Flutter valves and needle chest decompression

[Boothby]

Not to long ago I made an interesting call right around the corner from out station. It seems that this gentleman and his lady had gotten into it and she had worked him over with an ice pick. I counted 8 puncture wounds in his posterior left chest before I stopped trying to count. Any way the only thing this guy could get out was "I can't breath" and even that was a strain. He had zip for breath sounds on the left side, and was beginning to rapidly circle the drain. My partner and I snatched him up off the floor, put him on 15LPM, and I needled his left lateral chest on the mid axilary line with a 14 Gu IV cath complete with home made flutter valve. We then hit the road, got a quick IV on the way, and because his resperatory distress didn't improve much I put a second 14 in his anterior chest on the mid clavicular line. Again with a flutter valve.

After the trauma team had stabalized this patient the Head of the service pulled me aside and we had an interesting discussion over the merits of flutter valves. His argument was that if you put a flutter valve on the needle it can acutaly cause a second tension pneumo, where as if you leave the cath open you will relieve the original tension and maintain a simple pneumothorax. The idea being that the tension pnuemo is an immediate life threat (thus the needle in the chest) where a simple pneumo is a life threat that can acutaly be tollerated for quite some time.

To my way of thinking he makes alot of sense, but it is contrary to what I have been tought and what I teach in BTLS. Keep in mind that we are in the city and Very close to the trauma center.(on scene to trauma team was 11 min on that call). Any way what do you all think. I know what is taught......I want to know what you THINK and why. Thanks

------------------
Larry Boothby
Firefighter/Paramedic
Truck 3 A-shift
Local 1784
Memphis.

[Medic019]

I was taught to utilize a flutter valve when doing chest decompressions also. However, ran into the same thing you did...Told it is better to just 'pop' the chest with a cath without a flutter valve with the same reasoning you were given. I guess that maybe this is the new fad...Who knows maybe next week we'll be back to using the flutter valve because of a recent study somewhere out there...LOL

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Firefighter/Paramedic in Northwest Pennsylvania... Stay Safe

[Trauma_Dog]

Hey Booth, Sounds like you did just fine, If the valve is working ok it not should create a pneumo and really fully understand the logic behind that. We had used those in the past however switched to Cook pneumothorax kit. In the Cook kit the flapper vale is very large and suction tubing can attached to end of it and negitve pressure applied. They work good, but do require more training due to "some assembly required" and a incision has to be made for insertion. Keep up to good work and stay safe.

------------------
Kent Simon
Paramedic Incharge
MCHD EMS,
Montgomery Co.,TX

[skymedic]

Like most (if not all of you out there, we were all taught to use large bore IV cannulas with flutter valves. Heck, I've seen almost every kind of valve immaginable from glove fingers to condoms and fish tank valves (yep, those ones in the air pipes!)

That aside, I've found that the valves do tend to aggrevate matters for the following reasons:
1. The needle is already small, compared to the hole in the lung that's leaking. Lets face it, air (and most of us for that matter) will tend to take the path of least resistance. So, the pneumo continues to build, albeit slowly if the tear is of significant size, and the needle is unable to drain the pneumo at an acceptable rate. However, by the same analogy, with the flutter valve removed, the open needle will not couse leakage back into the pleural space significant enough to cause a problem. This is probably why the flutter valve is going out of fashion.
2. By adding a flutter valve, of whatever description, the intra thoracic pressure required to open the valve and drain air out is increased, hence complicating matters further.
3. If all you're dealing with is a simple tension pneumo, the needle thorocentesis works just fine. However, I had one patient with a left sided tension pneumo which turned out to be a tensioning hemo-pneumo. This guy's trachea was pointing to the middle of his right clavicle! When the first two needles went in, well old faithful move aside. But the blood blocked up the needles within three minutes as it clotted. Two more needles were added but suffered the same fate. The only thing left to do (which actually saved this guy's life) was to put up a chest drain with a heimlich valve. I immediately drained off 400ml of blood, and ing the hour and a half that followed in the trnasfer to hospital (Pt was MVA in the African bush), we must have drained of in excess of 15 litres of air. (the lung was still VERY actively leaking). And was I glad for having done ATLS!

Sometimes radical maneuvers are the only option available.

Fly High

Michael Dollenberg
Operations Manager / Flight Paramedic
Aeromed Namibia

[Paramark14]

I'm a pretty knew medic and I've not had to needle decomp. in the field yet. I was taught to use a glove finger or Hiemlich valve. Some of what you say makes sense. I guess I'll be having a talk with my medical director next shift. Thanks.


Mark
NREMTP
Indiana

[DFDWaagner]

This was a large point of contention in medic school about three weeks ago. On my unit in New Jersey we have those fancy Heimlich valves that have the neat noise maker on them for New Years. You know its a plastic tube with a flutter valve inside. It attaches to tubing with a cock valve which we were originally told to keep close. But my brain never stops processing and I'm thinking if you close the cock valve you are just going to build up the pressure again? Right? We still have not gotten a definitive answer yet to this question.
Correct me if I'm wrong you guys aren't decompressing a simple are you? Its not in our protocol or our curriculum to pop someone's chest with merely a simple. I do understand however a simple can lead to a tension pnuemo and this is where good assessment and monitoring comes into play en route to the ED.

I think if you use a heimlich with the flutter valve and cock valve the cock valve should stay open since the flutter will NOT allow air to reenter the plueral cavity around the lung.
It will be interesting to see what happens truly in the field. I just missed a decomp on Sunday. Oh well all thoughts would be appreciated.

Waagner
707
DFD
working towards those four numbers
Be safe

[QUOTE=Boothby]... We then hit the road, got a quick IV on the way, and because his resperatory distress didn't improve much I put a second 14 in his anterior chest on the mid clavicular line. Again with a flutter valve.

After the trauma team had stabalized this patient the Head of the service pulled me aside and we had an interesting discussion over the merits of flutter valves. His argument was that if you put a flutter valve on the needle it can acutaly cause a second tension pneumo, where as if you leave the cath open you will relieve the original tension and maintain a simple pneumothorax. The idea being that the tension pnuemo is an immediate life threat (thus the needle in the chest) where a simple pneumo is a life threat that can acutaly be tollerated for quite some time.

To my way of thinking he makes alot of sense, but it is contrary to what I have been tought and what I teach in BTLS. Keep in mind that we are in the city and Very close to the trauma center.(on scene to trauma team was 11 min on that call). Any way what do you all think. I know what is taught......I want to know what you THINK and why. Thanks
[QUOTE=Boothby]...

[mitllesmertz1]

I think flutter valves are over-rated.
We use a simple needle to relieve air/fluid.
I can't remember ever actually using a flutter valve.

[ALSfirefighter]

We utilize the kit with the heimlich valve in it also, however we do not leave the stop cock closed. I've used it several times with great success in alleviating the pnuemo. In fact every chest I've popped has still shown some signs of simple pnuemo upon ED arrival.

[bossteen]

mitlessmertz1 is spot on, don't waste your time with a flutter valve or any other such nonsense, the fact is, a 10g or 14g angio is gonna do a good job of releasing air under tension, but will not allow air to re-enter, with the upper airway being much larger and the path of least resistance....I have never used a flutter valve....

[bossteen]

mitlessmertz1 is spot on, don't waste your time with a flutter valve or any other such nonsense, the fact is, a 10g or 14g angio is gonna do a good job of releasing air under tension, but will not allow air to re-enter, with the upper airway being much larger and the path of least resistance....I have never used a flutter valve...good job on reviving an almost 7 year old thread

[AKflightmedic]

I have to agree, flutter valves are pointless.

When I saw this post I said "what are they still using them for?"

Quite honestly, I thought we had quit teaching this several years ago, as that was when we were instructed to cease using them.

They are not even taught in the flight medic program.

I have done a few field decompressions and never used a flutter valve.

Didnt even know it was still being taught these days.

[FDAIC485]

I try to make things really simple. I use a 10 drop and a bottle of sterile water as a one-way valve. All you have to do is hook a DRY 10 drop set to the 14 long cath. Then submerge the drip chamber into sterile water bottle. Of course, the bottle is kept at a level below the patient.

"I'm just an unfrozen caveman paramedic/firefighter, it scares me."

[NVdualrole]

I have been a medic for 12 yrs and it seems to me that the people writing the "BTLS, ITLS, PHTLS" or what ever. As far as any proceedure you do is always changing in the popular opinion arena. They dont even know what works the best most of the time. Whats worked for me is that if something is not working, change it. Flutter valve, no flutter valve. What ever seems to work you should stick with. I know your thinking, well thats common sense. But we know that not all ER MD or nurses think that way. But when you bring a pt in with a non-typical treatment modality (within limits), it makes you someone that is able to imprivise and be addaptible to your situation. To me, that what makes a good medic. It may rock the ER from time to time, but over time, you will be respected and known as someone that uses is head not his protocal book.......
Not to long ago I made an interesting call right around the corner from out station. It seems that this gentleman and his lady had gotten into it and she had worked him over with an ice pick. I counted 8 puncture wounds in his posterior left chest before I stopped trying to count. Any way the only thing this guy could get out was "I can't breath" and even that was a strain. He had zip for breath sounds on the left side, and was beginning to rapidly circle the drain. My partner and I snatched him up off the floor, put him on 15LPM, and I needled his left lateral chest on the mid axilary line with a 14 Gu IV cath complete with home made flutter valve. We then hit the road, got a quick IV on the way, and because his resperatory distress didn't improve much I put a second 14 in his anterior chest on the mid clavicular line. Again with a flutter valve.

After the trauma team had stabalized this patient the Head of the service pulled me aside and we had an interesting discussion over the merits of flutter valves. His argument was that if you put a flutter valve on the needle it can acutaly cause a second tension pneumo, where as if you leave the cath open you will relieve the original tension and maintain a simple pneumothorax. The idea being that the tension pnuemo is an immediate life threat (thus the needle in the chest) where a simple pneumo is a life threat that can acutaly be tollerated for quite some time.

To my way of thinking he makes alot of sense, but it is contrary to what I have been tought and what I teach in BTLS. Keep in mind that we are in the city and Very close to the trauma center.(on scene to trauma team was 11 min on that call). Any way what do you all think. I know what is taught......I want to know what you THINK and why. Thanks

------------------
Larry Boothby
Firefighter/Paramedic
Truck 3 A-shift
Local 1784
Memphis.

[phillydan]

I hate to pop any bubbles, but the little known fact in this debate is that the IV needles themselves don't work very well. I'm not surprised many don't think one-way vales do anything. On an IV catheter they really don't.

IV catheters have a soft plastic sheath, designed to remain soft & flexible inside the vein into which they were inserted. The problem is when you put them in a muscular chest wall, as soon as you pull out the metal stylus they close right off. You are not going to change anything if you do or do not attach a valve.

The first thing you can do to mitigate this problem is hold the needle with stylus in place for about a minute before pulling, to give time for air to escape. The other is to use a purpose built needle.

Some years back I worked with Cook to develop a needle decompression kit for EMS. The biggest single advantage of the kit is the reinforced needle, that will not "pinch off" easily. No - I don't make any money off of it, just thought some might be interested.

[mitllesmertz1]

Interesting point.
Like I stated previously, I have used the needle decompression mulitple times, usually with success.
I agree an IV catheter in the <18g range is fairly flexible.
However, a 10, 12, or 14g is pretty rigid and non-collapsible.

[phillydan]

Interesting point.
Like I stated previously, I have used the needle decompression mulitple times, usually with success.
I agree an IV catheter in the <18g range is fairly flexible.
However, a 10, 12, or 14g is pretty rigid and non-collapsible.

Please "burn one", and pinch the catheter off after you pull the needle. Imagine how much pressure really gets put on the catheter in an adults chest wall, who is breathing..They are not as rigid as you think. Musculature is a far different medium than a vein. Please actually try pinching one off once, and then let me know what you think OK? I don't think it takes much pressure to close them off at all.

[mitllesmertz1]

Ok, whatever works for you.
Based on my personal experience, they have been effective for the short duration of time needed between placement and the ED (ie <30 minutes).
Air comes out, sometimes blood flies out too.
But I won't argue the point with ya.

[medic27205]

[QUOTE=FDAIC485;743895]I try to make things really simple. I use a 10 drop and a bottle of sterile water as a one-way valve. All you have to do is hook a DRY 10 drop set to the 14 long cath. Then submerge the drip chamber into sterile water bottle. Of course, the bottle is kept at a level below the patient.

I was wondering if anybody else was using this method. Our medical director taught us this several years ago and it is approved for field use in our service.

[emsforlife69]

[QUOTE=FDAIC485;743895]I try to make things really simple. I use a 10 drop and a bottle of sterile water as a one-way valve. All you have to do is hook a DRY 10 drop set to the 14 long cath. Then submerge the drip chamber into sterile water bottle. Of course, the bottle is kept at a level below the patient.

I was wondering if anybody else was using this method. Our medical director taught us this several years ago and it is approved for field use in our service.

where did you learn that? I've never heard of that. Intresting concept though. Are you a combat medic? Sounds like load and go type stuff. I would cut the finger off a glove, cover the port and tape it to chest. Easy and practical and the best part is it passes the most important test EMS stadard: ITS CHEAP!!!!!

[mitllesmertz1]

[QUOTE=FDAIC485;743895]I try to make things really simple. I use a 10 drop and a bottle of sterile water as a one-way valve. All you have to do is hook a DRY 10 drop set to the 14 long cath. Then submerge the drip chamber into sterile water bottle. Of course, the bottle is kept at a level below the patient.

I was wondering if anybody else was using this method. Our medical director taught us this several years ago and it is approved for field use in our service.
And this is your idea of simple?:rolleyes:
With the types of pts that get a needle from me, the last thing I want is an open bottle of water sitting on the rig floor...

[wag11c]

I remeber working Aero-meds back in the mid 80-'s when it was "new". In suspected Tensions we would make the cut and put a # 6 ET tobe in the chest....that's the best we could do at the time....flutter valves are no help.

[Medic81]

[QUOTE=FDAIC485;743895]I try to make things really simple. I use a 10 drop and a bottle of sterile water as a one-way valve. All you have to do is hook a DRY 10 drop set to the 14 long cath. Then submerge the drip chamber into sterile water bottle. Of course, the bottle is kept at a level below the patient.

I was wondering if anybody else was using this method. Our medical director taught us this several years ago and it is approved for field use in our service.
I have taught this method to my Paramedic students for years. It works well if you have the time to set up the 10 gtt set (cutting off the drip chamber) and the sterile water bottle. The key is keeping the bottle below the level of the heart. Another consideration is to pour out about half the amount of fluid and when placing tape across the top (to secure the iv tubing) be sure to leave a hole for the air to escape.

[armymedic571]

John,
That's a great idea, but a little time consuming and overkill for transports under 30 minutes. Remember, decompression is a temporary fix. The definitive solution being the chest tube. If ou are in an environment where you have an extended tranport time, aeromedical is not available, or transport is no possible, then go for it. Otherwise, keep it simple. I have never had a problem using a Heimlich valve or simple flutter valve, but I do not see any wrong with not using one as well.

[LordMedic]

[QUOTE=medic27205;749142]
I have taught this method to my Paramedic students for years. It works well if you have the time to set up the 10 gtt set (cutting off the drip chamber) and the sterile water bottle. The key is keeping the bottle below the level of the heart. Another consideration is to pour out about half the amount of fluid and when placing tape across the top (to secure the iv tubing) be sure to leave a hole for the air to escape.so basically you have a makeshift pleuro-vac?

[ShaversFork]

I saw the water bottle trick on a NICU transport many years ago. Over the years I have decompressed a considerable amount of chests and never had an issue with the cath. becoming kinked. I agree with the above post that it is prudent to leave the supported needle in the cath until the majority of the buildup has been released. As for the flutter valve I thought that it went the way of the dinosaur. The Cook(e) setup is a pretty good tool if your agency stocks it. We have it but it's usually in the truck when you need it.