When is heimlich valve used

It can be used in many patients instead of a traditional water seal drainage system. The Heimlich chest drainage valve was developed so that the process of draining the pleural cavity could be accomplished in a safe, relatively simple, and efficient manner.

This valve system has replaced the cumbersome underwater drainage bottle system. The decompression was by tube thoracostomy which was connected to a Heimlich flutter valve. During air transportation the patient suffered from cardiorespiratory arrest with asystole and was admitted to the trauma room undergoing manual chest compressions. The initial chest film showed a persisting tension pneumothorax, despite the chest tube that had been correctly placed and connected properly to the Heimlich valve.

We assume that the Heimlich valve leaves did not open up and thus tension pneumothorax was not released. We would like to raise awareness to the fact that if a Heimlich flutter valve is applied in the pre-hospital setting it should be used with caution. Failure in this type of valve may lead to recurrent tension pneumothorax.

Decompression is considered as the gold standard for treating tension pneumothorax. However, there are many different methods of decompression using different techniques, devices, valves and drainage systems.

We herewith report a case of a defective Heimlich flatter valve used during resuscitation of a patient suffering from a traumatic cardiorespiratory arrest TCRA with persisting tension pneumothorax. At the 68 year old, male patient got injured after being attacked by a bull while working at a rural slaughterhouse.

Initially, the patient was in severe respiratory distress due to flail chest. He was able to communicate and to respond to given commands but had no measurable blood pressure.

Emergency endotracheal intubation was performed and as the breathsounds over the left side were impaired, a tube thoracostomy was performed via a Monaldi approach in the 3 rd intercostal space midclavicular line and connected to a Heimlich flatter valve. Fluid resuscitation with cristalloids and colloids was initiated. Epinephrine and dopamine were then given as the response to fluid resuscitation was not sufficient. The patient was transferred in a critical condition miles by helicopter from the rural district to the next level I trauma centre.

At , during transport, the patient suffered from cardiorespiratory arrest with asystole. At the patient was admitted to our trauma room undergoing manual external chest compressions with a massive subcutaneous emphysema despite the pre-hospital inserted chest tube, which had been inserted on the left side.

Inspection of the tube and valve showed no obstruction through bending or clotted blood. Assuming a contralateral tension pneumothorax, a chest tube was placed on the right side while still on the gurney. Prior auscultation of the breath sounds was not possible due to the massive emphysema.

An immediate chest film was taken the moment, when the patient was placed on the radiotranslucent trauma room table. Focused assessment with ultrasound in trauma FAST revealed neither pericardial effusion nor massive free abdominal fluid. A left side resuscitative thoracotomy was performed for direct cardiac massage and thoracic aortic occlusion. After opening the thorax it could be seen that the chest drain with the connected Heimlich flutter valve had been placed correctly in the pleural space.

Now available developed chest film demonstrated correct tube positioning corresponding to the in situ findings. A subcutaneous emphysema but also a massive tension pneumothorax on the left side was visible, despite the inserted chest tube on scene [figure 1 ].

Further exploration of the thorax showed an insufficient filling of the ventricles, an apical lung rupture and comminuted multiple rib fractures. Under manual cardiac massage, catecholamine adminstration and volume restoration, ventricular flutter occurred and was successfully defibrillated to a sinus rhythm with a blood pressure of mmHg.

Chest film revealing persisting tension pneumothorax on the left side despite the correctly placed chest tubes on both sides. Furthermore showing a massive subcutaneous emphysema also on the left side. The apical lung rupture on the left side was sutured and ml of blood, resulting from multiple rip fractures, was drained via a chest tube on the right side.

In the further progress celiotomy was performed and abdominal exploration showed no additional relevant findings. Despite the occluded thoracic aorta, high-dosage catecholamine medication and massive blood transfusion with 20 units of packed red blood cells, the patient remained hemodynamically unstable. Although supportive manual cardiac massage was performed, cardiac output detoriated and intermittent ventricular flutter episodes occurred.

Resuscitative efforts were stopped at Post mortem computed tomography and autopsy confirmed our major findings and revealed, except a pelvis fracture, no further relevant injuries.

Tension pneumothorax is a life-threatening injury which needs to be detected quickly and treated appropriately. In a recently published study of our group, we found out that chest decompression on scene seem to have a strong positive impact on probability of survival in traumatic cardiorespiratory arrest TCRA [ 3 ]. It is therefore important to have reliable parameters with respect to detection of tension pneumothorax in the pre-hospital setting. Waydhas et al. According to widespread expert opinion, loss of breath on the injured side, signs of life-threatening haemodynamic and respiratory compromise are seen as reliable clinical signs to diagnose a tension pneumothorax [ 4 ].

In the pre-hospital setting decompression of the pleural space is performed either by needle decompression, surgical decompression or by tube thoracostomy. The advantage of decompression by the use of a needle is speed, use of readily available material and the simple procedure [ 5 ]. Because of the narrow lumen, resulting in insufficient decompression, additional chest tube insertion may be required in a significant number of patients [ 6 ].

A surgical decompression is more effective but in terms of release of air it needs to be considered that the incision tends to close again spontaneously leading to recurrent tension pneumothorax and therefore requires close monitoring[ 4 ]. Chest tube insertion is considered an effective method to decompress tension pneumothorax [ 7 ].

However it can result in complications such as injury of the lung, heart and abdominal organs [ 8 — 10 ]. Failure rate due to malposition is reported to be For the lateral approach, injury to an intercostalartery, stenosis of the subclavian artery, injury to the vena cava inferior, perforation of a lung, perforation of the right atrium, of the right or left ventricle, Horner's syndrome and intraabdominal malposition have been reported [ 8 — 10 , 12 — 17 ].

Considering the ventral approach injury to the heart, to the oesophagus, mediastinum, induction of a contralateral pneumothorax, injury to the phrenic nerve, and an arteriovenous fistula have been described [ 9 , 11 , 18 , 19 ].

In a prospective study our group showed that both approaches, the ventral Monaldi 2. Considering malfunction of a chest tube due to malposition no statistical significant difference between the two different approaches could be identified. Our presented case leads to the question which drainage system should be applied in terms of pre-hospital management of tension pneumothorax. Common devices are closed bag or collection chamber systems with or without an incorporated air or water seal or the often used Heimlich flutter valve.

With regard to choosing a drainage system containing of a valve or not it is important whether the patient is breathing spontaneously or positive pressure ventilated by respirator.

If the patient is breathing spontaneously a vent is necessary. Whereas if the patient is positive pressure ventilated the pressure within the lung prevents it from collapsing and no vent is necessary.

A closed bag system can only be used under conditions that are well controlled. This valve system has replaced the cumbersome underwater drainage bottle system. Moreover; the Heimlich valve system connects to chest tubing and allows fluid and air to pass in one direction only. This system functions in any position, and it does not ever need to be clamped, a regulated suction can be attached to it if necessary.

The valve drains into a plastic bag that can be held at any level, allowing the patient undergoing chest drainage to be ambulatory simply by carrying the bag.