Did he get the ICC?

Hello there, great to see I have managed to generate a little discussion on this blog, exactly what it is for.  I was beginning to think no one was reading/checking up on it and that would have made me sad…

                                  

Now, the resolution of the case I post 1 week prior.  Essentially,  this case has prompted a discussion challenging the dogma, pre-hospital needle decompression mandates insertion of an intercostal catheter on arrival to ED.  I hate ‘dogma’ and feel we are intelligent beings who can make decisions are case by case basis’ and not necessarily ‘have’ to do anything.  The caveat to this case is the fact that this patient is under positive pressure ventilation and there is real concern of turning even the most minute breach in the pleural lining into an avenue for air to escape into that potential space.

A review of the pertinent findings in this case:  

• 48yo with inferior STEMI needing urgent re-vascularization and associated anticoagulation
• A needle decompression of the left side of chest performed by pre-hospital personnel without very much objective evidence of a tension PTX, if any really.
• Intubated, sedated/unconscious patient
• No compromise in hemodynamic, respiratory status throughout ED stay
• CXR showing no PTX and a very high, angulated decompressed needle positioning
• USS showing good lung sliding, comet tailing and NO evidence of PTX on either right or left side.

 Is it possible that the needle did not enter the thoracic cavity?

•  In a simple word, yes.  I won’t reinvent the wheel, smart people have reviewed the studies and you should read their summaries below:

1. EMcrit
2. The trauma professional’s blog
3. Resus.Me: here, here, and here

 Could we have taken the needle out, observed for a period of time while patient was under positive pressure ventilation, and re-assessed,  repeated an USS?

•  Probably not in this case, time was of the essence, this patient needed to have a coronary artery re-opened.
• However, I do believe it is a good learning tip and a very smart and feasible strategy in someone who did not have such a time critical illness. 
• In someone who is not intubated and spontaneously breathing I feel it is no question the correct management.

What happened?

Despite my cutting edge forward thinking, our consultant on that day made the safe and smart call to urgently insert a small pig-tail catheter into the mid-axillary line on the left side prior to his trip up to the cath lab.  Anticoagulants were given, he was cooled, went to the cath lab.   Interestingly, when we removed the plastic catheter from the needle decompression, it literally was barely subcutaneous and bent in a perfect 90 degree angle making if very hard to fathom that it or the needle that initially was in it made it anywhere near the thoracic cavity.

Cheers.scott

Update on Wednesday, July 18, 2012 at 8:06PM by tim cowan

Dammit. Back to USS school for me. Nice case mate.