechopen.76165 73

• Improper connections or leaks in the external tubing/water seal system

• Clotting of a smaller diameter chest tube or pigtail catheter by blood (may require low-dose

• If pneumothorax persists or large air leak despite well-placed tube, there is a need for

Central venous catheterization is one of the fundamental requirements for resuscitating criti-

• Hemodynamic monitoring such as central venous pressure measurement (CVP) and cen-

• Central venous access can be used for hemodialysis and transvenous pacemaker placement.

• Occlusion of bronchi or bronchioles by secretions or foreign body

• Damage to nerves/vessels/heart/lung/diaphragm/abdomen

• Re-expansion pulmonary edema

• Improper positioning of the tube

• Improper positioning of the tube

• Tear of one of the large bronchi

emergent bronchoscopy [17].

tral venous oxygen saturation.

Local infection in the area to be punctured.

• Rapid fluid and drug infusion.

• Parenteral nutrition.

**5.2. Contraindications**

**5. Central venous catheter placement**

cally ill patient in ED and intensive care unit (ICU).

Rapid venous access in emergency situation, e.g., cardiac arrest.

TPA to declot pigtails)

**5.1. Indications**

• Large tear of the lung parenchyma

• Tension pneumothorax

Failure to drain

**Table 1.** Adult chest tubesizes.

#### **4.12. Drainage system and suction**

	- The least amount of suction (including none) needed to maintain full expansion of the lung is appropriate.
	- Starting with Heimlich valve (no suction) or − 10 cm of water and increasing only as needed
	- −20 cm of water
	- Increased as indicated with the goal of achieving full lung expansion
	- Start −20 cm of water

#### Complications

	- Clamp tube immediately; take patient to the OR for emergent thoracostomy.
	- Reason why you never clamp the tube once it is in place (could cause tension pneumothorax)

#### Failure to drain

**4.12. Drainage system and suction**

• Empyema

**Table 1.** Adult chest tubesizes.

ventilation

72 Essentials of Accident and Emergency Medicine

○ The least amount of suction (including none) needed to maintain full expansion of the

• Alveolar-pleural fistulae (small air leak)

• Bronchial-pleural fistulae (large air leak)

• Bleeding (hemothorax/hemopneumothorax)

• Iatrogenic air

• Malignant fluid

• Thick pus

○ Starting with Heimlich valve (no suction) or − 10 cm of water and increasing only as

○ Increased as indicated with the goal of achieving full lung expansion

**Type of patient Underlying causes**

• Most spontaneous pneumothorax (primary and secondary) • Most iatrogenic pneumothorax

• Pneumothorax on mechanical

• Non-traumatic tension pneumothorax • Malignant effusion

• Traumatic pneumothorax

• Exsanguination (secondary to removing the tamponade effect of the hemothorax) ○ Clamp tube immediately; take patient to the OR for emergent thoracostomy.

○ Reason why you never clamp the tube once it is in place (could cause tension pneumothorax)

• Spontaneous pneumothorax

lung is appropriate.

needed • Fluid drainage

**Chest tubesize**

Small (8–14 Fr)

Medium (20–28 Fr)

Large (36–40 Fr)

Complications

• Air leak

• Failure • Infection

○ −20 cm of water

○ Start −20 cm of water

• For thoracic trauma, few data are available.

