Procedures in the Trauma Patient

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What is one of the most important things to remember before performing any prehospital procedures?

The most important thing to remember in any patient encounter is your safety and health. The patients that you encounter in the prehospital environment could possibly have any number of communicable diseases. This means that for every patient encounter, proper BSI (body substance isolation) is required. At the bare minimum, gloves are required every time you touch a patient. For more invasive procedures with a possibility of exposure to bodily fluids, a mask and face shield are required.

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What is the indication for a needle thoracostomy?

A needle thoracostomy (needle decompression) should be performed when there is concern for a tension pneumothorax. There are a number of physical exam findings that can lead to the diagnosis of a tension pneumothorax. There will be decreased or absent breath sounds on the side of the pneumothorax. You can also see hypotension from the effects of the pneumothorax preventing proper filling of the heart. Jugular venous distention (JVD) can be seen but may not be present in a patient with significant blood loss. A late sign of a tension pneumothorax is tracheal deviation away from the affected lung.

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Where should the needle be inserted during a needle thoracostomy?

There are several sites that can be utilized by the prehospital provider to choose from ( Fig. 79.1 ). The preferred site for a needle decompression is the 4th or 5th intercostal space in the anterior axillary line. The needle is inserted over the rib to avoid the nerves and blood vessels that run underneath every rib. A large angiocath (14 gauge) with a length of at least 3.5 cm should be used. The 4th/5th intercostal space in the anterior axillary line has the lowest average chest wall thickness and, therefore, the lowest failure rate.

Alternative sites for a needle decompression include the 2nd intercostal space in the midclavicular line, the 4th intercostal space in the midaxillary line, or the 5th intercostal space in the midaxillary line. See Table 79.1 for needle thoracostomy sites by success rate.

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What is a finger thoracostomy?

A finger thoracostomy is a procedure that is performed to rapidly relieve the cardiac dysfunction caused by either a tension pneumothorax or tension hemothorax. A scalpel, curved clamp, and gloved finger are all that are required. It is important to remember that this is a highly invasive procedure and there is a high risk of exposure to the patient’s blood so proper BSI is essential.

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