Thoracentesis During Cardiopulmonary Resuscitation
by Dr. Samuel Rice-Townsend and Dr. Christopher Weldon.
Introduction.
Thoracentesis, or pleural needle decompression,
is performed in patients with suspected tension thorax--
which may be hydro, hemo, pneumo,
or a combination of all three--
in order to restore normal cardiopulmonary function
and output.
In this video, we will be demonstrating
the blind technique that is used when a patient has
an emergent need for thoracentesis,
or pleural needle decompression, such as when
a patient is receiving active cardiopulmonary resuscitation.
Indications and Contraindications.
Patients with tension thorax have accumulation
of air, fluid, and/or blood in the pleural space causing
increased pressure with subsequent compression
of the heart and great vessels, impairing venous
return, cardiac output, and phasic respiratory function.
Signs of tension thorax may include tachycardia,
narrow pulse pressure, jugular venous distension,
decreased breath sounds on the affected side, decreased heart
sounds, hypotension or evidence of a hydro and or pneumothorax
on chest radiograph.
Patients may present clinically with varying degrees
of dyspnea, tachypnea, tachycardia, poor perfusion
and/or change in mental status, including agitation,
and thus a high degree of clinical suspicion
is required to make the diagnosis.
Complete cardiovascular collapse is also a possible presentation
to be considered in a patient who has arrested.
Pediatric patients at risk for tension thorax
include those that have had recent thoracic surgery, trauma
or injuries, cancer involving the lung,
either primary or secondary disease,
respiratory infections, autoimmune
or inflammatory disorders of the chest, lungs, pleura,
or placement of central venous catheters.
But tension thorax can also occur
for spontaneous or cryptogenic reasons.
Tension thorax is one of the Hs and Ts
that health care providers should remember
when providing cardiopulmonary resuscitation on a patient who
has pulseless electrical activity.
There are no absolute contraindications
to emergency decompression of tension thorax.
Equipment.
Appropriate personal protective equipment
including sterile gloves, emergency resuscitation
medications and equipment, antiseptic skin cleansers
such as chlorhexidine.
Any hollow-bore needle of any size or gauge
that will have a suitable length to go
into the pleural surface from the skin, but
ideally, a 20-gauge or larger and at least
one inch or longer.
A needle with a catheter attached
is preferred, any size syringe.
Positioning and Landmarks.
During active cardiopulmonary resuscitation,
the patient will be in a supine position.
The midclavicular line should be identified,
and the needle should be inserted approximately one
rib-space inferior to the clavicular edge.
The needle should be advanced over the superior edge
of the rib to avoid vessel puncture or injury
to the neurovascular bundle that runs along the inferior portion
of each rib.
Procedure.
Cleanse skin.
During active cardiopulmonary resuscitation,
the patient will not require local anesthesia.
But this should be considered for elective or semi-urgent
procedures.
Cardiopulmonary resuscitation should be briefly paused
during the advancement of needle and aspiration of the syringe.
Insert the needle with a syringe attached perpendicular
to the long axis of the chest, approximately one rib-space
below the inferior border of the clavicular edge, just
above the superior edge of the rib.
Angle the needle at 90 degrees at all times,
and advance slowly to the length of the needle.
An immediate rush of air or fluid
should be encountered when tension thorax is
a cause for the cardiovascular collapse.
The distance from the skin to the pleural space
is based on body habitus.
Secure the needle at the skin with your other hand
to make sure that the needle does not move unnecessarily
during the procedure.
Manually remove any fluid and/or air from the pleural space.
If air and/or fluid continues to accumulate,
you may consider inserting and leaving the catheter in place
and continuing to manually remove air
and/or fluid as it accumulates.
Remember to resume cardiopulmonary resuscitation
as soon as possible.
A tube thoracostomy should now be immediately performed
if a tension thorax is deemed to be the cause
and was relieved with the decompression.
Complications.
Complications include cardiac or vessel puncture, pneumo, hydro,
and/or hemothorax.
Post-procedure Monitoring and Documentation.
Continue cardiopulmonary resuscitation,
and monitor for any change in hemodynamics.
A chest radiograph should be obtained as soon
as possible following the procedure
if return of spontaneous circulation is achieved.
Remember to document the amount and quality of the fluid
and/or air removed.
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