Page 45 - PJ MED OPS Handbook 8th Ed

Equipment:
• 10 or 14 gauge, 3.25-inch angiocath
• Supplemental Oxygen (if available)

NOTE: 10 gauge catheter may allow decompression to be maintained longer than 14 gauge,
which may clot more easily

Procedure:
1. Administer oxygen 12L/min per NRB or positive pressure with BVM.
2. Locate the 4th or 5th intercostal space (about nipple level) on the anterior axillary line on the
side of the pneumothorax.
3. Clean area with betadine or alcohol swabs.
4. Local anesthetic if time and tactics permit. Leave needle in place as marker.
5. Insert 10–14-gauge, 3-inch catheter over the top of the rib into the pleural space. Once through
chest wall, advance catheter, and remove needle.
6. Listen for a decompression air rush from the catheter and observe for clinical improvement.
7. It is acceptable to either remove the catheter and re-sheath for repeat decompression (same
casualty) or leave in place.
8. Observe/monitor the patient (and catheter for kinking/obstruction).
9. If casualty responds positively to treatment, repeat as necessary. If no relief after 2 attempts,
proceed to finger or tube thoracostomy.

Thoracostomy (finger or tube, aka chest tube)
Indications:
• Chest trauma with respiratory distress after the following: unsuccessful ND × 2, need for mul-
tiple ND, signs of hemothorax (decreased breath sounds, dullness to percussion).

NOTE: Tension or symptomatic pneumothorax should initially be treated with ND (repeated
as necessary.) A stable patient with a pneumothorax should be observed closely and a chest
tube should be placed ONLY if the patient becomes significantly short of breath or has other
signs of decompensation which cannot be corrected with repeat ND. Formal chest tube place-
ment is RARELY required in the pre-hospital environment. Finger thoracostomy to ensure the
chest is fully decompressed is appropriate if time and tactics do not permit tube placement.

Equipment:
• Sterile gloves, chest tube (ETT may be substituted) and one-way valve (Heimlich valve)
• Scalpel, needle, 0-silk suture, material for occlusive dressing
• Lidocaine
• Syringe with needle
• Curved Kelly clamp

Chapter 6. Surgical and Medical Procedures n 43