We were in the ICU working on a intubated septic patient and had just managed to stabilize his hemodynamics. Then one of the nurses noticed how the tidal volumes on the ventilator were decreasing. Blood pressure and sats dropped gently too. A couple of hours before, I tried to insert a subclavian central line but failed. Pneumothorax?
Breath sounds were possibly more quiet on the right side of the chest. We had an ultrasound standing by for a new attempt at a central line. I put the probe to the chest. There were no ‘comet tails’, no ‘beads on a string’, no ‘sliding sign’ and, most definitely, no ‘waves on a beach’. Pneumothorax.
The patient was taken off the ventilator and was carefully bagged. I then proceeded with a needle-decompression. Immediately air started hissing out of the needle. I asked the nurse to call the surgical registrar for a chest tube.
By coincidence the radiographer was in the ICU for another patient. Hemodynamics at this stage had deteriorated somewhat, but had also plateaued. We had time to get a chest-x while waiting for the surgical reg. This is what came up. As you can tell, we were already a long way up a nasty creek.
Tension pneumothorax. This is where everything went to hell. Rapidly. Within 10-20 seconds the patients blood-pressure, sats and pulse went crashing through the floor – despite the pressure draining through the decompression needle. It became very obvious to me that my patient was dying a lot faster than I could decompress him through the B.S. needle I had in his chest.
I went for the scalpel, made the deep skin incision and pushed a finger through the chest wall between the ribs. I was rewarded with a massive long gush of air. Immediately, the patients vitals improved and within a minute or so normalised.
Here´s some stuff that went through my head afterwards.
1. Tension pneumothoraces, especially on ventilated patients, are sneakier and more potent than we tend to think. This patient must have compensated the initial build-up for a long time. There was no clear gradual deterioration of his vitals, no visible tracheal shift, no clearly absent breath sounds, none of that, until the patient suddenly crashed, and almost died within a time-span of 10-30 seconds.
2. Needle decompression is, at best, to be regarded as a diagnostic tool. It can’t be relied on to decompress a proper tension pneumothorax. Learn how to do a finger thoracostomy. Forget about the tube, tube placements, sutures and what not. The big hole in the chest is the fix you want for cases like this one. That’s what matters. You will have infinite amounts of time to sort out the rest after saving the patients life.
That’s all. These are my recollections of a quite intense situation that only lasted half a minute or so.