TIME to DECOMPRESS?

     Paramedics save lives, the saying goes, and EMTs save paramedics. That's glib and debatable, but it's certainly true that the role of the EMT-Basic is a vital one, and that there's relatively little out there in the way of information and tools to help him do it better. This column is a resource for EMT-Basics. It will cover everything from reviews of basic skills to assisting ALS providers with more advanced interventions.

Scenario
     At 12:36 p.m. Rescue 24 is dispatched to a motor vehicle accident on the local Interstate. Upon arrival and size-up, the crew finds the driver still sitting in the vehicle. Upon assessment, he informs the paramedics that he's extremely short of breath and cannot lie down on the long spineboard. They place him on the stretcher in Fowler's position and move him to the back of the ambulance.

     During the initial assessment, the patient is alert and has an open airway. He is breathing, and carotid and radial pulses are present. The patient has full neurovascular function, and no major hemorrhage is noted. Continuing the head-to-toe assessment, one medic auscultates the patient's chest, which reveals diminished breath sounds throughout both lung fields. In addition, the paramedics notice that the patient is hoarse while attempting to speak. His clothes are removed for visual and physical assessment.

     The patient has a blood pressure of 148/92, heart rate of 110 and respiratory rate of 28. The paramedics notice ecchymosis and swelling over the anterior cervical region. Oxygen is applied at 15 lpm via non-rebreather, pulse oximetry shows 90% saturation, ECG reveals a sinus tachycardia, and two large-bore IVs are established. The paramedics consider pleural decompression, but opt not to proceed. The patient's vital signs remain unchanged as he is transported in his position of comfort.

Keeping It Basic
     The key to treating this patient appropriately, as it always is, was a thorough assessment-in this case, the patient's hoarseness and difficulty speaking prompted further consideration. There were questions that needed to be answered:

• Were the medics correct in not decompressing the chest?
• Why was the patient hoarse when attempting to speak?
• What are some of the causes of diminished breath sounds?
• Why were diminished breath sounds present throughout both lung fields?

     The primary issue to address was maintaining an adequate airway. Upon auscultating the patient's chest, the paramedics found diminished breath sounds bilaterally. They faced a decision regarding pleural decompression of the chest.

     Were they correct in choosing not to decompress? Pleural decompression consists of releasing air that's trapped within the pleural cavity due to a puncture or rupture of the lung tissue. Unless corrected, the air will continue to accumulate in the pleural space, producing pressure within the cavity and surrounding structures and resulting in a tension pneumothorax. When carrying out a pleural decompression, paramedics will commonly use an IV catheter 14g or 16g x 2¼" or greater and insert it into the chest, usually in the second or third intercostal space on the affected side (midclavicular). As a basic provider, it is imperative to ensure that the insertion site be cleaned first; you may also assist the advanced provider with appropriate disposal of needles after insertion, or with catheter stabilization. The paramedics here opted not to decompress because they noticed the patient was very hoarse and experiencing difficulty speaking. These signs prompted them to investigate further.

Laryngeal Fracture
     The patient's hoarseness and difficulty speaking led to suspicion of a laryngeal fracture. A laryngeal fracture commonly results from direct trauma to the anterior cervical region or chest wall. These injuries can be seen in motor vehicle accidents, such as when a driver is unrestrained and moves forward upon impact, striking the unprotected cervical region against the steering wheel. These types of injuries may be catastrophic due to airway compromise.

     In this scenario, upon auscultating the trachea, the paramedics heard stridor. Stridor is an abnormal high-pitched respiratory sound caused by a partial blockage of the airway. The paramedics felt the diminished breath sounds were the result of an inadequate tidal volume, which, in turn, was the result of a potential blockage of the trachea due to rupture secondary to blunt trauma.

Diminished Breath Sounds
     Which leads to our next question: What can cause diminished breath sounds? In simple terms, diminished breath sounds may result due to insufficient tidal volume or decreased structural pulmonary function. Tidal volume, the amount of air we inhale or exhale in a single breath, may be diminished due to head injury, medication, chest wall pain, CNS depression, etc. These events may reduce the patient's ability to inhale adequately, thereby causing diminished breath sounds. In addition, a condition that directly affects the pulmonary structure or function-such as COPD, pneumothorax, pulmonary contusion or bronchoconstriction-will lead to absent or diminished breath sounds as well. In this case, there was an increased likelihood that the patient had experienced a pulmonary contusion as a result of the blunt-force trauma. Pulmonary contusion is essentially a bruising to the lung tissue resulting in bleeding and affecting pulmonary structure and function. Between 35%-75% of pulmonary contusions result from blunt force; they are most commonly seen in children. Pulmonary contusions associated with rib fractures are more common in adults. They may lead to hypoxemia due to a ventilation/perfusion mismatch; therefore, careful monitoring of the patient's airway performance is critical. In this scenario, the pulmonary contusions and chest wall pain also contributed to the diminished breath sounds.

Glossary
     Ecchymosis-Skin discoloration due to leakage of blood into the tissues, which causes irregular-shaped hemorrhagic areas.

     Fowler's position-Position assumed by the patient when the head of the stretcher is elevated.

     High Fowler's position-A sitting position with the head elevated approximately 90 degrees.

     Pleural cavity-The space within the thorax that contains the lungs.

     Stridor-An abnormal, high-pitched respiratory sound caused by a partial blockage of the airway.

     Tension pneumothorax-Gas accumulation within the pleural cavity that compresses the lungs and limits the ability of the heart to function.

     Tidal volume-The amount of air inhaled or exhaled in a single breath.

Final Outcome
     Upon arrival at the hospital, the patient was evaluated and stabilized. X-rays revealed a laryngotracheal fracture and bilateral pulmonary contusions. The patient was transported to surgery to repair the laryngeal fracture and was released from the hospital after several days. It was determined that he was not wearing a seat belt and struck the anterior aspect of the neck and chest on the steering wheel.

     Had some of these differential diagnoses not been considered in this scenario, the patient could easily have been inappropriately decompressed. Since he had bilateral pulmonary contusions and not a pneumothorax, he did not need this-the paramedics were correct in not decompressing the chest. Doing so could have punctured the lung and created the very pneumothorax they feared.

     This crew did a good job in thoroughly assessing the patient and determining the cause of his diminished breath sounds. We can't stress enough that the key to good patient care is directly tied to our patient assessments.

Orlando J. Dominguez, Jr., MBA, FF/EMT-P, is chief of EMS and public information officer for Brevard County Fire Rescue in Rockledge, FL.