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Scuba Forum / UK Scuba / February 2004First Aid Kit ----- Iain Smith
Needle thoracocentesis (sticking a large bore needle through the chest wall) is the only effective treatment for a tension pneumothorax, which is why I carry a suitable needle in my dive bag. Now, if it's me that needs it doing, I just hope there's another medic on the boat (or that one of my regular buddies remembers what I taught them). Iain I did not want to hijack the stoney cove thread out of respect. Iain your fist aid kit must be more comprehensive than mine ( have NO medical training other that rescue course) what do you carry ? is there a list somewhere. out of curiosity how big is this needle then. Regards David > Iain > [quoted text clipped - 5 lines] > > out of curiosity how big is this needle then. Errr... David... I don't think that I want to know in advance just what /Dr./ Iain Smith carries in his first aid box just in case he decides to use it on me :-) K > Errr... David... I don't think that I want to know in advance just what > /Dr./ Iain Smith carries in his first aid box just in case he decides to use > it on me :-) :-) I do have a first aid kit but I just wondered what a trained medical type person carried. when I met my girlfriend 10 years ago i new we would get on when she showed me her tool box.( nothing crude please). David > Iain your fist aid kit must be more comprehensive than mine > ( have NO medical training other that rescue course) > what do you carry ? is there a list somewhere. Not a lot more, actually. Our club trips always have our club first aid kit and O2 set (as per BSAC First Aid for Divers and O2 Admin course recommendations) although I recently added a non-rebreathing mask to the O2 kit (allows delivery of free-flow oxygen to a breathing casualty at about 85-90% if the demand valve (100%) is already in use) I tend to carry some simple oropharyngeal airways (as taught on the BSAC Rescue First Aid course) and I keep meaning to buy my own bag-and-mask resuscitator (also taught on RFA) but have never quite got round to it. And, of course, the cannula, which is the only one of the above items that enables me to do something that someone with oxygen administration and basic first aid training can't do at all (as opposed to being able to do some things better, eg airway maintenance and ventilation) FWIW, one thing I like to demonstrate when teaching oxygen administration is that you can deliver a lot more oxygen to a non-breathing casualty by having the rescuer breath from the demand mask than you can by using a typical "oxygen-enriched AV" setup (where you're doing standard AV with a free-flow O2 pocket mask.) > out of curiosity how big is this needle then. It's a 14G cannula. What this means is that it's the (large) type of needle one normally gives fluid through. The metal pointy bit is just over 1mm wide and is 45mm long. As Keith pointed out, yes, I am a doctor. Some on here may remember a chap called Paul Thomas who, at one point, suggested that we should teach people how to deal with tension pneumothoraces as part of either O2 Admin or RFA. I confess that I'm coming round to his point of view... Iain > > Iain your fist aid kit must be more comprehensive than mine > > ( have NO medical training other that rescue course) [quoted text clipped - 33 lines] > > Iain Well I hope I never see that needle comming my way sounds painfull but meybe I would be a little under the weather if that needle was pointing at me :-( thanks for reply David > > > Iain your fist aid kit must be more comprehensive than mine > > > ( have NO medical training other that rescue course) [quoted text clipped - 51 lines] > > David it's not as big as the needles I have used... But then I was using them on big bulls :) you don't have time to find a vein and slowly press it in... You jab randomly and squeeze the trigger before the bull is quite airborne :) > As Keith pointed out, yes, I am a doctor. Some on here may remember a chap > called Paul Thomas who, at one point, suggested that we should teach people > how to deal with tension pneumothoraces as part of either O2 Admin or RFA. I > confess that I'm coming round to his point of view... I think the main problem would be trying to teach peole _when_ to do it rather than how to do it. It wouldn't be very good if they went round and randomly stuck a big pointly think into every DCI casulty... Al. > > As Keith pointed out, yes, I am a doctor. Some on here may > > remember a chap called Paul Thomas who, at one point, [quoted text clipped - 6 lines] > good if they went round and randomly stuck a big pointly > think into every DCI casulty... :-) Agreed. Having spent most of this evening discussing this at my club night, I'm coming to the conclusion that it would have to be on a protocol along the lines of: [NB: The following is purely for discussion and should not be taken as a protocol by which a non-medically trained person should attempt to diagnose a tension pneumothorax and particularly should not be used to make a decision as to whether to attempt decompression of a tension pneumothorax] History: Has the casualty had a rapid/breath-holding ascent? (ie could they have burst a lung?) Did they have chest pain on arrival at the surface? Is there blood stained spittle? (Not necessarily present, but suspicious) Examination: (given that using a stethoscope isn't really an option on a dive boat and percussion isn't hugely reliable if done by someone inexperienced) Are the casualty in obvious respiratory distress? (Breathing rapid and shallow) Is one side of the chest moving more than the other? Has the casualty got a very weak/absent pulse? (A Tension Pneumo will reduce BP) Has the casualty got distended neck veins? (?ability of non-medic to identify these) Has the trachea deviated? (Very late sign, by which stage the casualty really, really needs something doing! I also can't think of any other diving situation in which the trachea would deviate unless someone had pre-existing deviation...which is pretty rare and would normally suggest some other pathology severe enough to prevent diving in the first place.) Possibly also: Is the casualty cyanosed? Has the casualty become unconscious? If the above conditions are met, decompress the side of the chest that is moving less and from which the trachea has deviated AWAY. In other words, make the diagnosis virtually bomb-proof and limit the use of the technique to the extreme situation. Iain > The following is purely for discussion and should not be taken as a > protocol by which a non-medically trained person should attempt to > diagnose a tension pneumothorax and particularly should not be used to > make a decision as to whether to attempt decompression of a tension > pneumothorax Which is of course another point, I'm sure there would be (lots of?) legal implications about arming people with the kit to do this and "certifing" them... > Has the casualty got a very weak/absent pulse? I was under the impression that measuring the pulse "in the field" for non-medics wasn't recommended these days as its been proved to be very unreliable (which is why we're no longer supposed to stop and check for a pulse while doing CC and AV). Al. > Which is of course another point, I'm sure there would be > (lots of?) legal implications about arming people with the > kit to do this and "certifing" them... Quite. Hence my "FFS don't do it!". If one were to introduce this as a diving first aid skill, there would have to be lots of discussion with lots of people to ensure that whatever protocol was implemented was robust enough to keep the blood sucking ambulance-chasing land sharks at bay. > > Has the casualty got a very weak/absent pulse? > [quoted text clipped - 3 lines] > longer supposed to stop and check for a pulse while doing CC > and AV). You're thinking of the situation where you have a non-breathing casualty. If someone is still conscious they _must_ have a pulse to find. If someone is still breathing, they _must_ have a pulse to find. Its when the breathing stops that you don't know whether they still have a pulse... Add cold hands, inexperience, etc. into the equation and it becomes more difficult. Is it something one must think of if considering a tension pneumothorax? Not necessarily, but it's another useful clinical sign consistent with such an event. If all else fails, stick your ear to their chest - if it's reasonable quiet ("TURN THOSE F'ING ENGINES OFF FOR A MOMENT!!!") you should be able to hear the heart beating which, if nothing else, will tell you how rapidly it's going. The point is, if someone has a tension pneumothorax, they're going to die in a very few minutes. Anything you do wrong will not speed their demise. Doing the right thing could save their life. It's how one gives people the ability to do it that I haven't quite worked out yet! Iain > > Which is of course another point, I'm sure there would be > > (lots of?) legal implications about arming people with the [quoted text clipped - 34 lines] > > Iain Just out of curiosity, why does one burst lung kill you, cant the body operate on the one lung? and how does a re inflated burst lung stay inflated? > Just out of curiosity, why does one burst lung kill you, cant the body > operate on the one lung? Hello again Richard, lungs work because of a drop in pressure in the (singular) lung cavity caused by movement of the diaphram. Burst one lung and air can go from the burst lung into the lung cavity, and neither lung works since it is no longer possible to lower the pressure in the lung cavity. Ben  SignatureBen Panter, Edinburgh My name (no spaces)@bigfoot which is a com. > > Just out of curiosity, why does one burst lung kill you, cant the body > > operate on the one lung? [quoted text clipped - 7 lines] > > Ben Ok thats understood, how does the needle correct this? >Ok thats understood, how does the needle correct this? Thanks, Richard. You've given me the impetus to start revising again. No, really: thanks. Signatureferret Best before: see end > >Ok thats understood, how does the needle correct this? > > Thanks, Richard. You've given me the impetus to start revising again. > > No, really: thanks. For what trying to sort out a burst lung, where you studying cambridge? > > Just out of curiosity, why does one burst lung kill you, > > cant the body operate on the one lung? > lungs work because of a drop in pressure in the (singular) > lung cavity caused by movement of the diaphram. Burst one > lung and air can go from the burst lung into the lung cavity, > and neither lung works since it is no longer possible to > lower the pressure in the lung cavity. Not quite. That's closer to a description of a sucking chest wound/open pneumothorax (a wound which is bigger than about 2/3 of the trachea, a which point it is easier to draw air in through the chest wall than through the trachea. Unfortunately, if you do that, the air doesn't get into the airways and therefore doesn't take part in gas exchange.). A pneumothorax which has arisen without large defects in the chest wall tends to result from internal damage where a "flap-valve" has formed in the lung tissue. As one breaths in, the negative pressure in the pleural space opens this "valve" allowing movement of air from the lung to the pleural cavity. As the casualty breaths out, this "valve" is closed by the rising pressure in the pleural space. Hence air can build up in this pleural space. This "simple" pneumothorax kills if it progresses to a tension pneumothorax because of the accumulation of pressure in the affected pleural space. That pressure builds up and starts to compress the great veins (primarily the superior and inferior vena cava). These are very thin-walled vessels with a low blood pressure. It therefore doesn't require a great deal of pressure above ambient to compress them to a point that blood cannot flow through them. If blood cannot return to the heart, it can't be pumped. If you can't pump blood, you die. You also asked: "how does the needle correct this?" By passing a needle into the pneumothorax, you provide a route by which the excess pressure in the pleural space can equalise with ambient pressure. This allows blood to flow once more. This won't get rid of all of the pneumothorax, but it will allow the casualty to survive that bit longer. Future management options include: doing nothing else (rare in this situation); repeated aspiration of a recurring pneumothorax; insertion of a chest drain; surgery to repair the damaged lung. The option chosen would depend on the individual circumstances and severity of the injury. Hope this makes sense. Iain > > > Just out of curiosity, why does one burst lung kill you, > > > cant the body operate on the one lung? [quoted text clipped - 43 lines] > > Iain Very infomative Iain, thankyou for passing that on, I was under the illusion that the lung was re inflated using the needle which left me a little confused as the lung is clearly punctured. If the nose was not obstructed by the mask would the respitory system not automaticaly vent throught it. I know its possible to keep your mouth airway closed but the nose is another matter. > Very infomative Iain, thankyou for passing that on, I was under the illusion > that the lung was re inflated using the needle which left me a little [quoted text clipped - 3 lines] > I know its possible to keep your mouth airway closed but the nose is another > matter. I believe the point is the air has left the respiratory system, and the tear in the lungs effectively becomes a one way valve, so there's nowhere for it to go, so it stays there and gets bigger with each breath up to the point it's so big it kills the person. The needle gives the air an escape route. It can't go via the nose because it's got no (sensible!) route that's not via the lungs. Actually, re-reading your post above, did you mean "on ascent, would the expanding air in the lungs be able to leave via the nose without you explicitly exhaling it?" - in which case I don't know the answer, but I suspect not because surely the air would push out of the mask before the pressure difference was large enough to damage the lung. Stuart > I was under the illusion that the lung was re inflated using > the needle which left me a little confused as the lung is [quoted text clipped - 3 lines] > I know its possible to keep your mouth airway closed but the > nose is another matter. I'm not sure what you're asking here. If it's about how a lung over-pressure injury can occur, then no. The mouth and nose (oro- and naso-pharynx) join at the back of the throat. They then continue as a common airspace into the larynx, which is where one can close off one's airway, thus obstructing outflow via both mouth and nose. Also, the nose isn't particularly obstructed by the mask - if you think about exhaling through your nose underwater, it takes no effort at all to be able to breath out. Iain >>>Just out of curiosity, why does one burst lung kill you, >>>cant the body operate on the one lung? [quoted text clipped - 6 lines] > > Not quite. ...<snipped>... Cheers - I bow to your superior knowledge! Ben (PS - Althought the pedantic phsysicist in me takes great exception to the idea of "negative pressure") SignatureBen Panter, Edinburgh My name (no spaces)@bigfoot which is a com. > (PS - Althought the pedantic phsysicist in me takes great exception to > the idea of "negative pressure") That would be the one who can't spell his own pedantry, obviously... SignatureBen Panter, Edinburgh My name (no spaces)@bigfoot which is a com. > (PS - Althought the pedantic phsysicist in me takes great > exception to the idea of "negative pressure") As a fellow pedant, I acknowledge your concern, and accept that, in stead of "the negative pressure in the pleural space" I should have written: "the pressure in the pleural space, being reduced to below that in the lungs" or "the pressure in the pleural space, which is negative relative to that in the lungs" :-) Iain |
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